诊断学理论与实践 ›› 2023, Vol. 22 ›› Issue (02): 127-133.doi: 10.16150/j.1671-2870.2023.02.004
郝家琪1,2, 王鑫鹭1, 胡晓帆1, 潘晓霞1, 徐静1(), 马骏1()
收稿日期:
2023-02-16
出版日期:
2023-04-25
发布日期:
2023-08-31
通讯作者:
马骏 E-mail: jiangpuma@163.com; 徐静 E-mail:xj11564@rjh.com.cn
基金资助:
HAO Jiaqi1,2, WANG Xinlu1, HU Xiaofan1, PAN Xiaoxia1, XU Jing1(), MA Jun1()
Received:
2023-02-16
Online:
2023-04-25
Published:
2023-08-31
摘要:
目的:分析急性肾小管间质性肾炎(acute tubulointerstitial nephritis, ATIN)患者的临床及实验室检查特征,探讨该病与急性肾小管坏死(acute tubular necrosis nephritis, ATN)的鉴别诊断要点。方法:纳入2009年1月至2018年12月间在上海交通大学医学院附属瑞金医院肾脏科经肾活检病理诊断为ATIN、ATN的患者,收集其临床表现和实验室检查数据,并对两者进行比较分析。结果:10年间我院肾脏科行经肾活检的病例总计5 537例,其中诊断为ATIN的患者共135例(2.4%,135/5 537),诊断为ATN的患者109例(2.0%,109/5 537)。ATIN占急性肾脏病(acute kidney disease, AKD)肾活检患者的21.4%(135/630)。ATIN患者的中位确诊年龄为53岁,女性占57.0%,临床主要表现为发热、皮疹、关节痛,常见诱因为感染、药物应用和毒物接触。与ATN组相比,ATIN患者中女性占比高(57.0%比33.9%),平均体重指数(body weight index,BMI)低(22.9±3.6比24.6±3.9,P<0.01),且发生急性肾损伤(acute kidney injury, AKI)(14.8% 比64.2%)、少尿(17.0%比48.6%)及入院后需紧急透析(19.3%比39.4%)的百分比低(P<0.01)。ATIN患者入院时,血红蛋白(hemoglobin,Hb)[(100.9±20.9) g/L比(116.7±29.8) g/L]和血尿素氮/肌酐比值(blood urea nitrogen/creatinine ratio, BCR)(11.8±5.4比14.6±11.0)均较ATN组低(P<0.01)。多因素回归分析显示,入院时高白蛋白(>55 g/L)、低血清肌酐(serum creatine,Scr)(<62 μmol/L)、低血清尿酸(urine acid,UA)(<208 μmol/L)、低Hb水平(<130 g/L)与ATIN相关,联合这4项指标建立的预测模型,其诊断ATIN的受试者操作特征曲线下面积为0.798(95%CI为0.742~0.853),灵敏度为74.4%,特异度为71.4%。结论:ATIN在上海地区人群接受肾活检的AKD患者中占比高,好发于中年女性,半数患者诱因不明。患者入院时的白蛋白、Scr、Hb及UA水平有助于ATIN与AIN间的鉴别,基于上述4项指标构建的ATIN患者诊断预测模型具有较好的特异度和灵敏度。
中图分类号:
郝家琪, 王鑫鹭, 胡晓帆, 潘晓霞, 徐静, 马骏. 急性肾小管间质性肾炎与急性肾小管坏死的临床鉴别分析[J]. 诊断学理论与实践, 2023, 22(02): 127-133.
HAO Jiaqi, WANG Xinlu, HU Xiaofan, PAN Xiaoxia, XU Jing, MA Jun. Clinical differential diagnosis of acute tubulointerstitial nephritis and acute tubular necrosis[J]. Journal of Diagnostics Concepts & Practice, 2023, 22(02): 127-133.
表1
ATN与ATIN患者的临床资料比较
Indice | ATN(n=109) | ATIN(n=135) | P |
---|---|---|---|
Male(%) | 72(66.1%) | 58(43.0%) | <0.01 |
Age(year) | 49(15-85) | 53(14-82) | 0.09 |
BMI(kg/m2) | 24.6±3.9 | 22.9±3.6 | <0.01 |
AKD disease course(%) | 82(75.2%) | 60(44.4%) | <0.01 |
AKI(%) | 70(64.2%) | 20(14.8%) | <0.01 |
Urgent dialysis needed during hospitalization (%) | 43(39.4%) | 26(19.3%) | <0.01 |
Dialysis independent at hospital discharge(%) | 22(51.2%) | 20(76.9%) | 0.03 |
Clinical manifestation | |||
Fever(%) | 23(21.1%) | 40(29.6%) | 0.12 |
Rash(%) | 9(8.3%) | 10(7.4%) | 0.08 |
Arthralgia(%) | 6(5.5%) | 4(3.0%) | 0.32 |
Oliguria(%) | 53(48.6%) | 23(17.0%) | <0.01 |
Inducement | |||
Infection(%) | 22(20.2%) | 31(23.0%) | 0.60 |
Toxicant(%) | 8(7.3%) | 2(1.5%) | 0.05 |
Drugs(%) | 30(27.5%) | 34(25.2%) | 0.68 |
Unknown(%) | 49(45.0%) | 68(50.4%) | 0.40 |
Hypertension(%) | 39(35.8%) | 52(38.5%) | 0.66 |
Diabetes(%) | 8(7.3%) | 11(8.1%) | 0.82 |
表2
ATN和ATIN患者的实验室检查结果比较
Indice | ATN(n=109) | ATIN(n=135) | P |
---|---|---|---|
Scr at admission(μmol/L) | 314(81-2 290) | 238(101-876) | <0.01 |
Peak Scr (μmol/L) | 425(102-2 290) | 278(115-1 270) | <0.01 |
Scr at discharge(μmol/L) | 264(54-1 059) | 171.5(50-876) | 0.66 |
Prealbumin(mg/L) | 225.1±78.7 | 225.1±61.6 | 1.00 |
Alb(g/L) | 26(8-46) | 34(12-43) | <0.01 |
Uric acid(μmol/L) | 454(149-874) | 345(104-779) | <0.01 |
TG(mmol/L) | 2.1(0.8-15.1) | 1.7(0.5-7.0) | <0.01 |
TC(mmol/L) | 5.1(0.9-21.8) | 4.4(1.6-19.8) | <0.01 |
PTH(pg/mL)* | 1.9±0.4 | 1.9±0.4 | 0.30 |
Hb(g/L) | 116.7±29.8 | 100.9±20.9 | <0.01 |
BCR | 14.6±11.0 | 11.8±5.4 | 0.02 |
24 h urine protein(mg/24 h) | 1 350(52-23 555) | 1 036(75-27 303) | 0.31 |
hematuria(%) | 0.54 | ||
Gross hematuria(%) | 11(10.1%) | 12(8.9%) | |
Microscopic hematuria(%) | 41(37.6%) | 43(31.9%) | |
Urinary sodium/Potassium ratio | 2.2(0.1-15.8) | 2.8(0.2-21.5) | 0.04 |
Urinary urea nitrogen (mmol/24 h)# | 12.9±4.2 | 12.6±4.4 | 0.57 |
表3
ATIN的危险因素分析
Indice | Single factor regression | Multiple regression | |||
---|---|---|---|---|---|
OR(95%CI) | P | OR(95%CI) | P | ||
Clinical data | |||||
Female(%) | 2.58(1.53-4.36) | <0.01 | - | - | |
Age(year) | 1.01(1.00-1.03) | 0.07 | - | - | |
Non-AKI | 10.3(5.58-19.1) | <0.01 | - | - | |
Non-oliguria | 4.61(2.57-8.27) | <0.01 | - | - | |
BMI | 0.88(0.82-0.96) | <0.01 | - | - | |
Treatment | |||||
Urgent dialysis unneeded during hospitalization | 2.73(1.54-4.85) | <0.01 | - | - | |
Dialysis independent at hospital discharge | 3.18(1.07-9.47) | 0.04 | - | - | |
Laboratory examination | |||||
Scr at admission(μmol/L) | 0.998(0.997-0.999) | <0.01 | 0.997(0.995-0.999) | <0.01 | |
Alb(g/L) | 1.06(1.03-1.09) | <0.01 | 1.05(1.01-1.09) | 0.01 | |
UA(μmol/L) | 0.995(0.993-0.997) | <0.01 | 0.997(0.994-0.999) | 0.01 | |
TG(mmol/L) | 0.68(0.53-0.86) | <0.01 | - | ||
TC(mmol/L) | 0.82(0.73-0.91) | <0.01 | - | ||
Hb(g/L) | 0.98(0.97-0.99) | <0.01 | 0.97(0.95-0.98) | <0.01 | |
Urinary sodium/Potassium ratio | 1.02(0.93-1.12) | 0.65 | - |
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