目的:探讨肾动脉阻力指数(RRI)和尿血管紧张素原(UAGT)在脓毒症患者急性肾损伤(AKI)早期诊断中的价值。
方法:进行前瞻性研究。选择2021年1-9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。观察患者在1周内发生AKI。一般数据[性别,年龄,体重指数(BMI),主要感染部位和危重疾病相关评分],实验室指标[平均动脉压(MAP),中心静脉压(CVP),降钙素原(PCT),动脉血乳酸(Lac),等。],记录机械通气时间和重症监护病房(ICU)住院时间.患者血流动力学稳定后,在入住ICU后24小时内进行肾脏超声检查以测量RRI.诊断后立即采集尿样,酶联免疫吸附试验(ELISA)检测UAGT水平。比较两组的上述参数。采用多因素Logistic回归分析脓毒症患者发生AKI的危险因素。绘制受试者操作特征曲线(ROC曲线),分析相关指标对脓毒症AKI的预测价值。
结果:最终共纳入78例患者,其中45例发生AKI,33例未发生。与非AKI组相比,血管活性药物的使用率,28天死亡率,序贯器官衰竭评估(SOFA)评分,急性生理学和慢性健康评估II(APACHEII)评分,PCT,Lac,RRI和UAGT在AKI组中显著升高[血管活性药物使用率:68.9%vs.39.4%,28天死亡率:48.9%vs.24.2%,SOFA得分:12.0(10.5,14.0)vs.8.0(7.0,10.0),APACHEII评分:22.0(18.0,27.5)vs.16.0(15.0,18.5),PCT(μg/L):12.5±2.6vs.10.9±2.8,Lac(mmol/L):2.6(1.9,3.4)与1.9(1.3,2.6),RRI:0.74±0.03vs.0.72±0.02,UAGT(μg/L):75.16±19.99vs.46.28±20.75,均P<0.05],机械通气的持续时间和ICU住院时间显着延长[机械通气的持续时间(天):8.0(7.0,12.0)vs.5.0(4.0,6.0),ICU住院时间(天):14.0(10.0,16.0)vs.9.0(8.0,11.5),两者P<0.01],并且MAP显着降低[mmHg(1mmHg≈0.133kPa):68.5±11.2vs.74.2±12.8,P<0.05。其他参数两组间差异无统计学意义。多因素Logistic回归分析显示,SOFA评分[比值比(OR)=2.088,95%置信区间(95CI)为1.322-3.299],APACHEII评分(OR=1.447,95CI为1.134-1.845),RRI(OR=1.432,95CI为1.103-1.859),UAGT(OR=1.077,95CI为1.035~1.121)是脓毒症并发AKI的独立危险因素(均P<0.01)。ROC曲线分析显示,SOFA评分,APACHEII得分,RRI和UAGT对脓毒症患者AKI有一定的预测价值,ROC曲线下面积(AUC)为0.814(95CI为0.716-0.912),0.804(95CI为0.708-0.901),0.789(95CI为0.690-0.888),和0.840(95CI为0.747-0.934),分别,RRI联合UAGT的AUC为0.912(95CI为0.849-0.974),优于上述单项指标(均P<0.05)。
结论:RRI联合UAGT对脓毒症AKI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 evaluation II (APACHE II) 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), APACHE II score: 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], APACHE II score (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, APACHE II score, 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).
CONCLUSIONS: RRI combined with UAGT has a high early predictive value for septic AKI.