可溶性血栓调节蛋白在脓毒症急性肾损伤预测价值的研究

Predictive value of soluble thrombomodulin in acute renal injury induced by sepsis

目的 评估内皮细胞损伤相关的生物标记物预测脓毒症急性肾损伤（AKI）发生的价值。方法 本研究分析了2015-07-2017-10期间我院重症监护室收治的114例脓毒症患者。采用预后肌酐标准来确定AKI患者，包括需行肾脏替代治疗的患者。由APACHEⅡ评分和SOFA评分衡量病情严重程度。将单因素分析中有统计学差异的参数纳入Logistic回归模型中进行多因素分析，确定AKI的独立预测因素。结果 最终114例脓毒症患者符合纳入和排除标准，其中非AKI组63例，AKI组51例。两组年龄、性别、BMI、感染部位等差异无统计学意义（P＞0.05）。AKI组与非AKI组比较APACHEⅡ评分、SOFA评分、慢性肾功能不全、感染性休克、弥散性血管内凝血、机械通气、ICU停留时间、CRRT、28 d病死率差异均有统计学意义（P＜0.05）。内皮细胞标志物中，AKI组较非AKI组sTM（11.9±3.3和7.6±2.1, P＜0.001）、E-选择素（65.7±13.5和45.5±10.5, P＜0.001）和PAI-1（178.6±32.6和75.5±21.0, P＜0.001）均有显著升高，而蛋白C水平显著降低（45.6±9.6和56.8±11.3, P＜0.001）。凝血生物标志物中，AKI组血小板计数、FDP、PT、ATⅢ、纤溶酶原和α2-PI与非AKI组比较差异均有统计学意义（P＜0.05）。sTM具有高特异度（98%），但敏感度有限（55%），AUC为0.735（P＜0.001）。多因素Logistic回归分析显示sTM是AKI的独立预测因子（OR：0.74, 95%CI0.35-1.24，P=0.033）。结论 内皮生物标志物在AKI脓毒症患者中发生显著变化。sTM是脓毒症AKI的独立预测因子，其优于其他凝血和炎症生物标志物以及器官功能。

Objective Evaluate the value of endothelial injury biomarkers in predicting acute kidney injury （AKI） in patients with sepsis. Methods This study analyzed 114 sepsis patients admitted to our ICU between July 2015 and October 2017. The researchers used kidney - based criteria to improve overall prognostic creatinine in patients with AKI, including those requiring renal replacement therapy. The severity of the illness was measured by the APACHE Ⅱ score and the SOFA score. Statistically significant parameters in the univariate analysis were included in a Logistic regression model for multivariate analysis to determine independent predictors of AKI. Results The final 114 patients with sepsis met the inclusion and exclusion criteria, of which 63 cases non - AKI group and 51 cases with AKI group. There was no significant difference between the two groups in age, gender, BMI, infection site （ P 〉 0.05 ）. There were significant differences in APACHE Ⅱ score, SOFA score, chronic renal insufficiency, septic shock, disseminated intravascular coagulation, mechanical ventilation, ICU stay, CRRT and 28 - day mortality in AKI group compared with non - AKI group （ P 〈 0.05 ）. In the endothelial markers, soluble thrombomodulin （ sTM, ng/mL： 11.9 ± 3.3 vs. 7.6 ± 2.1, P 〈 0.001 ）, E-selectin （ng/mL： 65.7 ±13.5 vs. 45.5 ±10.5, P〈0.001） and PAI-1 （ng/mL： 178.6 ±32.6 vs. 75.5±21.0, P 〈0.001 ）, while the level of protein C was significantly lower （ % ： 45.6±9.6 vs. 56.8±11.3, P 〈0.001 ）. In coagulation biomarkers, platelet count, FDP, PT, AT Ⅲ, plasminogen and α2 - PI in AKI group were significantly different from those in non - AKI group （ P 〈 0.05 ）. sTM has high specificity （ 98% ） but limited sensitivity （ 55% ） and AUROC of 0. 735 （ P 〈 0. 001 ）. Multivariate Logistic regression analysis showed that sTM was an independent predictor of AKI （ OR： 0.74, 95 % CI 0. 35 - 1.24, P = 0. 033 ）. Conclusion Endothelial biomarkers change significantly in patients with AKI and sepsis, sTM is an independent predictor of AKI in sepsis that outperforms other coagulation and inflammatory biomarkers and organ function.