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目的 探讨超声造影在脓毒症性急性肾损伤(AKI)中的诊断价值.方法 选择2015年1月至2017年6月天津市第三中心manbet官网登录 重症医学科收治的脓毒症患者作为研究对象.所有患者入院后完成6 h集束化治疗(Bundle),并于入院24 h内完成双侧肾脏超声造影,定量分析双侧肾血流灌注,测量峰值强度(PSI)、达峰时间(PIT)和内洗率(WIR),同时进行肾功能指标测定.根据改善全球肾脏病预后组织(KDIGO)的AKI诊断标准将患者分为AKI 24 h组和非AKI 24 h组,比较两组间各指标的差异;用受试者工作特征曲线(ROC)分析肾脏超声造影参数对脓毒症性AKI的诊断价值.于入院第7天,再次对入院24 h非AKI患者进行肾功能指标测定,进一步根据KDIGO标准分为AKI 7 d组和非AKI 7 d组,比较两组入院时超声造影参数和肾功能参数的差异.结果 ① 最终纳入96例脓毒症患者,入院24 h内发生AKI 39例,24 h发生率为40.6%.超声造影显示,非AKI患者时间-强度曲线(TIC)表现为急速上升至高峰后缓慢下降;AKI患者TIC曲线则表现为上升速度缓慢,且至高峰后下降速度更加缓慢.与非AKI 24 h组比较,AKI 24 h组PSI减弱,PIT延长,WIR减低〔PSI(dB):114.41±19.38比141.24±24.65,PIT(s):22.86±4.29比17.39±3.68,WIR(dB/s):5.53±4.17比7.85±1.84,均1<0.01〕.ROC曲线分析显示,WIR、PIT、PSI诊断脓毒症性AKI的ROC曲线下面积(AUC)分别为0.85、0.84、0.82(均1<0.01).WIR最佳截断值为7.18 dB/s时,诊断AKI的敏感度为82.05%,特异度为80.70%,准确度为81.25%;PIT最佳截断值为18.45 s时,诊断AKI的敏感度为74.35%,特异度为73.68%,准确度为73.95%;PSI最佳截断值为121.21 dB时,诊断AKI的敏感度为71.79%,特异度为87.72%,准确度为81.25%.② 57例入院24 h内非AKI患者中有15例于入院7 d内发生AKI,7 d发生率为26.3%.与非AKI 7 d组比较,AKI 7 d组入院时PIT、WIR、PSI差异均有统计学意义〔PSI(dB):124.97±26.64比147.02±21.51,PIT(s):20.61±3.27比16.24±3.13,WIR(dB/s):6.81±1.76比8.22±1.75,均1<0.05〕,但血肌酐(SCr)、尿素氮(BUN)、肌酐清除率(CCr)差异均无统计学意义.结论 相较传统AKI诊断指标(SCr、BUN),超声造影参数能早期反映肾功能损伤,有助于脓毒症性AKI的早期诊断.

Objective To evaluate the diagnostic value of contrast-enhanced ultrasound in acute kidney injury (AKI) caused by sepsis. Methods The sepsis patients admitted to intensive care unit of Tianjin Third Central Hospital from January 2015 to June 2017 were enrolled. All of the patients were completed the 6-hour Bundle treatment and the bilateral renal contrast-enhanced ultrasound within 24 hours, and the peak signal intensity (PSI), peak intensity time (PIT), wash internal rate (WIR) and renal function parameters were measured at the same time. The patients were divided into AKI 24 hours group and non-AKI 24 hours group according to Kidney Disease: Improving Global Outcomes (KDIGO)-AKI diagnostic criteria, and the parameters differences were compared between the two groups. The receiver operating characteristic (ROC) curve were used to analyze the diagnostic value of the parameters. Renal function of the non-AKI group patients was measured again 7 days after hospital admission, and patients were divided into AKI 7 days group and non-AKI 7 days group, and the related parameters of the two groups measured within 24 hours were compared. Results ① Ninety-six patients were enrolled, with 39 cases of AKI occurred within 24 hours after admission, and with an incidence of 40.6%. Contrast-enhanced ultrasound showed that the time-intensity curve (TIC) of non-AKI patients manifested as a slow down after rapid rise to the peak, but the AKI patients showed as slow rise to the peak and more slow decrease. Compared with non-AKI 24 hours group, AKI 24 hours group performance as PSI weakened, PIT extended and WIR decreased [PSI (dB): 114.41±19.38 vs. 141.24±24.65, PIT (s): 22.86±4.29 vs. 17.39±3.68, WIR (dB/s): 5.53±4.17 vs. 7.85±1.84, all 1 < 0.01]. ROC curve analysis showed that area under the ROC curve (AUC) of WIR, PIT, PSI was 0.85, 0.84, 0.82 respectively (all 1 < 0.01), the cut-off value of WIR was 7.18 dB/S, the sensitivity, specificity and accuracy were 82.05%, 80.70% and 81.25% respectively; the cut-off value of PIT was 18.45 s, the sensitivity, specificity and accuracy were 74.35%, 73.68% and 73.95% respectively;the cut-off values of PSI was 121.21 dB, the sensitivity, specificity and accuracy were 71.79%, 87.72% and 81.25% respectively. ② The incidence of AKI within 7 days in non-AKI patients was 26.3% (15/57). There were significant differences in PIT, WIR and PSI between AKI 7 days group and non-AKI 7 days group [PSI (dB): 124.97±26.64 vs. 147.02±21.51, PIT (s): 20.61±3.27 vs. 16.24±3.13, WIR (dB/s): 6.81±1.76 vs. 8.22±1.75, all 1 < 0.05]. However, there was no significant difference in serum creatinine (SCr), blood urea nitrogen (BUN) and creatinine clearance rate (CCr). Conclusion Compared to SCr and BUN, contrast-enhanced ultrasound parameters can early response to renal dysfunction, and contribute to early diagnosis of sepsis induced AKI.