膿毒癥性急性腎損傷患者T淋巴細胞內三磷酸腺苷水平變化及其與腎功能轉歸的關系

朱潮涌，李 潔，毛明鋒，黃甘霖，鮑曉紅，金 烈

323000浙江省麗水市中心醫院腎內科

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·論著·

朱潮涌，李 潔，毛明鋒，黃甘霖，鮑曉紅，金 烈

323000浙江省麗水市中心醫院腎內科

【摘要】目的探討T淋巴細胞內三磷酸腺苷T cell-iATP)水平預測膿毒癥并發急性腎損傷(AKI)患者預后的價值。方法前瞻性選擇2013年7月—2014年12月于麗水市中心醫院ICU、感染科及腎內科住院的膿毒癥并發AKI患者69例為研究對象，分別于入組0、48、96 h檢測患者T cell-iATP水平。根據腎功能臨床轉歸情況將患者分為腎功能完全恢復組(18例)、腎功能部分恢復組(38例)、依賴透析組(4例)和死亡組(9例)。結果各組eGFR、功能衰竭臟器數量、AKI分期及0、48 hT cell-iATP水平比較，差異有統計學意義(P<0.05)。多分類Logistic回歸分析結果顯示，相對于預后不良(依賴透析或死亡)，eGFR、功能衰竭臟器數量和48 hT cell-iATP水平為腎功能完全恢復、腎功能部分恢復的影響因素(P<0.05)。ROC曲線分析顯示，48 hT cell-iATP水平預測膿毒癥并發AKI患者預后的ROC曲線下面積為0.926(P<0.01)，取48 hT cell-iATP臨界點為344.2 μg/L時，靈敏度為92.3%，特異度為87.5%。結論T cell-iATP水平低的膿毒癥患者腎功能恢復良好，膿毒癥患者早期T cell-iATP水平是腎功能轉歸的預測指標。

【關鍵詞】膿毒癥；急性腎損傷；T 淋巴細胞； 臨床轉歸

1對象與方法

1.1研究對象前瞻性選擇2013年7月—2014年12月于麗水市中心醫院ICU、感染科及腎內科住院的膿毒癥并發AKI患者69例為研究對象，均符合2001年美國胸科醫師學會(ACCP)和重癥醫學會(SCCM)膿毒癥的診斷標準[4]；根據急性腎損傷網絡(AKIN)工作小組標準[5]，1期25例，2期20例，3期24例。排除標準：(1)年齡<18歲；(2)有慢性腎臟病史；(3)合并免疫缺陷性疾病、惡性腫瘤。

1.2方法

1.2.1臨床資料測量患者身高、體質量，計算體質指數(BMI)。檢測血清肌酐(Scr)水平，根據腎臟病飲食修正公式(MDRD)估算腎小球濾過率(eGFR)，eGFR=186-1.154×Scr×年齡-0.203(女性則×0.742)，記錄高血壓史、糖尿病史、細菌培養、功能衰竭臟器數及腎功能轉歸等臨床資料。

1.2.3治療患者在治療原發病基礎上予抗感染、液體復蘇、控制血糖、營養支持等綜合對癥治療，出現呼吸衰竭者予機械通氣治療，出現難治性高血鉀癥、Scr>3 mg/dl和/或尿素氮>100 mg/dl、尿量減少導致的液體超負荷中的1項及以上者予血液凈化治療。

1.2.4腎功能臨床轉歸的判定患者入組后28 d進行腎功能轉歸的判斷，eGFR正常判定為腎功能完全恢復，eGFR持久下降但不需腎臟替代治療判定為腎功能部分恢復，eGFR持久下降且需長期腎臟替代治療判定為需依賴透析。根據腎功能臨床轉歸情況將患者分為腎功能完全恢復組(18例)、腎功能部分恢復組(38例)、依賴透析組(4例)和死亡組(9例)。

2結果

表2膿毒癥并發AKI患者預后影響因素的多分類Logistic回歸分析

Table2MultivariableLogisticregressionanalysisoffactorsinfluencingtheprognosisofSIAKIpatients

注：選擇預后不良(依賴透析或死亡)作為參照

3討論

作者貢獻：朱潮涌進行課題設計與實施、資料收集整理、撰寫論文、成文并對文章負責；李潔、毛明鋒、黃甘霖、鮑曉紅進行課題實施、評估、資料收集；金烈進行質量控制及審校。

本文無利益沖突。

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(本文編輯：吳立波)

ZHUChao-yong，LIJie，MAOMing-feng，etal.

DepartmentofNephrology，LishuiCentralHospital，Lishui323000，China

【Abstract】ObjectiveTo investigate the value ofT cell-iATP level in the prediction of the prognosis of sepsis patients complicated with acute kidney injury (AKI).MethodsFrom July 2013 to December 2014，a total of 69 sepsis inpatients complicated with AKI in the ICU，the Department of Infectious Disease and Nephrology in Lishui Center Hosipital were enrolled in this prospective study.The levels ofT cell-iATP at 0 h，48 h and 96 h after onset of SIAKI were detected.According to the prognosis of acute kidney injury (AKI)，the subjects were divided into four groups:complete renal recovery group(18 cases)，partial renal recovery group(38 cases)，dialysis dependency group(4 cases) and death group (9 cases).ResultsThe four groups were significantly different in estimated glomerular filtation rate(eGFR)，the number of visceral organs with function failure，and numbers of patient in each stage of AKI and the levelsT cell-iATP at 0 and 48 h (P<0.05).Multivariable Logistic regression analysis indicated that eGFR，the number of visceral organ with function failure and the levels ofT cell-iATP(48 h)were influencing factors for the complete recovery and partial recovery of renal function (P<0.05)，compared with unfavorable prognosis (dialysis dependency or death).ROC curve analysis showed that the AUC ofT cell-iATP(48 h) predicting the prognosis of sepsis patients complicated with AKI was 0.926(P<0.01)，with a sensitivity and a specificity as 92.3% and 87.5% respectively at a critical point of 344.2 μg/L forT cell-iATP(48 h) level.ConclusionSepsis patients with lowerT cell-iATP level have better recovery of renal function，andT cell-iATP level of patients with early-stage sepsis may serve as a predictor for the renal function outcome.

【Key words】Sepsis；Acute kidney injury；T lymphocyte；Clinical outcomes

通信作者：金烈，323000浙江省麗水市中心醫院腎內科；E-mail：carrol_506@hotmail.com

【中圖分類號】R 631R 692.5

【文獻標識碼】A

doi：10.3969/j.issn.1007-9572.2016.08.006

(收稿日期：2015-04-22；修回日期：2016-01-12)

·膿毒癥性急性腎損傷專題研究·