50例自发性肾脏出血患者的临床分析

Spontaneous renal hemorrhage: a clinical analysis of 50 patients

目的回顾性分析自发性肾脏出血(Wünderlich综合征)患者的临床表现、影像学检查表现、病因、治疗及预后情况,旨在为自发性肾脏出血的诊断及治疗提供临床经验。方法检索2000年1月1日至2020年4月10日期间北京大学第一医院的电子病历系统、病案扫描系统、介入血管外科登记系统和医学影像系统的病历档案,收集和回顾性分析自发性肾脏出血患者的临床资料,包括临床表现、实验室检查、影像学表现、治疗方案及预后。对比分析和评估超声、计算机断层扫描(CT)、磁共振成像(MRI)和血管造影等影像学检查对肾脏出血的诊断效能和病因诊断的准确率。结果共50例(51例次)自发性肾脏出血患者入选本研究,血红蛋白为(103.3±29.4)g/L。48例患者(96.0%)主诉腰腹痛,其他症状包括发热(17例,34.0%)、恶心(10例,20.0%)、呕吐(9例,18.0%)和肉眼血尿(4例,8.0%)等。9例(18.0%)患者初次就诊或病程中血压出现休克水平(收缩压﹤90 mmHg)。影像学检查初步诊断肾脏出血的准确率为98.0%(49/50),判断出血原因的准确率为54.0%(27/50),其中腹(盆)部CT平扫诊断肾脏出血的诊断率为100.0%(25/25)。自发性肾脏出血的最常见病因为肾脏肿瘤[27例(54.0%)],其中血管平滑肌脂肪瘤20例(40.0%)。其他病因包括:肾囊肿10例(20.0%)、自身免疫性疾病4例(8.0%)、出血倾向3例(6.0%)和特发性肾脏出血6例(12.0%)。12例(24.0%)患者接受保守治疗,29例(58.0%)接受了介入栓塞治疗,11例(22.0%)接受肾切除术。首次介入治疗成功率为86.2%(25/29),有13.8%(4/29)患者需要2次介入治疗或肾切除术。结论自发性肾脏出血患者临床症状表现不特异,容易被漏诊或误诊。CT平扫判断肾脏出血的诊断率高,病因判断需结合临床表现、实验室检查、影像学和病理检查。患者经积极治疗可有效止血,预后良好。

Objective To provide clinical experience for the diagnosis and treatment of spontaneous renal hemorrhage through retrospective analysis of clinical features,imaging manifestations,underlying causes,treatment,and prognosis of spontaneous renal hemorrhage.Methods By searching hospital information system,medical records scanning system,department of the interventional vascular surgery registry system,and picture archiving and communication systems,the patients with spontaneous renal hemorrhage admitted to Peking University First Hospital between January 1,2000 to April 10,2020 were enrolled.The clinical manifestations,investigations,imaging features,treatment,and prognosis of patients were retrospectively reviewed.The diagnostic efficiency and the accuracy of etiological diagnosis of renal hemorrhage by imaging examinations such as ultrasound,computed tomography(CT),magnetic resonance imaging(MRI),and angiography were compared and evaluated.Results A total of 50 patients with 51 events of spontaneous renal hemorrhage were enrolled in the study.Laboratory tests showed hemoglobin was(103.3±29.4)g/L.The most common clinical features were flank or abdominal pain(48 cases,96.0%),fever(17 cases,34.0%),nausea(10 cases,20.0%),vomiting(9 cases,18.0%),and gross hematuria(4 cases,8.0%).Nine patients(18.0%)experienced hypovolemic shock(systolic pressure<90 mmHg).With an initial assessment of the imaging method,the diagnostic accuracy of bleeding was 98.0%(49/50),yet the accuracy of underlying causes was 56.0%(28/50).The diagnostic accuracy of bleeding was 100.0%(25/25)by non-contrast abdominopelvic CT.The most common cause of spontaneous renal hemorrhage syndrome was renal tumors(27 cases,54.0%),among which angiomyolipoma occurred most frequently(20 cases,40.0%).Other causes included renal cyst(10 cases,20.0%),autoimmune diseases(4 cases,8.0%),bleeding diathesis(3 cases,6.0%),and idiopathic renal hemorrhage(6 cases,12.0%).Twelve patients(24.0%)received conservative management,29 patients(58.0%)underwent interventional embolization therapy,and 11 patients(22.0%)received nephrectomy.The success rate on first embolization therapy was 86.2%(25/29),and approximately 13.8%(4/29)required second embolization therapy or nephrectomy.Conclusions Spontaneous renal hemorrhage has no specific clinical features and is easy to be underdiagnosed or misdiagnosed.Non-contrast CT scan has a high diagnostic value for renal bleeding.Comprehensive judgement consisting of clinical features,laboratory tests,imaging manifestations and pathological examinations should be relied on for finding the underlying causes.Prompt diagnosis and management can guarantee a better prognosis.