肾动脉阻力指数及尿血管紧张素原对脓毒症急性肾损伤患者早期诊断的临床价值

Clinical value of renal artery resistance index and urinary angiotensinogen in early diagnosis of acute kidney injury in patients with sepsis

目的探讨肾动脉阻力指数(RRI)与尿血管紧张素原(UAGT)在脓毒症急性肾损伤(AKI)早期诊断中的价值。方法采用前瞻性研究方法,选择2021年1月至9月宁夏医科大学总医院重症医学科收治的78例脓毒症患者。观察患者1周内是否发生AKI;记录患者的一般资料〔性别、年龄、体质量指数(BMI)、主要感染部位、危重症相关评分〕、实验室指标〔平均动脉压(MAP)、中心静脉压(CVP)、降钙素原(PCT)、血乳酸(Lac)等〕、机械通气时间及重症监护病房(ICU)住院时间;待患者血流动力学稳定后进行肾脏超声检查,测定入ICU 24 h内RRI;于确诊即刻取尿液样本,采用酶联免疫吸附试验(ELISA)检测UAGT水平。比较发生与未发生AKI两组患者上述指标的差异;采用多因素Logistic回归法分析脓毒症患者发生AKI的危险因素;绘制受试者工作特征曲线(ROC曲线),分析相关指标对脓毒症AKI的预测价值。结果最终共78例患者纳入分析,其中45例发生AKI,33例未发生AKI。与非AKI组比较,AKI组患者血管活性药物使用率、28 d病死率、序贯器官衰竭评分(SOFA)、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、PCT、Lac、RRI及UAGT均显著升高〔血管活性药物使用率:68.9%比39.4%,28 d病死率:48.9%比24.2%,SOFA评分(分):12.0(10.5,14.0)比8.0(7.0,10.0),APACHEⅡ评分(分):22.0(18.0,27.5)比16.0(15.0,18.5),PCT(μg/L):12.5±2.6比10.9±2.8,Lac(mmol/L):2.6(1.9,3.4)比1.9(1.3,2.6),RRI:0.74±0.03比0.72±0.02,UAGT(μg/L):75.16±19.99比46.28±20.75,均P<0.05〕,机械通气时间和ICU住院时间明显延长〔机械通气时间(d):8.0(7.0,12.0)比5.0(4.0,6.0),ICU住院时间(d):14.0(10.0,16.0)比9.0(8.0,11.5),均P<0.01〕,MAP则明显降低〔mmHg(1 mmHg≈0.133 kPa):68.5±11.2比74.2±12.8,P<0.05〕;两组其他指标比较差异均无统计学意义。多因素Logistic回归分析显示,SOFA评分〔优势比(OR)=2.088,95%可信区间(95%CI)为1.322~3.299〕、APACHEⅡ评分(OR=1.447,95%CI为1.134~1.845)、RRI(OR=1.432,95%CI为1.103~1.859)及UAGT(OR=1.077,95%CI为1.035~1.121)均是脓毒症患者发生AKI的独立危险因素(均P<0.01);ROC曲线分析显示,SOFA评分、APACHEⅡ评分、RRI、UAGT对脓毒症AKI均有一定预测价值,ROC曲线下面积(AUC)分别为0.814(95%CI为0.716~0.912)、0.804(95%CI为0.708~0.901)、0.789(95%CI为0.690~0.888)、0.840(95%CI为0.747~0.934),且RRI联合UAGT的AUC为0.912(95%CI为0.849~0.974),优于上述任何单一指标的AUC(均P<0.05)。结论RRI联合UAGT对脓毒症AKI具有较高的早期预测价值。

Objective To investigate the value of renal artery resistance index(RRI)and urinary angiotensinogen(UAGT)in the early diagnosis of acute kidney injury(AKI)in patients with sepsis.Methods A prospective study was conducted.Seventy-eight patients with sepsis admitted to the department of critical care medicine of General Hospital of Ningxia Medical University from January to September 2021 were enrolled.Patients were observed for the development of AKI within 1 week.General data[gender,age,body mass index(BMI),major infection sites and critical illness related scores],laboratory indicators[mean arterial pressure(MAP),central venous pressure(CVP),procalcitonin(PCT),arterial blood lactic acid(Lac),etc.],duration of mechanical ventilation and length of intensive care unit(ICU)stay were recorded.After hemodynamic stabilization of the patients,renal ultrasound was performed to measure the RRI within 24 hours after ICU admission.Urine samples were taken immediately after diagnosis,and the level of UAGT was detected by enzyme-linked immunosorbent assay(ELISA).The above parameters were compared between the two groups.Multivariate Logistic regression was used to analyze the risk factors of AKI in patients with sepsis.Receiver operator characteristic curve(ROC curve)was drawn to analyze the predictive value of related indicators for AKI in sepsis.Results A total of 78 patients were finally enrolled,of which 45 developed AKI and 33 did not.Compared with the non-AKI group,the rates of vasoactive drugs use,28-day mortality,sequential organ failure assessment(SOFA)score,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,PCT,Lac,RRI and UAGT were significantly higher in the AKI group[rates of vasoactive drugs use:68.9%vs.39.4%,28-day mortality:48.9%vs.24.2%,SOFA score:12.0(10.5,14.0)vs.8.0(7.0,10.0),APACHEⅡscore:22.0(18.0,27.5)vs.16.0(15.0,18.5),PCT(μg/L):12.5±2.6 vs.10.9±2.8,Lac(mmol/L):2.6(1.9,3.4)vs.1.9(1.3,2.6),RRI:0.74±0.03 vs.0.72±0.02,UAGT(μg/L):75.16±19.99 vs.46.28±20.75,all P<0.05],the duration of mechanical ventilation and the length of ICU stay were significantly prolonged[duration of mechanical ventilation(days):8.0(7.0,12.0)vs.5.0(4.0,6.0),length of ICU stay(days):14.0(10.0,16.0)vs.9.0(8.0,11.5),both P<0.01],and MAP was significantly lowered[mmHg(1 mmHg≈0.133 kPa):68.5±11.2 vs.74.2±12.8,P<0.05].There was no significant difference in other parameters between the two groups.Multivariate Logistic regression analysis showed that SOFA score[odds ratio(OR)=2.088,95%confidence interval(95%CI)was 1.322-3.299],APACHEⅡscore(OR=1.447,95%CI was 1.134-1.845),RRI(OR=1.432,95%CI was 1.103-1.859),and UAGT(OR=1.077,95%CI was 1.035-1.121)were independent risk factors for sepsis complicated with AKI(all P<0.01).ROC curve analysis showed that SOFA score,APACHEⅡscore,RRI and UAGT had certain predictive value for AKI in septic patients,the area under the ROC curve(AUC)were 0.814(95%CI was 0.716-0.912),0.804(95%CI was 0.708-0.901),0.789(95%CI was 0.690-0.888),and 0.840(95%CI was 0.747-0.934),respectively,and the AUC of RRI combined with UAGT was 0.912(95%CI was 0.849-0.974),which was better than the above single index(all P<0.05).Conclusion RRI combined with UAGT has a high early predictive value for septic AKI.