急性胰腺炎致急性肾损伤及影响肾功能预后的相关因素分析

Analysis of the related factors for acute renal injury caused by acute pancreatitis and the prognosis of renal function

目的探讨急性胰腺炎致急性肾损伤及影响肾功能预后的相关因素。方法选取就诊于中国医科大学附属盛京医院诊断急性胰腺炎患者343人,85人无复查肾功能结果,余下258人。A组:肾小球率过滤(estimated glomerular filtration rate,e GFR)<125ml/min;B组:e GFR≥125ml/min;A组治疗后e GFR下降者为C组,e GFR上升者为D组。结果轻症急性胰腺炎患者无死亡,中重症急性胰腺炎患者病死率9.7%,重症急性胰腺炎患者病死率60%。发病48h后肾损伤持续存在患者病死率(85.7%)明显高于48h后肾功能好转患者病死率(42.2%)。A组患者年龄(t=5.709,P<0.001)、急性生理与慢性健康评分II(acute physiology and chronic health evaluation II,APACHE II)(t=4.557,P<0.001)、谷草转氨酶(Z=-4.225,P<0.001)、血乳酸脱氢酶(t=6.085,P<0.001)、血淀粉酶(t=3.505,P=0.001)、N末端脑利钠肽前体(Z=-2.120,P=0.034)、血降钙素原(Z=-3.870,P<0.001)、胸腔积液发生率(χ2=6.529,P=0.011)高于B组患者;A组患者血钙(t=-6.507,P<0.001)低于B组患者。多因素回归分析显示,高血降钙素原(β=-1.340,t=-2.562,P=0.019)与低肾小球滤过率相关;低收缩压(β=-0.008,t=-2.651,P<0.001)、高C反应蛋白(β=0.001,t=3.321,P=0.001)、高APACHE-II评分(β=0.035,t=2.670,P=0.008)与高24h尿蛋白定量相关。C、D 2组患者入院比较,C组红细胞压积(t=2.588,P=0.011)高于D组;C、D 2组治疗后比较,C组24h尿蛋白定量(Z=-2.791,P=0.005)、谷草转氨酶(Z=-2.861,P=0.004)、血降钙素原(Z=-2.095,P=0.036)高于D组,C组收缩压(Z=-2.633,P=0.008)低于D组,2组持续肾脏替代治疗/日间持续肾脏替代治疗时间(χ~2=0.018,P=1.000)及血液灌流次数(χ~2=0.850,P=0.361)无统计学差异。结论急性胰腺炎合并急性肾损伤病死率高。高龄、感染重、胰腺损伤重、组织液渗出多常伴有肾脏和其他多脏器的损伤。感染不仅是肾脏损伤的起因,也是肾功能预后不佳的影响因素。血液净化治疗是否有助于急性胰腺炎合并急性肾损伤患者肾功能的恢复有待进一步研究证实。

Objective To investigate the related factors for acute renal injury caused by acute pancreati-tis and the prognosis of renal function. Methods A total of 343 patients with acute pancreatitis diagnosed at Shengjing Hospital Affiliated to China Medical University were selected. Eight-five of the 343 patients had no follow-up data of renal function, and 258 patients were then retrospectively analyzed in this study. The 258 pa-tients were divided into group A （eGFR〈125ml/min） and group B （eGFR≥125ml/min）. Patients in group A were subdivided into group C （eGFR decreased after treatment） and group D （eGFR increased after treat-ment）. Results The mortality rate was 0% in mild acute pancreatitis patients, 9.7% in moderately severe acute pancreatitis patients, and 60%in severe acute pancreatitis patients. The mortality rate was 85.7%in pa-tients with sustained renal injury after 48 hours from onset of acute pancreatitis, significantly higher than that of 42.2% in patients with improved renal injury after 48 hours. In group A, age （t=5.709, P〈0.001）, APACHE II score （t=4.557,P〈0.001）, aspartate aminotransferase （Z=-4.225, P〈0.001）, lactate dehydroge-nase （t=6.085,P〈0.001）, serum amylase （t=3.505, P=0.001）, NT-proBNP （Z=-2.120, P=0.034）, serum procal-citonin （Z=-3.870, P=0.000）, and rate of pleural effusion （x2=6.529, P=0.011） were significantly higher than those in group B, while serum calcium （t=-6.507, P〈0.001） was significantly lower in group A than in group B. Multivariate regression analysis showed that high blood procalcitonin （β=-1.340, t=-2.562, P=0.019） was related to low eGFR, and low systolic blood pressure （β=-0.008, t=-2.651, P〈0.001）, high C-reactive protein （β=0.001, t=3.321, P=0.001） and high APACHE II score （β=0.035, t=2.670, P=0.008） were related to higher 24-hours urine protein. When comparisons of the indices were made between group C and group D, hemato-crit at admission （t=2.588, P=0.011） was higher in group C than in group D;after the treatment, 24-hour urine protein （Z=-2.791, P=0.005）, aspartate aminotransferase （Z=-2.861, P=0.004） and blood procalcitonin （Z=-2.095, P=0.036） were higher in group C than in group D, while systolic blood pressure （Z=-2.633, P=0.008） was lower in group C than in group D. There were no statistical differences in the treatment time of CRRT/day-time CRRT （x2=0.018, P=1.000） and number of hemoperfusion （x2=0.850, P=0.361） between the two groups. Conclusions Acute pancreatitis complicated with acute renal injury has a high fatality rate. Older age, severe infection, serious pancreatic injury and tissue fluid exudation were often associated with kidney and multiple organ damages. Infection was not only the cause of kidney injury, but also the factor for unfavor-able prognosis of renal function. It needs to be further studied whether blood purification is helpful for the re-covery of renal function in acute pancreatitis patients complicated with acute kidney injury.