肾血管阻力指数对重症急性胰腺炎相关性急性肾损伤早期预测价值的临床研究

Clinical study on the early predictive value of renal resistive index in acute kidney injury associated with severe acute pancreatitis

目的探讨肾血管阻力指数(RRI)在重症急性胰腺炎(SAP)相关性急性肾损伤(AKI)早期诊断及趋势判断中的价值。方法回顾性分析2016年1月至2019年6月上海交通大学医学院附属瑞金医院重症医学科收治的SAP(发病1周内)合并AKI并于入科24 h内进行RRI测定患者的临床资料。收集患者急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、心率(HR)、平均动脉压(MAP)、中心静脉压(CVP)、腹腔内压(IAP)、动脉血乳酸(Lac)、氧合指数(PaO2/FiO2)、剩余碱(BE)、血清肌酐(SCr)、尿量、去甲肾上腺素(NE)、RRI等相关资料。根据24 h内和7 d时AKI分级〔改善全球肾脏病预后组织(KDIGO)标准〕将患者进行分组并比较相关参数的差异;采用Logistic回归分析筛选影响AKI分级的指标;采用Pearson相关法分析RRI与其他参数的相关性;采用受试者工作特征曲线(ROC)分析RRI对AKI分级的预测价值。结果共纳入57例患者,年龄(54.6±13.5)岁,APACHEⅡ评分(21.8±5.6)分。24 h内AKI 1~3级者分别为19例(33.3%)、18例(31.6%)和20例(35.1%);7 d时AKI 0~3级者分别为21例(36.9%)、8例(14.0%)、9例(15.8%)和19例(33.3%)。AKI级别越高,特别是7 d评为AKI 3级者APACHEⅡ评分、CVP、IAP、Lac、NE用量及RRI值越高。24 h内AKI 3级者RRI显著高于AKI 1级、2级者(0.74±0.04比0.65±0.05、0.68±0.05,均P<0.05);7 d时AKI 2级、3级者RRI显著高于AKI 0级、1级者(0.70±0.04、0.74±0.04比0.65±0.05、0.66±0.05,均P<0.05)。多因素Logistic回归分析显示,RRI是AKI分级的独立影响因素〔优势比(OR)=3.15,95%可信区间(95%CI)=1.09~9.04,P<0.05〕,IAP和CVP也对AKI分级评估具有显著影响〔OR值分别为2.11(95%CI=1.16~4.22)、3.78(95%CI=1.21~12.90),均P<0.05〕。ROC曲线分析显示,RRI预测SAP患者7 d AKI≥2级的曲线下面积(AUC)为0.87(P<0.05);当临界值RRI>0.71时,敏感度和特异度分别为71%、83%。相关性分析显示,RRI与IAP、Lac呈一定相关性(r1=0.49,r2=0.39,均P<0.05)。结论SAP相关性AKI早期高RRI往往提示后期进展为严重AKI,RRI可协助预判SAP相关性AKI的进展趋势。

Objective To investigate the value of renal resistive index(RRI)in early predictor and discriminator of severe acute pancreatitis(SAP)-related acute kidney injury(AKI).Methods A retrospective observational study was conducted.SAP patients complicated with AKI(within 1 week of onset)and admitted to intensive care unit(ICU)of Ruijin Hospital Shanghai Jiaotong University School of Medicine from January 2016 to June 2019 were enrolled.The RRI within 24 hours admission was measured.Clinical data such as acute physiology and chronic health evaluationⅡ(APACHEⅡ),heart rate(HR),mean arterial pressure(MAP),central venous pressure(CVP),intra-abdominal pressure(IAP),arterial blood lactate(Lac),oxygenation index(PaO2/FiO2),base excess(BE),serum creatinine(SCr),urine output,norepinephrine(NE)and RRI were collected.Within 24 hours and 7 days after ICU admission,patients were grouped according to AKI classification criteria of Kidney Disease:Improving Global Outcomes(KDIGO),and the differences of relevant parameters were statistically analyzed.Influence factors of AKI grading were screened by Logistic regression analysis.Pearson correlation analysis was used to analyze the correlation between RRI and other parameters.The predictive value of RRI for AKI classification was analyzed by receiver operating characteristic(ROC)curve.Results A total 57 patients were included,with an average age of(54.6±13.5)years old,and APACHEⅡscore of 21.8±5.6.Within 24 hours,the number of patients suffered from stage 1-3 AKI were 19(33.3%),18(31.6%)and 20(35.1%),respectively.On day 7,the number of patients suffered from stage 0-3 AKI were 21(36.9%),8(14.0%),9(15.8%)and 19(33.3%),respectively.The higher APACHEⅡscore,CVP,IAP,Lac,NE dosage and RRI were found in the group with higher AKI grades,especially in the group with stage 3 AKI on day 7.RRI of patients with stage 3 AKI was significantly higher than that of patients with stage 1 and 2 AKI within 24 hours(0.74±0.04 vs.0.65±0.05,0.68±0.05,both P<0.05).Similarly,RRI of patients with stage 2 and 3 AKI were significantly higher than that of patients with stage 0 and 1 AKI on day 7(0.70±0.04,0.74±0.04 vs.0.65±0.05,0.66±0.05,all P<0.05).Multivariate Logistic regression analysis showed that RRI was an independent factor of AKI classification[odds ratio(OR)=3.15,95%confidence interval(95%CI)=1.09-9.04,P<0.05],and IAP and CVP also had significant impacts on AKI grading[OR value was 2.11(95%CI=1.16-4.22),3.78(95%CI=1.21-12.90),both P<0.05].ROC curve analysis showed that the area under curve(AUC)of RRI for predicting AKI≥2 stage was 0.87(P<0.05);the cut-off>0.71,sensitivity was 71%and specificity was 83%.The correlation analysis showed that RRI was positively correlated to a certain extent with IAP and lactic acid(r1=0.49,r2=0.39,both P<0.05).Conclusion High RRI on ICU admission was a significant predictor for development of severe AKI during the first week,and RRI can help predict the tendency of AKI in SAP.