新生儿窒息肾脏损害的临床研究

Clinical analysis of kidney damage after neonatal asphyxia

目的通过新生儿窒息肾脏损害的临床表现、肾功能、尿酶测定、肾血流超声检测进一步探讨新生儿窒息肾脏损害的诊断。方法选择2016-01-01~2017-06-30在清华大学第一附属医院新生儿重症监护病房(NICU)住院的新生儿窒息患儿,胎龄>37周、出生体质量>2500g的患儿共111例,每例患儿出生后均进行脐动脉血气分析。采用Apgar评分诊断新生儿窒息。根据脐动脉血气将重度窒息组再分别分为严重酸中毒组(pH≤7和或碱剩余≤-12mmol/L)、非严重酸中毒组(pH>7.0和或碱剩余>-12mmol)。根据缺氧病史、临床表现、肾功能及尿酶诊断新生儿窒息肾脏损害。比较轻度窒息组(n=74)、重度窒息组(n=37)中肾脏损害发生率、肾脏损害相关的临床表现及肾功能、血、尿β2微球蛋白(β2M)及尿-N乙酰-β-D-氨基葡萄糖苷酶(NAG)和尿β-D-半乳糖苷酶(GAL)。结果①新生儿窒息肾脏损害的发生率为35.13%(39/111)。重度窒息组肾脏损害的比例高于轻度窒息组(51.39%vs27.03%),差异有统计学意义(χ^2=6.404,P=0.011)。②重度窒息组中严重酸中毒的肌酐、尿素氮明显高于非严重酸中毒组和轻度窒息组(均P<0.05)。出生后7d,三组肌酐与尿素氮均明显改善,但重度窒息合并严重酸中毒组中Cr和BUN水平仍高于其他两组,差异有统计学意义。③出生后48h,重度窒息组中严重酸中毒的血、尿β2微球蛋白明显高于非严重酸中毒组和轻度窒息组(均P<0.05)。④出生后48h,轻度窒息组、重度窒息中严重酸中毒组与非严重酸中毒组相比,尿NAG和尿GAL均有升高趋势,但差异无统计学意义(均P>0.05)。⑤肾血流超声检查显示,重度窒息组中严重酸中毒组的左肾收缩期峰值血流高于非严重酸中毒组、轻度窒息组及对照组(P=0.003),但其余指标组间比较差异无统计学意义。结论新生儿窒息可发生肾脏损害。结合脐血pH值可判断窒息严重程度,合并严重酸中毒的患儿肾脏损害更严重。

Objective To investigate the early diagnosis of kidney injury after neonatal asphyxia based on the clinical manifestations of renal function,urease assay,and renal blood flow ultrasonic testing.Methods From January 1,2016 to June 30,2017,111 cases of neonatal asphyxia in the Neonatal Intensive Care Unit of Pediatrics of the First Hospital of Tsinghua University,with a gestational age>37 weeks and a birth weight>2 500 g,were enrolled.Apgar scores were used to diagnose neonatal asphyxia.According to the umbilical arterial blood gas analysis,severe asphyxia was divided into two groups:severe asphyxia with severe acidosis group(pH≤7 and/or BE≤-12 mmol/L),and severe asphyxia without acidosis group(pH>7.0 and/or BE>-12 mmol/L).Kidney damage after neonatal asphyxia was diagnosed according to the hypoxia history,clinical presentation,renal function,urease enzymes and renal blood flow with Doppler ultrasonography.The incidence of kidney damage,clinical manifestations associated with kidney damage,renal function,blood and urineβ2-microglobulin(β2M),urine-N-acetyl-β-D-glucosaminidase(NAG)and urineβ-D-galactosidase(GAL)were compared between mild asphyxia(n=74)and severe asphyxia(n=37).One-way ANOVA,the LSD test,Kruskal-Wallis test for independent samples,Chi square test and Fisher’s exact test were used for statistical analysis.Results①The incidence of kidney damage after asphyxia was 35.13%(39/111).It was higher in severe asphyxia group than in mild asphyxia group(51.39%vs 27.03%,χ^2=6.404,P=0.011).②The levels of creatinine,urea nitrogen were higher in severe asphyxia with severe acidosis group than in severe asphyxia without acidosis group and mild asphyxia group(P<0.05).After birth for 7 d,both creatinine and urea nitrogen levels recovered significantly,but the levels of creatinine and urea nitrogen were still higher in severe asphyxia with severe acidosis group than those of the other two groups(P<0.05).③At 48 h after birth,blood and urinaryβ2 microglobulin were higher in severe asphyxia with severe acidosis group and mild asphyxia group than that in severe asphyxia without acidosis group(P<0.05).④At 48 h after birth,urinary NAG and urinary GAL levels were higher in severe asphyxia with severe acidosis group and mild asphyxia group than that in severe asphyxia without acidosis group,but the difference was not statistically significant.⑤The values of the peak systolics right kidney were higher in severe asphyxia with severe acidosis group than in other groups by renal blood flow with Doppler ultrasonography(P=0.003).Conclusion Kidney damage can occur after neonatal asphyxia.Cord blood pH value should be combined to determine the severity of asphyxia.Kidney damage is more serious in the severe asphyxia with severe acidosis neonates.