摘要目的 探讨血清细胞黏附分子对重症脓毒症患者急性肾损伤(AKI)的预测价值.方法 回顾性分析2015年7月至2017年7月湖北省十堰市国药东风总医院收治的72例重症脓毒症患者的临床资料.其中,发生AKI 45例(AKI组),未发生AKI 27例(非AKI组).记录两组患者一般资料,入院时评估急性生理学和慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官功能衰竭评分(SOFA),检测血常规、血清肌酐、C反应蛋白、降钙素原(PCT)、乳酸、细胞间黏附分子-1 (ICAM-1)、E-选择素、P-选择素和血管细胞黏附分子-1(VCAM-1).结果 AKI组感染性休克和呼吸衰竭发生率、APACHEⅡ、SOFA、肌酐、乳酸、ICAM-1、E-选择素、VCAM-1明显高于非AKI组[84.4%(38/45)比51.9%(14/27)、51.1%(23/45)比22.2%(6/27)、(20.6 ± 2.8)分比(15.9 ± 3.2)分、(7.4 ± 1.5)分比(4.5 ± 0.7)分、(131.9 ± 48.7)μmol/L比(76.8 ± 10.3)μmol/L、(3.28 ± 0.78)mmol/L比(2.64 ± 0.37) mmol/L、(0.93 ± 0.12) mg/L 比(0.59 ± 0.07) mg/L、(2.25 ± 0.20) mg/L 比(1.13 ± 0.17)mg/L和(2.65 ± 0.31)mg/L比(1.86 ± 0.16)mg/L],差异有统计学意义(P<0.01或＜0.05);两组性别构成、年龄、基础疾病、血压、心率、呼吸频率、感染部位、白细胞、淋巴细胞比例、血小板、血糖、C反应蛋白、降钙素原和P-选择素比较差异无统计学意义(P>0.05).Pearson相关性分析结果显示,血清ICAM-1、E-选择素、VCAM-1与血清肌酐呈正相关(r=0.625、0.358、0.441,P<0.05),血清乳酸与血清肌酐无相关性(r=0.146,P>0.05).逐步Logistic回归分析结果显示,肌酐、乳酸、ICAM-1、E-选择素和VCAM-1是重症脓毒症患者发生AKI的独立危险因素(OR=2.758、1.710、2.955、1.801 和 2.218,95% CI 1.845～4.371、1.335～2.314、1.674～4.163、1.572～3.235 和1.339～3.752,P<0.01或＜0.05).血清ICAM-1、E-选择素、VCAM-1联合检测预测重症脓毒症患者发生AKI的曲线下面积为0.876(95% CI 0.777～0.942),特异度为80.0%,敏感度为85.2%.结论 血清ICAM-1、E-选择素、VCAM-1联合检测可以作为重症脓毒症发生AKI的预测指标.

abstractsObjective To assess the clinical value of serum cell adhesion molecules in predicting of acute kidney injury (AKI) in patients with severe sepsis. Methods The clinical data of 72 patients with severe sepsis from July 2015 to July 2017 in Sinopharm Dongfeng General Hospital were retrospectively analyzed. Among them, AKI occurred in 45 cases (AKI group), and AKI did not occur in 27 cases (non-AKI group). The clinical data of 2 groups were recorded; the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and sequential organ failure assessment (SOFA) on admission were evaluated; the blood routine, serum creatinine, C reactive protein, procalcitonin, lactic acid, intercellular adhesion molecular-1 (ICAM-1), E-selectin, P-selectin and vascular cell adhesion molecule-1 (VCAM-1) were detected. Results The incidences of infectious shock and respiratory failure, APACHEⅡ, SOFA, creatinine, lactic acid, ICAM-1, E-selectin, VCAM-1 in AKI group were significantly higher than those in non-AKI group: 84.4% (38/45) vs. 51.9% (14/27), 51.1% (23/45) vs. 22.2% (6/27), (20.6 ± 2.8) scores vs. (15.9 ± 3.2) scores, (7.4 ± 1.5) scores vs. (4.5 ± 0.7) scores, (131.9 ± 48.7) μmol/L vs. (76.8 ± 10.3) μmol/L, (3.28 ± 0.78) mmol/L vs. (2.64 ± 0.37) mmol/L, (0.93 ± 0.12) mg/L vs. (0.59 ± 0.07) mg/L, (2.25 ± 0.20) mg/L vs. (1.13 ± 0.17) mg/L and (2.65 ± 0.31) mg/L vs. (1.86 ± 0.16) mg/L, and there were statistical differences (P < 0.01 or ＜0.05); there were no statistical differences in gender, age, basic disease, blood pressure, heart rate, respiratory frequency, infection site, white blood cell, lymphocyte ratio, platelet, blood glucose, C reactive protein, procalcitonin and P-selectin between 2 groups (P＞0.05). Pearson correlation analysis result showed that serum ICAM-1, E-selectin, VCAM-1 were positively correlated with serum creatinine (r = 0.625, 0.358 and 0.441; P < 0.05); but there was no correlation between serum lactic acid and serum creatinine (r = 0.146, P > 0.05). Stepwise Logistic regression analysis result showed that creatinine, lactic acid, ICAM-1, E-selectin and VCAM-1 were independent risk factors of AKI in patients with severe sepsis ( OR = 2.758, 1.710, 2.955, 1.801 and 2.218; 95% CI 1.845 to 4.371, 1.335 to 2.314, 1.674 to 4.163, 1.572 to 3.235 and 1.339 to 3.752; P<0.01 or＜0.05). The area under curve of serum ICAM-1, E-selectin, VCAM-1 combined detection for predicting of AKI in patients with severe sepsis was 0.876 (95% CI 0.777 to 0.942), with a specificity of 80.0% and a sensitivity of 85.2% . Conclusions serum ICAM-1, E-selectin, VCAM-1 combined detection can be used as predictor of AKI in patients with severe sepsis.