摘要目的 比较肾动脉阻力指数(RRI)、能量多普勒超声(PDU)评分及血清胱抑素C(Cys C)对重症医学科(ICU)急性心力衰竭(心衰)和脓毒症患者发生急性肾损伤(AKI)的预测价值.方法 采用前瞻性观察性研究方法,将2018年1月1日至12月31日入住沧州市中心医院急诊ICU的急性心衰和脓毒症患者作为研究对象.记录患者一般资料;于入ICU 6 h内测定血清Cys C水平,并计算RRI、PDU评分;入ICU 5 d用改善全球肾脏病预后组织(KDIGO)标准评估肾功能.将入ICU 5 d内进展为AKI 2期或3期的患者纳入AKI 2～3期组,未发生AKI或发生AKI 1期的患者纳入AKI 0～1期组;在所有患者、心衰患者、脓毒症患者中比较不同AKI分期两组间各指标的差异;采用多因素二元Logistic回归分析发生AKI的独立危险因素;并绘制受试者工作特征曲线(ROC),分析Cys C、RRI、PDU评分、RRI+PDU对患者发生AKI 2～3期的预测价值.结果 共纳入37例心衰患者(无AKI 11例,AKI 1期10例,AKI 2期3例,AKI 3期13例)和26例脓毒症患者(无AKI 8例,AKI 1期2例,AKI 2期7例,AKI 3期9例).在所有患者或心衰患者中,与AKI 0～1期组比较,AKI 2～3期组急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、连续性肾脏替代治疗(CRRT)比例、28 d病死率、血肌酐(SCr)、Cys C、RRI较高,而尿量、PDU评分较低;在脓毒症患者中,与AKI 0～1期组比较,AKI 2～3期组CRRT比例、SCr、Cys C较高,而尿量较少.Logistic回归分析显示, Cys C和PDU评分是所有患者发生AKI 2～3期的独立危险因素〔Cys C :优势比(OR)＝11.294,95%CI可信区间(95%CI)为2.801～45.541,P＝0.001 ;PDU评分:OR＝0.187,95%CI为0.056～0.627,P＝0.007〕;RRI和PDU评分是心衰患者发生AKI 2～3期的独立危险因素〔RRI(×10):OR＝6.172,95%CI为0.883～43.153, P＝0.067 ;PDU评分:OR＝0.063,95%CI为0.007～0.584,P＝0.015〕;Cys C是脓毒症患者发生AKI 2～3期的独立危险因素(OR＝22.830,95%CI为1.345～387.623,P＝0.030).ROC曲线分析显示,在心衰患者中,RRI、PDU评分、Cys C对AKI 2～3期的预测价值较好〔ROC曲线下面积(AUC,95%CI)分别为0.839(0.673～0.942)、0.894(0.749～0.971)、0.777(0.610～0.897),均P＜0.01〕;其中RRI+PDU的预测价值最高(AUC＝0.956,95%CI为0.825～0.997,P＜0.01),且高于单用Cys C的预测价值 〔AUC(95%CI): 0.956(0.825～0.997)比0.777(0.610～0.897),P＝0.034〕.在脓毒症患者中,血清Cys C水平对AKI 2～3期的预测价值较好(AUC＝0.913,95%CI为0.735～0.987,P＜0.01),而RRI、PDU及RRI+PDU对AKI 2～3期无预测价值.结论 RRI和PDU评分对急性心衰患者AKI的预测价值良好,而对脓毒症患者AKI无预测价值;血清Cys C对心衰和脓毒症患者AKI的预测价值相似.

abstractsObjective To explore the predicting performance of renal resistive index (RRI), semi quantitative power Doppler ultrasound (PDU) score and serum cystatin C (Cys C) for acute kidney injury (AKI) in patients with cardiac failure or sepsis. Methods A prospective, observational study was conducted. Critically ill patients with acute cardiac failure or sepsis admitted to the emergency intensive care unit (ICU) of Cangzhou Central Hospital from January 1st to December 31st in 2018 were enrolled. In addition to the demographic data, serum Cys C, RRI, and PDU score were measured within 6 hours after admission to ICU. Renal function was assessed on day 5 according to Kidney Disease:Improving Global Outcomes (KDIGO) criteria. Patients who proceeded to AKI stage 2 or 3 within 5 days from admission were defined as the AKI 2-3 group; other patients were classified into the AKI 0-1 group. The differences of each index were compared in all patients, cardiac failure patients and sepsis patients between the two groups. Multivariate binary Logistic regression was carried out to identify the independent risk predictors of AKI 2-3. Receiver operator characteristic (ROC) curves were plotted to examine the values of Cys C, RRI, PDU score, and RRI+PDU in predicting AKI 2-3. Results Thirty-seven patients with cardiac failure (11 with no AKI, 10 with AKI stage 1, 3 with AKI stage 2, and 13 with AKI stage 3) and 26 patients with sepsis (8 with no AKI, 2 with AKI stage 1, 7 with AKI stage 2, and 9 with AKI stage 3) were recruited. In all patients as well as the subgroup of cardiac failure, compared with the AKI 0-1 group, acute physiology and chronic health evaluationⅡ(APACHEⅡ) score, sequential organ failure assessment (SOFA) score, rate of continuous renal replacement therapy (CRRT), 28-day mortality, serum creatinine (SCr), Cys C and RRI were higher in AKI 2-3 group, and urine output, PDU score were lower; in the subgroup of sepsis, rate of CRRT, SCr, and Cys C were higher in AKI 2-3 group, and urine output was lower. Multivariate Logistic regression analysis found that Cys C and PDU score were independent risk factors for AKI 2-3 in all patients [Cys C: odds ratio (OR) = 11.294, 95% confidence interval (95%CI) was 2.801-45.541, P = 0.001; PDU score: OR = 0.187, 95%CI was 0.056-0.627, P = 0.007]; RRI and PDU score were independent risk factors for AKI 2-3 in patients with cardiac failure [RRI (×10): OR = 6.172, 95%CI was 0.883-43.153, P = 0.067; PDU score: OR = 0.063, 95%CI was 0.007-0.584, P = 0.015]; Cys C was the independent risk factor for AKI 2-3 in patients with sepsis (OR = 22.830, 95%CI was 1.345-387.623, P = 0.030). It was shown by ROC curve analysis that: in the subgroup of cardiac failure, the predictive values of RRI, PDU score and Cys C were well [area under the curve (AUC) and 95%CI was 0.839 (0.673-0.942), 0.894 (0.749-0.971), 0.777 (0.610-0.897), all P < 0.01]. RRI+PDU performed best in predicting AKI (AUC = 0.956, 95%CI was 0.825-0.997, P < 0.01), and the predictive value was higher than Cys C [AUC (95%CI): 0.956 (0.825-0.997) vs. 0.777 (0.610-0.897), P = 0.034]. In the subgroup of sepsis, the predictive value of Cys C was well (AUC = 0.913, 95%CI was 0.735-0.987, P < 0.01), however, the predictive value of RRI, PDU, RRI+PDU were poor. Conclusions RRI and PDU score effectively predict AKI stage 2 or 3 in cardiac failure patients, but not in patients with sepsis. The predictive values of Cys C for AKI are similar in patients with cardiac failure or sepsis.