胱抑素C对根治性肾切除术后急性肾损伤的早期诊断价值和手术预后的预测价值

The value of cystatin C in early diagnosis of acute kidney injury and predicting prognosis after radical nephrectomy

目的探讨胱抑素C(Cys-C)对根治性肾切除术后急性肾损伤(AKI)的早期诊断价值,以及基于Cys-C的估算肾小球滤过率(eGFRcys-c)对手术预后的预测价值。方法回顾性分析2019年1月至2020年12月118例于苏州大学附属第三医院行单侧根治性肾切除术患者的临床资料。根据AKI诊断标准将患者分为2组,急性肾损伤(AKI)组75例,非急性肾损伤(no-AKI)组43例。AKI组男49例,女26例;年龄(62.7±10.7)岁。no-AKI组男21例,女22例;年龄(62.3±12.8)岁。AKI组术前尿素氮(4.9±1.3)mmol/L,肌酐(75.7±14.5)μmol/L,Cys-C(0.85±0.22)mg/L,eGFR_(cr)(76.3±11.2)ml/(min·1.73m^(2)),eCFR_(cys-c)(101.4±17.4)ml/min·1.73m^(2));no-AKI组术前尿素氮(4.9±1.5)mmol/L,肌酐(74.5±13.1)μmol/L,Cys-C(0.81±0.29)mg/L,eGFR_(cr)(78.6±12.5)ml/(min·1.73m^(2))eGFR_(cys-c)(99.3±18.8)ml/(min·1.73m^(2)),两组比较差异均无统计学意义(P>0.05)。采用受试者工作特征(ROC)曲线分析术后48h的尿素氮、肌酐、Cys-C,eGFRcr和eGFRcys-c对AKI的诊断价值,分析发生AKI的危险因素。以eGFR_(Cys-c)<eGFRcr的70%,即eGFRcys-c/eGFRcr≤0.7定义为收缩孔综合征(SPS),比较两组SPS确诊情况和术后6个月肌酐的差异。结果术后48h,AKI组肌酐(115.2±22.1)μmol/L,Cys-C(1.8±0.27)mg/L,eGFRcr(51.6±9.6)ml/(min·1.73m^(2)),eGFR_(Cys-C)(43.4±8.5)ml/(min·1.73m^(2));no-AKI组肌酐(92.7±13.3)μmol/L,Cys-C(1.3±0.23)mg/L,eGFRc.(62.2±11.3)ml/(min·1.73m^(2)),eGFR_(Cys-c)(61.5±9.5)ml/(min·1.73m^(2)),两组比较差异均有统计学意义(P<0.01)。ROC曲线显示,肌酐、Cys-C、eGFRcr和eCFRcys-c的曲线下面积分别为0.809.0.889、0.761、0.925对AKI均有诊断价值(P<0.01);eGFRcys-c诊断AKI的敏感性为93.3%,特异性为74.4%,曲线下面积最大。二元logistic回归分析结果显示,肌酐(0R=10.851,95%CI 2.322~50.688,P=0.004)、Cys-C(OR=10.016,95%CI 2.306~43.362,P=0.001)、eGFRcr(OR=17.923,95%CI 3.216~53.172,P=0.001)和eGFRcy-c(OR=19.817,95%CI=3.367~55.263,P=0.001)均是发生AKI的独立危险因素。eGFR_(Cys-C)、肌酐、Cys-C、eGFR_(Cr)的预测准确率分别为91.6%、85.7%、90.2%、88.5%。AKI组和no-AKI组确诊SPS例数分别为15例和2例,差异有统计学意义(Kappa值5.22,P=0.02)。术后6个月,确诊SPS者肌酐(103.8±23.4)μmol/L,未确诊SPS者肌酐(86.8±27.2)μmol/L,差异有统计学意义((P<0.01)。结论基于Cys-C计算的eGFR_(Cys-C)诊断AKI的敏感性高,具有早期诊断价值。基于eGFR_(Cys-C)确诊的SPS患者术后6个月肌酐更高。

Objective To investigate the value of cystatin C(Cys-C)in the early diagnosis of acute kidney injury(AKI)after radical nephrectomy and the predictive value for the prognosis of Cys-C based estimated glomerular filtration rate(eGFR_(cys-c))after surgery.Methods The clinical data of 118 patients who underwent unilateral radical nephrectomy in our hospital from January 2019 to December 2020 were retrospectively analyzed.According to the diagnostic criteria of AKI,they were divided into AKI group of 75 cases and no-AKI group of 43 cases.AKI group was(62.7±10.7)years old,with 49 males and 26 females.The no-AKI group was(62.3±12.8)years old,with 21 males and 22 females.The urea nitrogen was(4.9±1.3)mmol/L,creatinine(75.7±14.5)μmol/L,Cys-C(0.85±0.22)mg/L,eGFRcr(76.3±11.2)ml/(min·1.73m^(2)),and eGFR_(_(cys-c))(101.4±17.4)ml/(min·1.73m^(2))in AKI group before operation.In no-AKI group,preoperative urea nitrogen was(4.9±1.5)mmol/L,creatinine(74.5±13.1)μmol/L,Cys-C(0.81±0.29)mg/L,eGFRcr(78.6±12.5)ml/(min·1.73m^(2)),and eCFR_(cys-c)(99.3±18.8)ml/(min·1.73m^(2)),and there were no significant diferences in the values of urea nitrogen,creatinine,Cys-C and eGFR between the two groups before surgery(P>0.05).ROC curve was used to analyze the diagnostic value of urea nitrogen,creatinine,Cys-C,eGFR calculated based on creatinine and Cys-C at 48h after surgery,and binary Logistic regression was used to analyze the risk factors for AKI.The creatinine status of patients diagnosed with SPS was evaluated 6 months after surgery,based on the definition of Cys-C based eGFR being less than 70%of creatinine-based eGFR(SPS=eGFR_(cys-c)/eGFRc,≤0.7).Results In AKI group,creatinine was(115.2±22.1)μumol/L,Cys-C(1.8±0.27)mg/L,eGFRcr(51.6±9.6)ml/(min-1.73m^(2)),and eGFR_(cys-c)(43.4±8.5)ml/(min·1.73m^(2))48 h after operation.The creatinine was(92.7±13.3)μmol/L,Cys-C(1.3±0.23)mg/L,eCFRcr(62.2±11.3)ml/(min:1.73m^(2)),and eGFR_(cys-c)(61.5±9.5)ml/(min·1.73m^(2))in no-AKI group,and difference were statistically significant between the two groups(P<0.01).ROC curve was used to analyze the diagnosis of AKI.Creatinine,Cys-C,eGFRcr and eGFRcy-c were all of diagnostic value for AKI(all P<0.01),and AUC(Area under curve)were 0.809,0.889,0.761 and 0.925 respectively.The sensitivity,specificity and area under the curve of eGFRcy-c were 93.3%,74.4%and 92.5%respectively.Binary Logistic regression analysis showed that creatinine(0R=10.851,95%CI 2.322-50.688,P=0.004),Cys-C(OR=10.016,95%CI 2.306-43.362,P=0.001),eGFRcr(0R=17.923,95%CI 3.216-53.172,P=0.001)and eGFRcy-c(OR=19.817,95%CI 3.367-55.263,P=0.001)were all independent risk factors for AKI.The predictive accuracy of eCFRcy-c,creatinine,Cys-C,eGFRer were 91.6%,85.7%,90.2%,88.5%,respectively.There were 15 cases were confirmed SPS in the AKI group,and only 2 cases were confirmed SPS in the no-AKI group,indicating patients in the AKI group developed more SPS than those in the no-AKI group,with statistically significant difference(Kappa value was 5.22,P=0.02).The 6-month follow-up showed that the creatinine of confirmed SPS was(103.8±23.4)μmol/L and the creatinine of unconfirmed SPS was(86.8±27.2)μmol/L,with statistiellysignificant diference(P<0.01).Conclusions eGFRey.c calculated based on Cys-C has high sensitivity in diagnosing AKI and has early diagnostic value.Patients diagnosed with SPS based on eGFR_(cys-c)had higher creatinine 6 months after surgery.