中性粒细胞明胶酶相关脂质运载蛋白对脓毒症合并急性肾损伤患者连续性肾脏替代治疗的预测价值
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摘要
目的探讨中性粒细胞明胶酶相关脂质运载蛋白(NGAL)对脓毒症合并急性肾损伤(AKI)患者选择连续性肾脏替代治疗(CRRT)的临床预测价值。方法选择2014年1月～2017年12月上海中医药大学附属第七人民医院急诊重症监护室收治的68例脓毒症且并发AKI的患者。确诊后24 h内收集患者血清NGAL (sNGAL)、尿NGAL(uNGAL)标本,采用酶联免疫吸附测定(ELISA)法进行检测;同时检测血清肌酐(Scr)水平,并进行急性生理与慢性健康评价(APACHEⅡ)评分。根据患者是否需CRRT治疗,分为脓毒症CRRT组(32例)及脓毒症非CRRT组(36例),比较两组s NGAL、uNGAL、Scr水平及APACHEⅡ评分。通过绘制ROC曲线,分别评价sNGAL、uNGAL及两者联合在脓毒症合并AKI早期患者进行CRRT治疗的预测价值。结果两组年龄、性别、发病原因及诊断脓毒症合并AKI当天的Scr水平差异均无统计学意义(P> 0.05)。但脓毒症CRRT组的sNGAL、uNGAL以及APACHEⅡ评分高于脓毒症非CRRT组(P <0.05)。ROC曲线分析显示,sNGAL、uNGAL以及APACHEⅡ评分在预测脓毒症合并AKI患者需CRRT治疗的95%可信区间(95%CI)曲线下面积(AUC)分别为0.863、0.899及0.679。sNGAL联合uNGAL预测价值最高,AUC为0.932。结论在脓毒症合并AKI早期,sNGAL及uNGAL均可作为患者是否需要开展CRRT治疗的预测指标,两者联合的预测价值更高。
Objective To explore the clinical predictive value of neutrophil gelatinase-associated lipocalin(NGAL) in selecting continuous renal replacement therapy(CRRT) for septic patients combined with acute kidney injury(AKI).Methods Sixty-eight cases of sepsis patients combined with AKI admitted to Intensive Care Unit of Emergency of the Seventh People′ s Hospital of Shanghai University of Traditional Chinese Medicine from January 2014 to December2017 were selected. Serum NGAL(sNGAL) and urine NGAL(uNGAL) samples were collected within 24 h after diagnosis of AKI, and detected by ehzyme-linked immuno sorbent assay(ELISA) method. Serum creatinine(Scr) level and APACHE Ⅱ score were detected at the same time. According to whether patients needed CRRT treatment, they were divided into sepsis CRRT group(32 cases) and sepsis non CRRT group(36 cases). The differences of sNGAL, uNGAL,Scr and APACHE Ⅱ scores between the two groups were compared. By drawing the ROC curve, the predictive value of sNGAL, uNGAL and their combination in the early stage of sepsis combined with AKI in patients with CRRT was evaluated. Results There were no significant differences in the age, sex, pathogenesis and Scr level between the two groups on the day of sepsis combined with AKI(P > 0.05). However, the scores of sNGAL, uNGAL and APACHE Ⅱ in sepsis CRRT group were higher than those in non CRRT group(P < 0.05). ROC curve analysis showed that sNGAL,uNGAL and APACHE Ⅱ score in predicting sepsis combined with AKI patients needed CRRT treatment(95%CI), the area under the curve(AUC) was 0.863, 0.899 and 0.679, respectively. The prediction value of sNGAL combined with uNGAL was the largest and AUC was 0.932. Conclusion In the early stage of sepsis combined with AKI, sNGAL and uNGAL can be used as predictors of whether patients need CRRT treatment. The predictive value of combination of the two is more valuable.
Objective To explore the clinical predictive value of neutrophil gelatinase-associated lipocalin(NGAL) in selecting continuous renal replacement therapy(CRRT) for septic patients combined with acute kidney injury(AKI).Methods Sixty-eight cases of sepsis patients combined with AKI admitted to Intensive Care Unit of Emergency of the Seventh People′ s Hospital of Shanghai University of Traditional Chinese Medicine from January 2014 to December2017 were selected. Serum NGAL(sNGAL) and urine NGAL(uNGAL) samples were collected within 24 h after diagnosis of AKI, and detected by ehzyme-linked immuno sorbent assay(ELISA) method. Serum creatinine(Scr) level and APACHE Ⅱ score were detected at the same time. According to whether patients needed CRRT treatment, they were divided into sepsis CRRT group(32 cases) and sepsis non CRRT group(36 cases). The differences of sNGAL, uNGAL,Scr and APACHE Ⅱ scores between the two groups were compared. By drawing the ROC curve, the predictive value of sNGAL, uNGAL and their combination in the early stage of sepsis combined with AKI in patients with CRRT was evaluated. Results There were no significant differences in the age, sex, pathogenesis and Scr level between the two groups on the day of sepsis combined with AKI(P > 0.05). However, the scores of sNGAL, uNGAL and APACHE Ⅱ in sepsis CRRT group were higher than those in non CRRT group(P < 0.05). ROC curve analysis showed that sNGAL,uNGAL and APACHE Ⅱ score in predicting sepsis combined with AKI patients needed CRRT treatment(95%CI), the area under the curve(AUC) was 0.863, 0.899 and 0.679, respectively. The prediction value of sNGAL combined with uNGAL was the largest and AUC was 0.932. Conclusion In the early stage of sepsis combined with AKI, sNGAL and uNGAL can be used as predictors of whether patients need CRRT treatment. The predictive value of combination of the two is more valuable.
引文
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[3] Ishag S,Thakar CV. Stratification and Risk Reduction of Perioperative Acute Kidney Injury[J]. Anesthesiol Clin,2016,34(1):89-99.
[4]梅长林,刘森炎.急性肾损伤诊治进展[J].解放军医学杂志,2013,38(5):342-346.
[5] Krawczeski CD,Goldstein SL,Woo JG,et al. Temporal relationship and predictive value of urinary acute kidney injury biomarkers after pediatric cardiopulmonary bypass[J].J Am Coll Cardiol,2011,58(22):2301-2309.
[6] Vanmassenhove J,Glorieux G,Lameire N,et al. Influence of severity of illness on neutrophil gelatinase-associated lipocalin performance as a marker of acute kidney injury:a prospective cohort study of patients with sepsis[J]. BMC Nephrol,2015,16(1):1-10.
[7] Cruz DN,Bagshaw SM,Maisel A,et al. Use of biomarkers to assess prognosis and guide management of patients with acute kidney injury[J]. Contrib Nephrol,2013,182:45-64.
[8]马帅,丁峰.连续性肾脏替代治疗的过去、现在与未来[J].上海医药,2018,39(9):3-11.
[9]黄健平.连续性肾替代治疗在脓毒症相关性急性肾损伤中的应用[J].中国当代医药,2016,23(1):74-76.
[10] Namas RA,Namas R,Lagoa C,et al. Hemoadsorption reprograms inflammation in experimental gram-negative septic peritonitis:insights from in vivo and in silico studies[J]. Mol Med,2012,18(1):1366.
[11]李敏雄,黄永鹏,叶燕红,等.连续性肾脏替代治疗重症感染引起急性肾损伤患者的临床效果[J].中国医药导报,2016,13(34):81-84.
[12] Green JP,Adams J,Panacek EA,et al. The 2012 Surviving Sepsis Campaign:Management of Severe Sepsis and Septic Shock—An Update on the Guidelines for Initial Therapy[J]. Current Emergency&Hospital Medicine Reports,2013,1(3):154-171.
[13] Khwaja A. KDIGO Clinical Practice Guidelines for Acute Kidney Injury[J]. Nephron Clin Pract,2012,120(4):179-184.
[14] Koyner JL,Bennett MR,Worcester EM,et al. Urinary cystatin C as an early biomarker of acute kidney injury following adult cardiothoracic surgery[J]. Kidney Int,2008,74(8):1059-1069.
[15] Hur M,Kim H,Lee S,et al. Diagnostic and prognostic utilities of multimarkers approach using procalcitonin,Btype natriuretic peptide,and neutrophil gelatinase-associated lipocalin in critically ill patients with suspected sepsis[J]. BMC Infect Dis,2014,14(1):1-8.
[16] de Geus HR,Woo JG,Wang Y,et al. Urinary Neutrophil Gelatinase-Associated Lipocalin Measured on Admission to the Intensive Care Unit Accurately Discriminates between Sustained and Transient Acute Kidney Injury in Adult Critically Ill Patients[J]. Nephron Extra,2011,1(1):9-23.
[17] Lee YJ,Hu YY,Lin YS,et al. Urine neutrophil gelatinase-associated lipocalin(NGAL)as a biomarker for acute canine kidney injury[J]. BMC Vet Res,2012,8(1):236-248.
[18] Nickolas TL,Kai SO,Canetta P,et al. Diagnostic and Prognostic Stratification in the Emergency Department Using Urinary Biomarkers of Nephron Damage:A Multicenter Prospective Cohort Study[J]. J Am Coll Cardiol,2012,59(3):246-255.
[19] Nisula S,Yang R,Kaukonen KM,et al. The urine protein NGAL predicts renal replacement therapy,but not acute kidney injury or 90-day mortality in critically ill adult patients[J]. Anesth Analg,2014,119(1):95-102.
[20]徐建国,金献冠,李钰.尿肾损伤分子1和中性粒细胞明胶酶相关脂质运载蛋白对脓毒症合并急性肾损伤患者早期连续性肾脏替代治疗的预测价值[J].中华危重症医学杂志:电子版,2016,9(4):250-255.
[21]胡明磊,金献冠,李钰,等.脓毒症AKI生物学标志物在CRRT中的临床价值[J].医学研究杂志,2017(9):100-103.
[22] de Geus HR,Betjes MG,Bakker J. Neutrophil gelatinaseassociated lipocalin clearance during veno-venous continuous renal replacement therapy in critically ill patients[J]. Intensive Care Med,2010,36(12):2156-2157.
[23] Haase M,Bellomo R,Devarajan P,et al. Accuracy of Neutrophil Gelatinase-Associated Lipocalin(NGAL)in Diagnosis and Prognosis in Acute Kidney Injury:A Systematic Review and Meta-analysis[J]. Am J Kidney Dis,2009,54(6):1012-1024.
[2] M覽rtensson J,Bellomo R. Sepsis-Induced Acute Kidney Injury[J]. Crit Care Clin,2015,31(4):649-660.
[3] Ishag S,Thakar CV. Stratification and Risk Reduction of Perioperative Acute Kidney Injury[J]. Anesthesiol Clin,2016,34(1):89-99.
[4]梅长林,刘森炎.急性肾损伤诊治进展[J].解放军医学杂志,2013,38(5):342-346.
[5] Krawczeski CD,Goldstein SL,Woo JG,et al. Temporal relationship and predictive value of urinary acute kidney injury biomarkers after pediatric cardiopulmonary bypass[J].J Am Coll Cardiol,2011,58(22):2301-2309.
[6] Vanmassenhove J,Glorieux G,Lameire N,et al. Influence of severity of illness on neutrophil gelatinase-associated lipocalin performance as a marker of acute kidney injury:a prospective cohort study of patients with sepsis[J]. BMC Nephrol,2015,16(1):1-10.
[7] Cruz DN,Bagshaw SM,Maisel A,et al. Use of biomarkers to assess prognosis and guide management of patients with acute kidney injury[J]. Contrib Nephrol,2013,182:45-64.
[8]马帅,丁峰.连续性肾脏替代治疗的过去、现在与未来[J].上海医药,2018,39(9):3-11.
[9]黄健平.连续性肾替代治疗在脓毒症相关性急性肾损伤中的应用[J].中国当代医药,2016,23(1):74-76.
[10] Namas RA,Namas R,Lagoa C,et al. Hemoadsorption reprograms inflammation in experimental gram-negative septic peritonitis:insights from in vivo and in silico studies[J]. Mol Med,2012,18(1):1366.
[11]李敏雄,黄永鹏,叶燕红,等.连续性肾脏替代治疗重症感染引起急性肾损伤患者的临床效果[J].中国医药导报,2016,13(34):81-84.
[12] Green JP,Adams J,Panacek EA,et al. The 2012 Surviving Sepsis Campaign:Management of Severe Sepsis and Septic Shock—An Update on the Guidelines for Initial Therapy[J]. Current Emergency&Hospital Medicine Reports,2013,1(3):154-171.
[13] Khwaja A. KDIGO Clinical Practice Guidelines for Acute Kidney Injury[J]. Nephron Clin Pract,2012,120(4):179-184.
[14] Koyner JL,Bennett MR,Worcester EM,et al. Urinary cystatin C as an early biomarker of acute kidney injury following adult cardiothoracic surgery[J]. Kidney Int,2008,74(8):1059-1069.
[15] Hur M,Kim H,Lee S,et al. Diagnostic and prognostic utilities of multimarkers approach using procalcitonin,Btype natriuretic peptide,and neutrophil gelatinase-associated lipocalin in critically ill patients with suspected sepsis[J]. BMC Infect Dis,2014,14(1):1-8.
[16] de Geus HR,Woo JG,Wang Y,et al. Urinary Neutrophil Gelatinase-Associated Lipocalin Measured on Admission to the Intensive Care Unit Accurately Discriminates between Sustained and Transient Acute Kidney Injury in Adult Critically Ill Patients[J]. Nephron Extra,2011,1(1):9-23.
[17] Lee YJ,Hu YY,Lin YS,et al. Urine neutrophil gelatinase-associated lipocalin(NGAL)as a biomarker for acute canine kidney injury[J]. BMC Vet Res,2012,8(1):236-248.
[18] Nickolas TL,Kai SO,Canetta P,et al. Diagnostic and Prognostic Stratification in the Emergency Department Using Urinary Biomarkers of Nephron Damage:A Multicenter Prospective Cohort Study[J]. J Am Coll Cardiol,2012,59(3):246-255.
[19] Nisula S,Yang R,Kaukonen KM,et al. The urine protein NGAL predicts renal replacement therapy,but not acute kidney injury or 90-day mortality in critically ill adult patients[J]. Anesth Analg,2014,119(1):95-102.
[20]徐建国,金献冠,李钰.尿肾损伤分子1和中性粒细胞明胶酶相关脂质运载蛋白对脓毒症合并急性肾损伤患者早期连续性肾脏替代治疗的预测价值[J].中华危重症医学杂志:电子版,2016,9(4):250-255.
[21]胡明磊,金献冠,李钰,等.脓毒症AKI生物学标志物在CRRT中的临床价值[J].医学研究杂志,2017(9):100-103.
[22] de Geus HR,Betjes MG,Bakker J. Neutrophil gelatinaseassociated lipocalin clearance during veno-venous continuous renal replacement therapy in critically ill patients[J]. Intensive Care Med,2010,36(12):2156-2157.
[23] Haase M,Bellomo R,Devarajan P,et al. Accuracy of Neutrophil Gelatinase-Associated Lipocalin(NGAL)in Diagnosis and Prognosis in Acute Kidney Injury:A Systematic Review and Meta-analysis[J]. Am J Kidney Dis,2009,54(6):1012-1024.