血浆suPAR及尿NGAL、KIM-1对成人心脏手术相关性急性肾损伤的早期诊断价值

The value of plasma suPAR,urinary NGAL and KIM-1 for early diagnosis of adult with cardiac surgery-associated acute kidney injury

目的探讨血浆可溶性尿激酶型纤溶酶原激活物受体(suPAR)及尿中性粒细胞明胶酶相关载脂蛋白(NGAL)、尿肾脏损伤分子-1(KIM-1)对成人心脏手术相关性急性肾损伤(CSA-AKI)的早期诊断价值。方法采用前瞻性病例对照研究,连续纳入2020年3月-2021年2月在陆军军医大学第一附属医院心脏外科行体外循环心脏手术的患者170例,在术前和术后2 h、2 d、7 d分别留取静脉血及尿液,采用酶联免疫吸附(ELISA)法检测血浆suPAR、尿NGAL、尿KIM-1水平。按术后7 d是否发生AKI分为AKI组(n=34)和非AKI组(n=136),比较两组血浆suPAR、尿NGAL、尿KIM-1水平的差异;采用logistic回归分析CSA-AKI的危险因素;通过受试者工作特征(ROC)曲线评价血浆suPAR,尿NGAL、尿KIM-1对CSA-AKI的早期诊断价值。结果AKI组血浆suPAR水平明显高于非AKI组(P<0.01),AKI组术后2 h的尿KIM-1及术后2 h、7 d的尿NGAL水平均明显高于非AKI组(P<0.05)。ROC曲线分析结果显示,术前、术后2 h血浆suPAR,术后2 h尿KIM-1、NGAL诊断CSA-AKI的曲线下面积(AUC)分别为0.683、0.717、0.643、0.631;联合检测术后2 h血浆suPAR+尿KIM-1+尿NGAL的AUC最大(AUC=0.793,95%CI 0.708~0.879,P<0.001),敏感度为64.71%,特异度为82.35%。Logistic回归分析结果显示,在校正了性别,术前左室射血分数(LVEF)、白蛋白(ALB)及术后2 h肌酐、估算肾小球滤过率(eGFR)、血尿素氮(BUN)、KIM-1、NGAL后,术后2 h suPAR仍为CSA-AKI的独立危险因素。结论血浆suPAR、尿NGAL、尿KIM-1均可早期诊断CSA-AKI;单独检测时,术后2 h血浆suPAR的诊断效能最佳;联合检测术后2 h血浆suPAR、尿NGAL、尿KIM-1可进一步提高对CSA-AKI的诊断效能。

Objective To explore the value of plasma soluble urokinase-type plasminogen activator receptor(suPAR),urinary neutrophil gelatinase associated apolipoprotein(NGAL)and urinary kidney injury molecule-1(KIM-1)in the early diagnosis of adult with cardiac surgery-associated acute kidney injury(CSA-AKI).Methods A prospective case-control study was conducted with consecutively recruited 170 patients undergoing cardiac surgery with cardiopulmonary bypass in the Department of Cardiac Surgery,the First Affiliated Hospital of Army Medical University from March 2020 to February 2021.Venous blood and urine were collected before operation,2 hours,2 days and 7 days after operation,and the levels of plasma suPAR,urine NGAL and urine KIM-1 were detected by enzyme linked immunosobent assay(ELISA).According to the occurrence of AKI 7 days after operation,the patients were divided into AKI group(n=34)and non-AKI group(n=136).The levels of plasma suPAR,urinary NGAL and urinary KIM-1 were compared between the two groups.The risk factors of CSA-AKI were analyzed by logistic regression,and the value of plasma suPAR,urine NGAL and KIM-1 for the early diagnosis of CSA-AKI was evaluated by receiver operating characteristic(ROC)curve.Results The level of plasma suPAR was significantly higher in AKI group than that in non-AKI group(P<0.01).The levels of urinary KIM-1 at 2 h after operation and urinary NGAL at 2 h and 7 d after operation were significantly higher in AKI group than those in non-AKI group(P<0.05).ROC analysis showed that the area under curve(AUC)of preoperative plasma suPAR,postoperative 2 h plasma suPAR,urine Kim-1 and urine NGAL diagnosed CSA-AKI were 0.683,0.717,0.643 and 0.631,respectively.The AUC area which combined detection of postoperative 2 h plasma suPAR+postoperative 2 h urine KIM-1+2 h urine NGAL was the largest(AUC=0.793,95%CI 0.708-0.879,P<0.001),and the sensitivity and the specificity were 64.71%and 82.35%.Logistic regression analysis showed that after adjusting for sex,preoperative left ventricular ejection fraction(LVEF),albumin(ALB),postoperative 2 h creatinine,postoperative 2 h estimated glomerular filtration rate(eGFR),postoperative 2 h blood urea nitrogen(BUN),postoperative 2 h KIM-1 and postoperative 2 h NGAL,postoperative 2 h suPAR was still an independent risk factor for CSA-AKI.Conclusion Plasma suPAR,urine NGAL and urine Kim-1 can be used for early diagnosis of CSA-AKI.The diagnostic efficacy of plasma suPAR at 2 hours after operation is the best when detected alone.Combined detection of plasma suPAR,urine NGAL and urine Kim-1 at 2 hours after operation can further improve the diagnostic efficiency of CSA-AKI.