超声背向散射积分对慢性肾炎肾功能不全代偿期诊断价值的初步研究
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摘要
研究背景
超声诊断肾脏局限性病变的敏感性和特异性较高，早已应用于诊断肾盂积水、肾囊肿及肾实质性肿瘤等疾病，但对肾实质弥漫性病变，超声诊断的敏感性和特异性均较低。长期以来，经皮肾脏穿刺活检术是诊断慢性肾病的“金标准”，这种方法也被用来监测病变的进展情况。但肾穿刺活检需获取肾脏组织标本、可导致出血且患者感到疼痛不适、费用较高等，作为创伤性手段不能成为一种可重复进行的常规监测方法。因此，寻找一种能评价肾皮质结构改变的无创性检查方法具有重要的意义。
背向散射积分(integrated backscatter，IBS)联机分析，它可以通过分析处理组织散射的射频信号来判断组织的病理状态。背向散射积分受探头频率、深度、增益等因素影响，为了使不同患者间IBS测值具有可比性，需要对肾实质IBS值进行标化。目前一般以肾实质／肾窦IBS％作为肾实质的标化IBS值。肾实质／肾窦IBS％在尿毒症期及
浙江大学硕士学位论文中文摘要
氮质血症期较正常对照组明显升高，但肾功能不全代偿期与正常对照
组之间差异无显著性.正常成人肾实质/肾窦IBs%值随年龄增长而增
加。，因此，以肾实质IBS值与肾窦IBS值之比为肾实质校正IBs值
并非十分理想，更好的校正指标有待探讨。
研究目的
为探讨以脾脏作为肾皮质IBs值新的校正指标，并与肾窦IBs作为
校正指标进行比较，是否前者标化值更为可靠稳定;同时研究超声背
向散射对慢性肾炎肾功能不全代偿期的诊断价值及其相关临床、病理
指标的相关性，以及与正常对照组的差异，探讨超声组织定征一背向
散射积分技术对此类患者早期鉴别诊断的价值.
研究方法
选择经穿刺活检确诊的慢性肾炎肾功能不全患者27例及正常志
愿者47例，分别测定其肾皮质与窦区的IBS值，以二者之比值为肾皮
质校正IBS(肾皮质/肾窦IBs%)值.测定相同深度脾脏的IBS值，
以肾皮质与脾脏IBS之比值为肾皮质新的校正IBS(肾皮质/脾脏IBs
%)值。所有患者的肾活检后病理切片呈于光镜下测量肾小球的大小
(包括肾小囊)，选择经过血管极的肾小球进行测量，共测ts个肾
小球，取其平均值.剔除可供测量的肾小球数小于5个的穿刺标本，
尚余20例用于肾小球直径与肾脏背向散射参数相关性分析.用受试者
工作特性曲线(rece iver operator eharacteristie curve，ROC)来
浙江大学硕士学位论文
中文摘要
确定用于诊断慢性肾炎肾功能代偿期的临界值(cutoff Point)
结果
1.正常人脾脏IBs及肾皮质IBS随年龄增长而增加，肾窦IBs在不同年
龄组间差异无统计学意义.肾皮质/肾窦IBS%随年龄增长而增加，
肾皮质/脾脏IBs%在不同年龄组间差异无统计学意义。正常人脾
脏工Bs与双肾皮质IBS之间存在显著正相关关系.正常人肾皮质/脾
脏IBS%值95%可信限左肾为55.7%一1似.8%，右肾为59.2%-
1 1 2.3%。
2.慢性肾炎组肾皮质/脾脏IBS%较正常对照组高，两者的差异有显
著的统计学意义.根据ROC曲线，以左肾皮质/脾脏IBS%=88.5
%为截止值，预测肾功能不全代偿期的慢性肾炎发生的敏感性为
64%、特异性为70.2%、准确性为69.0%、阳性预测值为55.2%、
阴性预测值为78.6%;以右肾皮质/脾脏IBs%=”.1%为截止值，
预测肾功能不全代偿期的慢性肾炎发生的敏感性为68%、特异性
为80%、准确性为75.7%、阳性预测值为65.4%、阴性预测值为
81.8%。慢性肾炎组肾皮质/肾窦IBs%、肾皮质及肾窦IBS值与正
常对照组相比差异无统计学意义.
3.左肾皮质及左肾皮质/脾脏IBs%与左肾肾小球直径之间均存在正
相关关系.根据多元逐步回归法得出回归方程:左肾肾小球直径
(料m)=126.4+87.8*左肾皮质/脾脏IBS%.左肾皮质/肾窦IBS
%与肾小球直径之间无相关关系。
浙江大学硕士学位论文
中文摘要
结论
1.采用脾脏作为肾皮质IBS的标化值，与以肾窦作为标化值比较，具
有稳定性较好，敏感性较高的优点。该方法是目前无创诊断肾功
能不全代偿期慢性肾炎的最新方法之一。
2.根据多元逐步回归法可得出回归方程:左肾肾小球直径(林m)=
126.4+87.8*左肾皮质/脾脏IBs%.可作为无创性预测肾小球直径
及监测病情进展情况的方法之一。
Background
Ultrasonic imaging of the kidney has proven useful in detecting hydronephrosis, renal cysts, and many solid renal tumors. Although findings such as increased echogenicity, loss of the cortico-medullary junction, and cortical thinning have been reported in diffuse renal disease, ultrasound has proven more useful as a guiding method for percutaneous biopsy than as a tool for direct diagnosis of diffuse renal disease. Percutaneous renal biopsy has long been the main method used for initial diagnosis of diffuse renal disease, this procedure also is frequently used to monitor disease progression. The major disadvantages of renal biopsy are the risk of renal hemorrhage, the small sample of kidney tissue obtained, and the high cost of the procedure. A noninvasive means evaluating structural changes in the renal cortex is, therefore, of great potential value.
On-line analysis of integrated backscatter (IBS) is a new technique of ultrasonic tissue characterization. Transducer frequency, depth and gain are influences on IBS, thus the IBS value should be standardized to make it more comparable. The IBS values of renal parenchyma and sinus were measured, and the ratio was defined as the revised IBS of renal parenchyma. This standardized value has been used in recent years. Renal parenchyma/sinus IBS% among the CRF cases in azotemia stage and in uremia stage were significant different with normal controls, but there is no significance between those of CRF in normal function stage and normal controls.
Renal parenchyma/sinus IBS% in normal persons increases with age. Therefore, renal parenchyma/sinus IBS% is not an ideal standardized value.
Objective
To compare renal cortex/spleen IBS% with Renal cortex/sinus IBS% in normal persons and explore clinical value of integrated backscatter on detecting chronic nephritis with renal failure in compensatory stage.
Methods
Ultrasonic backscatter data were acquired from the kidneys of patients with biopsy-proven chronic nephritis with renal failure in compensatory stage(27 patients plus 47 normal volunteers). The IBS values of spleen, renal cortex and sinus were measured. The renal cortex/sinus IBS% was defined as the revised IBS of renal cortex, and renal cortex/spleen IBS% was defined as a new standardized value of renal cortex. (For 20 native kidney patients in which renal biopsy slides were available, the size of glomeruli in representative sections were counted(the diameters of the glomeruli include Bowman's capsule). This was done by first selecting only those glomeruli that were sectioned centrally by identification of the afferent/efferent arteriole. Only patients having at least 5 centrally sectioned glomeruli were included in the analysis on the relationship between the diameters of the glomeruli and renal cortex/spleen IBS%). Operator characteristic curve(ROC)was used to determine the cutoff point of the renal cortex/spleen IBS% in diagnosing chronic nephritis with renal failure in compensatory stage.
Results
1. The IBS values of renal cortex and spleen , the renal cortex/sinus IBS% in normal persons increase with age. There was no significant difference in the IBS value of renal sinus and the renal cortex/spleen IBS% in different age groups. There was strong positive correlation between the IBS value of spleen and cortex in both kidneys.
2. The renal cortex/spleen IBS% was statistically significantly different between the chronic nephritis group and normal control group in both kidneys. In normal
persons, the 95% confidence interval of the renal cortex/spleen IBS% was 55.7% - 102.8% in the left kidney and 59.2% ~ 112.3% in the right kidney. Using the renal cortex/spleen IBS% in left kidney with 88.5% as the cutoff value, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of diagnostic chronic nephritis was 64%, 70.2%, 69.0%, 55.2, and 78.6%, respectively. Using the renal cortex/spleen IBS% in right kidney with 93.1 % as the cutoff value, the sensitivity, specificity, accuracy, positive p
超声诊断肾脏局限性病变的敏感性和特异性较高，早已应用于诊断肾盂积水、肾囊肿及肾实质性肿瘤等疾病，但对肾实质弥漫性病变，超声诊断的敏感性和特异性均较低。长期以来，经皮肾脏穿刺活检术是诊断慢性肾病的“金标准”，这种方法也被用来监测病变的进展情况。但肾穿刺活检需获取肾脏组织标本、可导致出血且患者感到疼痛不适、费用较高等，作为创伤性手段不能成为一种可重复进行的常规监测方法。因此，寻找一种能评价肾皮质结构改变的无创性检查方法具有重要的意义。
背向散射积分(integrated backscatter，IBS)联机分析，它可以通过分析处理组织散射的射频信号来判断组织的病理状态。背向散射积分受探头频率、深度、增益等因素影响，为了使不同患者间IBS测值具有可比性，需要对肾实质IBS值进行标化。目前一般以肾实质／肾窦IBS％作为肾实质的标化IBS值。肾实质／肾窦IBS％在尿毒症期及
浙江大学硕士学位论文中文摘要
氮质血症期较正常对照组明显升高，但肾功能不全代偿期与正常对照
组之间差异无显著性.正常成人肾实质/肾窦IBs%值随年龄增长而增
加。，因此，以肾实质IBS值与肾窦IBS值之比为肾实质校正IBs值
并非十分理想，更好的校正指标有待探讨。
研究目的
为探讨以脾脏作为肾皮质IBs值新的校正指标，并与肾窦IBs作为
校正指标进行比较，是否前者标化值更为可靠稳定;同时研究超声背
向散射对慢性肾炎肾功能不全代偿期的诊断价值及其相关临床、病理
指标的相关性，以及与正常对照组的差异，探讨超声组织定征一背向
散射积分技术对此类患者早期鉴别诊断的价值.
研究方法
选择经穿刺活检确诊的慢性肾炎肾功能不全患者27例及正常志
愿者47例，分别测定其肾皮质与窦区的IBS值，以二者之比值为肾皮
质校正IBS(肾皮质/肾窦IBs%)值.测定相同深度脾脏的IBS值，
以肾皮质与脾脏IBS之比值为肾皮质新的校正IBS(肾皮质/脾脏IBs
%)值。所有患者的肾活检后病理切片呈于光镜下测量肾小球的大小
(包括肾小囊)，选择经过血管极的肾小球进行测量，共测ts个肾
小球，取其平均值.剔除可供测量的肾小球数小于5个的穿刺标本，
尚余20例用于肾小球直径与肾脏背向散射参数相关性分析.用受试者
工作特性曲线(rece iver operator eharacteristie curve，ROC)来
浙江大学硕士学位论文
中文摘要
确定用于诊断慢性肾炎肾功能代偿期的临界值(cutoff Point)
结果
1.正常人脾脏IBs及肾皮质IBS随年龄增长而增加，肾窦IBs在不同年
龄组间差异无统计学意义.肾皮质/肾窦IBS%随年龄增长而增加，
肾皮质/脾脏IBs%在不同年龄组间差异无统计学意义。正常人脾
脏工Bs与双肾皮质IBS之间存在显著正相关关系.正常人肾皮质/脾
脏IBS%值95%可信限左肾为55.7%一1似.8%，右肾为59.2%-
1 1 2.3%。
2.慢性肾炎组肾皮质/脾脏IBS%较正常对照组高，两者的差异有显
著的统计学意义.根据ROC曲线，以左肾皮质/脾脏IBS%=88.5
%为截止值，预测肾功能不全代偿期的慢性肾炎发生的敏感性为
64%、特异性为70.2%、准确性为69.0%、阳性预测值为55.2%、
阴性预测值为78.6%;以右肾皮质/脾脏IBs%=”.1%为截止值，
预测肾功能不全代偿期的慢性肾炎发生的敏感性为68%、特异性
为80%、准确性为75.7%、阳性预测值为65.4%、阴性预测值为
81.8%。慢性肾炎组肾皮质/肾窦IBs%、肾皮质及肾窦IBS值与正
常对照组相比差异无统计学意义.
3.左肾皮质及左肾皮质/脾脏IBs%与左肾肾小球直径之间均存在正
相关关系.根据多元逐步回归法得出回归方程:左肾肾小球直径
(料m)=126.4+87.8*左肾皮质/脾脏IBS%.左肾皮质/肾窦IBS
%与肾小球直径之间无相关关系。
浙江大学硕士学位论文
中文摘要
结论
1.采用脾脏作为肾皮质IBS的标化值，与以肾窦作为标化值比较，具
有稳定性较好，敏感性较高的优点。该方法是目前无创诊断肾功
能不全代偿期慢性肾炎的最新方法之一。
2.根据多元逐步回归法可得出回归方程:左肾肾小球直径(林m)=
126.4+87.8*左肾皮质/脾脏IBs%.可作为无创性预测肾小球直径
及监测病情进展情况的方法之一。
Background
Ultrasonic imaging of the kidney has proven useful in detecting hydronephrosis, renal cysts, and many solid renal tumors. Although findings such as increased echogenicity, loss of the cortico-medullary junction, and cortical thinning have been reported in diffuse renal disease, ultrasound has proven more useful as a guiding method for percutaneous biopsy than as a tool for direct diagnosis of diffuse renal disease. Percutaneous renal biopsy has long been the main method used for initial diagnosis of diffuse renal disease, this procedure also is frequently used to monitor disease progression. The major disadvantages of renal biopsy are the risk of renal hemorrhage, the small sample of kidney tissue obtained, and the high cost of the procedure. A noninvasive means evaluating structural changes in the renal cortex is, therefore, of great potential value.
On-line analysis of integrated backscatter (IBS) is a new technique of ultrasonic tissue characterization. Transducer frequency, depth and gain are influences on IBS, thus the IBS value should be standardized to make it more comparable. The IBS values of renal parenchyma and sinus were measured, and the ratio was defined as the revised IBS of renal parenchyma. This standardized value has been used in recent years. Renal parenchyma/sinus IBS% among the CRF cases in azotemia stage and in uremia stage were significant different with normal controls, but there is no significance between those of CRF in normal function stage and normal controls.
Renal parenchyma/sinus IBS% in normal persons increases with age. Therefore, renal parenchyma/sinus IBS% is not an ideal standardized value.
Objective
To compare renal cortex/spleen IBS% with Renal cortex/sinus IBS% in normal persons and explore clinical value of integrated backscatter on detecting chronic nephritis with renal failure in compensatory stage.
Methods
Ultrasonic backscatter data were acquired from the kidneys of patients with biopsy-proven chronic nephritis with renal failure in compensatory stage(27 patients plus 47 normal volunteers). The IBS values of spleen, renal cortex and sinus were measured. The renal cortex/sinus IBS% was defined as the revised IBS of renal cortex, and renal cortex/spleen IBS% was defined as a new standardized value of renal cortex. (For 20 native kidney patients in which renal biopsy slides were available, the size of glomeruli in representative sections were counted(the diameters of the glomeruli include Bowman's capsule). This was done by first selecting only those glomeruli that were sectioned centrally by identification of the afferent/efferent arteriole. Only patients having at least 5 centrally sectioned glomeruli were included in the analysis on the relationship between the diameters of the glomeruli and renal cortex/spleen IBS%). Operator characteristic curve(ROC)was used to determine the cutoff point of the renal cortex/spleen IBS% in diagnosing chronic nephritis with renal failure in compensatory stage.
Results
1. The IBS values of renal cortex and spleen , the renal cortex/sinus IBS% in normal persons increase with age. There was no significant difference in the IBS value of renal sinus and the renal cortex/spleen IBS% in different age groups. There was strong positive correlation between the IBS value of spleen and cortex in both kidneys.
2. The renal cortex/spleen IBS% was statistically significantly different between the chronic nephritis group and normal control group in both kidneys. In normal
persons, the 95% confidence interval of the renal cortex/spleen IBS% was 55.7% - 102.8% in the left kidney and 59.2% ~ 112.3% in the right kidney. Using the renal cortex/spleen IBS% in left kidney with 88.5% as the cutoff value, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of diagnostic chronic nephritis was 64%, 70.2%, 69.0%, 55.2, and 78.6%, respectively. Using the renal cortex/spleen IBS% in right kidney with 93.1 % as the cutoff value, the sensitivity, specificity, accuracy, positive p
引文
1. Perez JE, Miller JG, Wickline SA, et al. Quantitative ultrasonic imaging: tissue characterization and instantaneous quantification of cardiac function. Am J Cardiol. 1992, 69(20): 104-111
2. Insana MF, Wood JG, Hall TJ, et al. Identifying acoustic scattering sources in normal renal parenchyma in vivo by varying arterial and urethral pressures. Ultrasound Med Biol. 1992, 18(6-7): 587-599
3．顾再荣，李军，陈宇翔等．背向散射积分超声组织定征在尿毒症检测中的初步应用．中华超声影像学杂志．1998，7(4)：220-222
4．杨锦茹，张秉亨，艾红等．弥漫性肾脏疾病超声背向散射积分与病理对照．西安医科大学学报．2002，23(2)：21 3-214
5．黄晓玲，高云华等．正常成人肾实质超声背向散射积分测定．中国超声医学杂志．2000，16(4)：29 5-297
6. Garra BS, Insana MF, Sesterhenn IA, et al. Quantitative ultrasonic detection of parenchymal structural change in diffuse renal disease. Invest-Radio1. 1994, 29(2): 134-140
7．卢纹岱主编．SPSS10.0 for windows统计分析．第2版．北京：电子工业出版社．2003：153—302
8．陈灏珠．实用内科学．第10版．北京：人民卫生出版社．1997：511—512．
9. Emamian SA, Nielsen NB, Pedersen JF. Intraobserver and interobserver variations in sonographic measurements of kidney size in adult volunteers. Acta Radiol. 1995, 36(4): 399-401
10. Turnbull DH, Wilson SR, Hine AL, et al. Ultrasonic characterization of selected renal tissues. Ultrasound Med Biol. 1989, 15(3): 241-253
11. Nicoll RG, Jackson MW, Knipp BS, et al. Quantitative ultrasonography of the liver in cats during obesity induction and dietary restriction. ResVet Sci. 1998, 64(1): 1-6
12. Zheng FL, Zagzebskiand JA, Lee FT, et al. Ultrasound backscatter and attenuation in human liver with diffuse disease. Ultrasound in Medicine & Biology. 1999, 25(7): 1047-1054
13. Fogo A, Hawkins EP, Berry PL, et al. Glomerular hypertrophy in minimal change disease predicts subsequent progression to focal glomerular sclerosis. Kidney Int. 1990, 38(1): 115-123
14. Reddi AS, Camerini-Davalos RA. Diabetic nephropathy. Arch Intern Med. 1990, 150(1): 31-43.
15. Takahiro Ota, Damian MC, Joseph Kisslo, et al. Influence of ultrasonic machine settings, transducer frequency and placement of region of interest on measurement of integrated backscatter and cyclic variation. Ultrasound in Med & Biol, 1997, 23: 1059-1070.
2. Insana MF, Wood JG, Hall TJ, et al. Identifying acoustic scattering sources in normal renal parenchyma in vivo by varying arterial and urethral pressures. Ultrasound Med Biol. 1992, 18(6-7): 587-599
3．顾再荣，李军，陈宇翔等．背向散射积分超声组织定征在尿毒症检测中的初步应用．中华超声影像学杂志．1998，7(4)：220-222
4．杨锦茹，张秉亨，艾红等．弥漫性肾脏疾病超声背向散射积分与病理对照．西安医科大学学报．2002，23(2)：21 3-214
5．黄晓玲，高云华等．正常成人肾实质超声背向散射积分测定．中国超声医学杂志．2000，16(4)：29 5-297
6. Garra BS, Insana MF, Sesterhenn IA, et al. Quantitative ultrasonic detection of parenchymal structural change in diffuse renal disease. Invest-Radio1. 1994, 29(2): 134-140
7．卢纹岱主编．SPSS10.0 for windows统计分析．第2版．北京：电子工业出版社．2003：153—302
8．陈灏珠．实用内科学．第10版．北京：人民卫生出版社．1997：511—512．
9. Emamian SA, Nielsen NB, Pedersen JF. Intraobserver and interobserver variations in sonographic measurements of kidney size in adult volunteers. Acta Radiol. 1995, 36(4): 399-401
10. Turnbull DH, Wilson SR, Hine AL, et al. Ultrasonic characterization of selected renal tissues. Ultrasound Med Biol. 1989, 15(3): 241-253
11. Nicoll RG, Jackson MW, Knipp BS, et al. Quantitative ultrasonography of the liver in cats during obesity induction and dietary restriction. ResVet Sci. 1998, 64(1): 1-6
12. Zheng FL, Zagzebskiand JA, Lee FT, et al. Ultrasound backscatter and attenuation in human liver with diffuse disease. Ultrasound in Medicine & Biology. 1999, 25(7): 1047-1054
13. Fogo A, Hawkins EP, Berry PL, et al. Glomerular hypertrophy in minimal change disease predicts subsequent progression to focal glomerular sclerosis. Kidney Int. 1990, 38(1): 115-123
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