动态监测降钙素原对脓毒症急性肾损伤近期恢复预测价值

Predictive Value of Dynamic Monitoring of Procalcitonin for Short-term Recovery of Acute Kidney Injury in Sepsis

目的探讨降钙素原(PCT)及其动态变化对脓毒症持续性急性肾损伤(AKI)的预测价值。方法收集2020年3月至2021年4月上海市浦东新区周浦医院重症医学科收治的74例脓毒症AKI患者的临床资料进行回顾性分析。收集AKI确诊时、确诊1 d、确诊2 d的血常规[白细胞(WBC)计数]、肾功能、PCT、C反应蛋白(CRP)检测结果。根据AKI后48 h内血清肌酐(SCr)水平是否恢复正常将患者分为持续性AKI组(44例)与短暂性AKI组(30例)。比较两组上述指标及各指标动态变化的差异,并对有统计学意义的变量进行多因素Logistic回归分析。采用受试者工作特征曲线(ROC曲线)分析独立危险因素对脓毒症持续性AKI的早期预测价值。结果持续性AKI组序贯器官衰竭评估(SOFA)评分、急性生理学和慢性健康状况评价Ⅱ(APACHEⅡ)评分以及改善全球肾脏病预后组织(KDIGO)3级患者占比均高于短暂性AKI组[10.0(7.0,12.0)分比5.0(3.0,7.0)分、(25.0±6.7)分比(19.6±5.8)分、31.8%(14/44)比3.3%(1/30)](均P<0.01)。AKI确诊当日,两组SCr、WBC计数、PCT、CRP比较差异均无统计学意义(P>0.05)。AKI确诊1 d,持续性AKI组SCr、PCT水平高于短暂性AKI组[211.0(160.0,295.5)μmol/L比117.5(89.8,155.5)μmol/L、11.62(3.28,25.59)μg/L比4.69(1.09,11.15)μg/L](P<0.05或P<0.01);AKI确诊2 d,持续性AKI组SCr、WBC计数、PCT、CRP均高于短暂性AKI组[250.5(168.0,403.8)μmol/L比82.0(57.0,97.8)μmol/L、14.48(10.44,18.54)×109/L比10.73(8.14,14.92)×109/L、11.68(8.23,30.24)μg/L比2.08(0.52,5.76)μg/L、146.0(61.4,216.6)mg/L比65.4(29.0,107.9)mg/L](P<0.05或P<0.01)。且持续性AKI组ΔSCr-24 h、ΔSCr-48 h、ΔWBC-48 h、ΔPCT-24 h、ΔPCT-48 h、ΔCRP-48 h均高于短暂性AKI组(P<0.05或P<0.01),但两组ΔWBC-24 h、ΔCRP-24 h比较差异无统计学意义(P>0.05)。PCT动态变化显示,确诊后持续性AKI组PCT水平呈进行性升高趋势,而短暂性AKI组PCT水平呈进行性降低趋势。Spearman相关分析显示,ΔScr-24 h与ΔPCT-24 h呈正相关(r=0.560,P<0.001),ΔScr-48 h与ΔPCT-48 h呈正相关(r=0.773,P<0.001)。Logistic回归分析显示,SOFA评分、确诊1 d的PCT、ΔPCT-24 h是脓毒症持续性AKI的独立预测因子(OR=1.327,95%CI 1.081-1.628;OR=0.952,95%CI 0.960-0.999;OR=1.077,95%CI 1.010-1.148)(P<0.05或P<0.01)。ΔPCT-24 h的ROC曲线下面积高于SOFA评分、APACHEⅡ评分、确诊1 d的PCT,其最佳截断值为0.110μg/L,灵敏度、特异度分别为77.27%、86.67%。结论脓毒症患者发生AKI后,PCT水平进行性升高与持续性AKI发病密切相关。ΔPCT-24 h是脓毒症持续性AKI早期诊断的独立预测因子。

Objective To investigate the predictive value of procalcitonin(PCT)and its dynamic changes for persistent acute kidney injury(AKI)in sepsis.Methods The clinical data of 74 septic AKI patients admitted to Intensive Care Unit in Shanghai Pudong New Area Zhoupu Hospital from Mar.2020 to Apr.2021 was collected for retrospective analysis.We collected the routine blood,renal function,PCT and C-reactive protein(CRP)indexes at the time point of diagnosis of AKI,as well as at the following day 1 and 2.According to whether the serum creatinine(SCr)level returned to normal within 48 hours after AKI,they were divided into a persistent AKI group(44 cases)and a transient AKI group(30 cases).The differences of the above indexes and the dynamic changes of each index between the two groups were compared,and the statistically significant variables were analyzed by multivariate Logistic regression.The receiver operating characteristic(ROC)curve was used to analyze the early predictive value of independent risk factors for persistent AKI in sepsis.Results The sequential organ faliure assessment(SOFA)score,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score and Kidney Disease:Improving Global Outcomes(KDIGO)grade 3 patients in the persistent AKI group were higher than those in the transient AKI group[10.0(7.0,12.0)vs 5.0(3.0,7.0),(25.0±6.7)vs 19.6±5.8,31.8%(14/44)vs 3.3%(1/30)](all P<0.01).On the day of AKI diagnosis,there were no significant differences in SCr,WBC count,PCT and CRP between the two groups(P>0.05).On AKI diagnosis day 1,the levels of SCr and PCT in the persistent AKI group were higher than those in the transient AKI group[211.0(160.0,295.5)μmol/L vs 117.5(89.8,155.5)μmol/L,11.62(3.28,25.59)μg/L vs 4.69(1.09,11.15)μg/L](P<0.05 or P<0.01).On AKI diagnosis day 2,SCr,WBC,PCT and CRP in the persistent AKI group were higher than those in the transient AKI group[250.5(168.0,403.8)μmol/L vs 82.0(57.0,97.8)μmol/L,14.48(10.44,18.54)×109/L vs 10.73(8.14,14.92)×109/L,11.68(8.23,30.24)μg/L vs 2.08(0.52,5.76)μg/L,146.0(61.4,216.6)mg/L vs 65.4(29.0,107.9)mg/L](P<0.05 or P<0.01).AndΔSCr-24 h,ΔSCr-48 h,ΔWBC-48 h,ΔPCT-24 h,ΔPCT-48 h,ΔCRP-48 h in the persistent AKI group were higher than those in the transient AKI group(P<0.05 or P<0.01),while there was no significant difference inΔWBC-24 h andΔCRP-24 h between the two groups(P>0.05).The dynamic changes of PCT showed that after diagnosis of AKI,PCT level in the persistent AKI group showed a progressive increase trend,while that in the transient AKI group showed a progressive decrease trend.Spearman correlation analysis showed thatΔSCr-24 h was positively correlated withΔPCT-24 h(r=0.560,P<0.001),andΔSCr-48 h was positively correlated withΔPCT-48 h(r=0.773,P<0.001).Logistic regression analysis showed that,SOFA score,PCT day 1,andΔPCT-24 h were independent predictors of septic persistent AKI(OR=1.327,95%CI 1.081-1.628;OR=0.952,95%CI 0.960~0.999;OR=1.077,95%CI 1.010-1.148)(P<0.05 or P<0.01).The area under ROC curve ofΔPCT-24 h was higher than SOFA score,APACHEⅡscore and PCT day 1,the optimal cut-off value of which was 0.110μg/L,and the sensitivity and specificity were 77.27%and 86.67%,respectively.Conclusion After septic AKI occurrence,the progressive increase of PCT level is closely related to the onset of persistent AKI.ΔPCT-24 h is an independent predictor of the early diagnosis of persistent AKI in sepsis.