彩色多普勒超声对感染性休克患者急性肾损伤的预测价值

doi:10.12114/j.issn.1007-9572.2022.0459

摘要/Abstract

摘要： 背景感染性休克患者存在肾脏血液灌注异常，严重时可诱发急性肾损伤（AKI），严重威胁患者生命安全；彩色多普勒超声（CDU）可用于评估肾脏血流变化，但有关其在感染性休克患者AKI评估中价值的研究较少。目的通过CDU评价感染性休克患者AKI的发生情况及其血流动力学改变。方法选取2019年6月至2021年7月徐州市中心医院收治的105例确诊为感染性休克的患者并纳入感染组，选取同期健康体检者58例并纳入对照组，收集受试者一般资料。采用CDU检查受试者肾脏血流动力学指标〔肾动脉管腔内径（D）、收缩期血流峰值速度（Vs）、舒张末期血流速度（Vd）、阻力指数（RI）、搏动指数（PI）〕，比较感染组与对照组的一般资料及肾脏血流动力学指标。根据感染组患者入院72 h内发生AKI与否将其分为AKI组及非AKI组，比较AKI组与非AKI组肾脏血流动力学指标。应用受试者工作特征（ROC）曲线分析肾脏血流动力学指标对感染性休克患者发生AKI的预测价值。应用单因素分析及多因素Logistic回归分析探讨感染性休克患者发生AKI的影响因素。以AKI由轻到重的程度将患者分为AKIⅠ组、AKIⅡ组、AKIⅢ组，比较AKIⅠ组、AKIⅡ组、AKIⅢ组的肾脏血流动力学指标，采用Spearman秩相关分析探究肾脏血流动力学指标与AKI分期的相关性。结果确诊为感染性休克后，于72 h内发生AKI的患者共39例，其中AKIⅠ组19例、AKIⅡ组15例、AKIⅢ组5例。感染组D、Vs、Vd小于对照组，RI、PI大于对照组（P<0.05）。AKI组D、Vs、Vd小于非AKI组，RI、PI大于非AKI组（P<0.05）。D、Vs、Vd、RI、PI预测感染性休克患者发生AKI的ROC曲线下面积分别为0.782、0.772、0.708、0.842、0.683，最佳截断值分别为4.91 mm、71.19 cm/s、17.19 cm/s、0.71、1.50，灵敏度分别为66.67%、94.87%、58.97%、87.18%、56.41%，特异度分别为80.30%、51.52%、77.27%、66.67%、78.79%。多因素Logistic回归分析结果显示，D≥4.91 mm、Vs≥71.19 cm/s、RI≥0.71为感染性休克患者发生AKI的影响因素（P<0.05）。与AKI Ⅲ期患者比较，AKIⅡ期患者的D更大，RI更小（P<0.05）；与AKI Ⅲ期患者比较，AKIⅠ期患者的D、Vs、Vd更大，RI更小（P<0.05）；与AKI Ⅱ期患者比较，AKIⅠ期患者的Vd更大（P<0.05）。Spearman秩相关分析结果显示，AKI患者D、Vd与AKI分期呈强负相关，Vs与AKI分期呈弱负相关（rs=-0.421，-0.674，-0.358，P<0.05）；RI与AKI分期呈强正相关（rs=0.539，P<0.001）；PI与AKI分期无明显相关性（P>0.05）。结论 CDU可用于检查感染性休克患者的肾脏血流动力学指标。肾脏血流动力学指标与感染性休克患者AKI的发生及严重程度相关，并对感染性休克患者发生AKI具有预测价值。未来或可通过检测肾脏血流动力学指标来对感染性休克患者AKI发生情况进行诊断和评估。

关键词: 休克, 彩色多普勒超声, 感染性休克, 肾脏血流动力学, 急性肾损伤, 诊断, 预测

Abstract:

Background

Septic shock may lead to renal perfusion abnormalities, and even acute kidney injury (AKI) , seriously threatening the life of patients. Color Doppler ultrasound (CDU) can be used as a tool to evaluate changes of renal blood flow. However, there are few studies on its evaluation value for AKI in patients with septic shock.

Objective

To examine the value of CDU in assessing AKI and hemodynamic changes in patients with septic shock.

Methods

Participants were recruited from Xuzhou Central Hospital between June 2019 and July 2021, including 105 patients with septic shock, and 58 physical examinees. The general demographics and renal hemodynamic indices measured by CDU 〔the luminal diameter of renal artery (D) , peak systolic velocity (Vs) , end-diastolic velocity (Vd) , resistance index (RI) , pulsatility index (PI) 〕 were collected and compared with the groups. The renal hemodynamic indices were further compared between septic shock patients with and without AKI within 72 h after admission. The predictive value of renal hemodynamic indices for AKI in septic shock was analyzed by receiver operating characteristic (ROC) curve. The influencing factors of AKI in septic shock were explored by univariate and multivariate Logistic regression analyses. Then associations of the severity of AKI (stage 1, 2, 3 AKI) with renal hemodynamic indices were analyzed by Spearman rank analysis.

Results

Thirty-nine septic shock patients had AKI within 72 h after admission, including 19 cases with stage 1 AKI, 15 with stage 2 AKI, and 5 with stage 3 AKI. Septic shock patients had lower D, Vs and Vd, and higher RI and PI than physical examinees (P<0.05) . Septic shock patients with AKI had lower D, Vs and Vd, and higher RI and PI than those without AKI (P<0.05) . AUC of D in predicting AKI in septic shock was 0.782 with 66.67% sensitivity and 80.30% specificity when 4.91 mm was chosen as the optimal cut-off value, that of Vs was 0.772 with 94.87% sensitivity and 51.52% specificity when 71.19 cm/s was chosen as the optimal cut-off value, that of Vd was 0.708 with 58.97% sensitivity and 77.27% specificity when 17.19 cm/s was chosen as the optimal cut-off value, that of RI was 0.842 with 87.18% sensitivity and 66.67% specificity when 0.71 was chosen as the optimal cut-off value, and that of PI was 0.683 with 56.41% sensitivity and 78.79% specificity when 1.50 was chosen as the optimal cut-off value. Multivariate Logistic regression analysis showed that D≥4.91 mm, Vs≥71.19 cm/s and RI≥0.71 were associated with AKI in septic shock (P<0.05) . Patients with stage 3 AKI had lower D, and higher RI than those with stage 2 AKI (P<0.05) . Patients with stage 3 AKI had lower D, Vs and Vd, and higher RI than those with stage 1 AKI (P<0.05) . Patients with stage 2 AKI had lower Vd than those with stage I AKI (P<0.05) . Spearman rank analysis showed that both the D and Vd were strongly negatively correlated with the severity of AKI, and Vs was weakly negatively correlated with it (r_s=-0.421, -0.674, -0.358, P<0.05) . RI was strongly positively correlated with the severity of AKI (r_s=0.539, P<0.001) . PI was not significantly correlated with the severity of AKI (P>0.05) .

Conclusion

CDU could detect the changes of renal hemodynamics in patients with septic shock. Renal hemodynamic indices are related to the development and severity of AKI, which could be used as diagnostic markers or predictors of AKI in septic shock. So it may be possible to diagnose and predict AKI in septic shock by detecting renal hemodynamic indices.

Key words: Shock, Color Doppler ultrasound, Septic shock, Renal hemodynamics, Acute kidney injury, Evaluation value, Diagnosis, Forecasting

徐维,许继元,李茂琴,等. 彩色多普勒超声对感染性休克患者急性肾损伤的预测价值[J]. 中国全科医学, 2023, 26(09): 1104-1111. DOI: 10.12114/j.issn.1007-9572.2022.0459.
XU Wei,XU Jiyuan,LI Maoqin, et al. Predictive Value of Color Doppler Ultrasound for Acute Kidney Injury in Patients with Septic Shock[J]. Chinese General Practice, 2023, 26(09): 1104-1111. DOI: 10.12114/j.issn.1007-9572.2022.0459.

图/表 10

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组别	例数	性别（男/女）	年龄（±s，岁）	基础疾病〔n（%）〕			吸烟史〔n（%）〕	饮酒史〔n（%）〕	收缩压（±s，mm Hg）	舒张压（±s，mm Hg）	平均动脉压（±s，mm Hg）	APACHEⅡ评分（±s，分）
组别	例数	性别（男/女）	年龄（±s，岁）	糖尿病	高血压	冠心病	吸烟史〔n（%）〕	饮酒史〔n（%）〕	收缩压（±s，mm Hg）	舒张压（±s，mm Hg）	平均动脉压（±s，mm Hg）	APACHEⅡ评分（±s，分）
对照组	58	39 / 19	51.8±6.3	7（12）	11（19）	6（10）	19（32）	16（27）	113±5.73	69±8	86±5	5.34±0.38
感染组	105	72 / 33	52.3±5.1	15（10）	21（20）	9（9）	41（39）	28（27）	109±5.16	59±5	75±5	21.57±5.31
χ²（t）值		0.030	0.704^a	0.157	0.025	0.141	0.635	0.016	4.622^a	10.009^a	12.870^a	23.213^a
P值		0.862	0.482	0.692	0.874	0.708	0.425	0.899	<0.001	<0.001	<0.001	<0.001

组别	例数	性别（男/女）	年龄（±s，岁）	基础疾病〔n（%）〕			吸烟史〔n（%）〕	饮酒史〔n（%）〕	收缩压（±s，mm Hg）	舒张压（±s，mm Hg）	平均动脉压（±s，mm Hg）	APACHEⅡ评分（±s，分）
组别	例数	性别（男/女）	年龄（±s，岁）	糖尿病	高血压	冠心病	吸烟史〔n（%）〕	饮酒史〔n（%）〕	收缩压（±s，mm Hg）	舒张压（±s，mm Hg）	平均动脉压（±s，mm Hg）	APACHEⅡ评分（±s，分）
对照组	58	39 / 19	51.8±6.3	7（12）	11（19）	6（10）	19（32）	16（27）	113±5.73	69±8	86±5	5.34±0.38
感染组	105	72 / 33	52.3±5.1	15（10）	21（20）	9（9）	41（39）	28（27）	109±5.16	59±5	75±5	21.57±5.31
χ²（t）值		0.030	0.704^a	0.157	0.025	0.141	0.635	0.016	4.622^a	10.009^a	12.870^a	23.213^a
P值		0.862	0.482	0.692	0.874	0.708	0.425	0.899	<0.001	<0.001	<0.001	<0.001

组别	例数	D（ mm）	Vs（cm/s）	Vd（cm/s）	RI	PI
对照组	58	5.38±0.12	76.59±8.35	25.64±3.19	0.64±0.05	1.09±0.21
感染组	105	4.92±0.09	70.37±7.12	18.53±3.65	0.71±0.07	1.53±0.23
t值		27.664	5.017	12.438	6.723	12.054
P值		<0.001	<0.001	<0.001	<0.001	<0.001

组别	例数	D（ mm）	Vs（cm/s）	Vd（cm/s）	RI	PI
对照组	58	5.38±0.12	76.59±8.35	25.64±3.19	0.64±0.05	1.09±0.21
感染组	105	4.92±0.09	70.37±7.12	18.53±3.65	0.71±0.07	1.53±0.23
t值		27.664	5.017	12.438	6.723	12.054
P值		<0.001	<0.001	<0.001	<0.001	<0.001

组别	例数	D（mm）	Vs（cm/s）	Vd（cm/s）	RI	PI
AKI组	39	4.89±0.08	66.19±7.24	17.03±2.97	0.74±0.05	1.59±0.20
非AKI组	66	4.94±0.09	72.84±7.09	19.42±3.15	0.69±0.06	1.49±0.16
t值		2.926	4.728	3.926	4.466	2.910
P值		0.004	<0.001	<0.001	<0.001	0.004