摘要
目的探查中晚期慢性肾脏病(chronic kidney disease,CKD)患者经皮肾穿刺活检术(percutaneous renal biopsy,PRB)后严重出血的发生风险和相关危险因素。方法该研究为回顾性队列研究,收集2010年1月至2020年12月于南方医科大学南方医院肾内科住院且接受自体肾PRB的中晚期CKD患者。PRB后严重出血定义(任一标准):术后48 h内血红蛋白下降≥20 g/L,术后48 h内肾周血肿最大长径≥5 cm,术后48 h内使用垂体后叶素、输血、肾血管介入治疗。以发生PRB后严重出血为研究终点,采用Logistic回归模型分析中晚期CKD患者接受PRB后严重出血的发生风险和相关危险因素。结果共纳入895例患者进行研究,患者年龄为(46.1±14.1)岁,男性占60.1%(538/895),合并糖尿病占15.9%(142/895),合并高血压占57.9%(518/895),估算肾小球滤过率(estimated glomerular filtration rate,eGFR)为(40.1±13.2)ml∙min^(-1)∙(1.73 m^(2))-1,24 h尿蛋白量为2.5(1.1,4.9)g。PRB后发生严重出血患者占22.9%(205/895),其中术后使用垂体后叶素者30例(14.6%),术后输血者10例(4.9%),术后行肾血管介入止血者1例(0.5%),术后无死亡。相比于未严重出血组,PRB后严重出血组患者合并高血压比例较高[64.4%(132/205)比55.9%(386/690),χ^(2)=4.627,P=0.031],术前血肌酐、平均动脉压水平较高[(193.9±106.6)µmol/L比(180.8±102.6)µmol/L,t=-2.559,P=0.011;(95.8±10.9)mmHg比(93.9±11.0)mmHg,t=-2.134,P=0.033],血小板值较低[(227.5±70.3)×10^(9)/L比(247.5±74.8)×10^(9)/L,t=-3.788,P<0.001],且两组间年龄、性别、合并糖尿病比例和术前血清白蛋白、血红蛋白、其他凝血功能指标以及病理组织学类型等差异均无统计学意义(均P>0.05)。多因素Logistic回归分析显示,体重指数(OR=0.936,95%CI 0.891~0.984,P=0.010)、eGFR(OR=0.985,95%CI 0.971~0.999,P=0.034)、血清白蛋白(OR=1.041,95%CI 1.011~1.072,P=0.007)、24 h尿蛋白量(OR=1.092,95%CI 1.030~1.158,P=0.003)、血小板计数(OR=0.996,95%CI 0.994~0.999,P=0.002)与中晚期CKD患者PRB后严重出血独立相关。在PRB队列中,占比前6的肾脏组织学类型分别为IgAN(46.3%,414/895)、膜性肾小球肾炎(11.1%,99/895)、局灶节段性肾小球硬化(8.5%,76/895)、糖尿病肾病(7.6%,68/895)、硬化性肾(6.9%,62/895)和肾血管硬化(4.9%,44/895)。结论中晚期CKD患者PRB后严重出血发生风险较高,约22.9%。低BMI、低eGFR水平、低血小板计数、高血清白蛋白以及高24 h尿蛋白水平是中晚期CKD患者PRB后严重出血并发症的独立危险因素。
Objective To explore the incidence and risk factors of severe bleeding after percutaneous renal biopsy(PRB)in patients with advanced chronic kidney disease(CKD).Methods The study was a retrospective cohort analysis.The data were collected from patients with advanced CKD who were hospitalized in the Department of Nephrology,Nanfang Hospital,Southern Medical University and underwent PRB between January 2010 and December 2020.Severe bleeding after PRB was defined by any of the following criteria:a postoperative hemoglobin decrease of≥20 g/L within 48 hours,a maximum diameter of perirenal hematoma≥5 cm postoperatively,or the need for posterior pituitary hormone,blood transfusion,or renal vascular intervention post-surgery.The occurrence of severe bleeding following PRB served as the primary endpoint for this study.Logistic regression model was used to analyze the risk factors associated with severe bleeding in patients with advanced CKD undergoing PRB.Results A total of 895 patients aged(46.1±14.1)years were encompassed in the study.Among them,60.1%(538/895)were male,15.9%(142/895)were afflicted with diabetes,and 57.9%(518/895)suffered from hypertension.The estimated glomerular filtration rate(eGFR)was(40.1±13.2)ml∙min^(-1)∙(1.73 m^(2))-1,and the 24-hour urine protein excretion was 2.5(1.1,4.9)g.After PRB,22.9%(205/895)of the patients encountered severe bleeding,including 30 patients(14.6%)who received postoperative somatostatin,10 patients(4.9%)who underwent postoperative blood transfusion,1 patient(0.5%)who underwent postoperative renal vascular intervention for hemostasis,and no fatalities occurred.Compared to the non-severe bleeding group,patients in the severe bleeding group after PRB exhibited a higher proportion of hypertension[64.4%(132/205)vs.55.9%(386/690),χ²=4.627,P=0.031].Additionally,preoperative serum creatinine levels and mean arterial pressure were significantly elevated[(193.9±106.6)µmol/L vs.(180.8±102.6)µmol/L,t=-2.559,P=0.011;(95.8±10.9)mmHg vs.(93.9±11.0)mmHg,t=-2.134,P=0.033].Furthermore,platelet counts were lower in the severe bleeding group[(227.5±70.3)×10^(9)/L vs.(247.5±74.8)×10^(9)/L,t=-3.788,P<0.001].No statistically significant differences were observed between the two groups regarding age,gender distribution,prevalence of diabetes mellitus,as well as preoperative serum albumin level,hemoglobin concentration,other coagulation function indicators and pathological histological type(all P>0.05).Multivariate logistic regression analysis indicated that body mass index(OR=0.936,95%CI 0.891–0.984,P=0.010),eGFR(OR=0.985,95%CI 0.971–0.999,P=0.034),serum albumin level(OR=1.041,95%CI 1.011–1.072,P=0.007),24 hours urinary protein excretion(OR=1.092,95%CI 1.030–1.158,P=0.003),and platelet count(OR=0.996,95%CI 0.994–0.999,P=0.002)were independently associated with the severe bleeding following PRB in patients with advanced CKD.In the PRB cohort analyzed,the six most prevalent renal histological types were as follows:IgA nephropathy(46.3%,414/895),membranous nephropathy(11.1%,99/895),focal segmental glomerulosclerosis(8.5%,76/895),diabetic nephropathy(7.6%,68/895),sclerotic kidney disease(6.9%,62/895),and vascular sclerosis of the kidneys(4.9%,44/895).Conclusions Patients with advanced CKD exhibit a heightened risk of severe bleeding following PRB,estimated at approximately 22.9%.Independent risk factors for the occurrence of severe bleeding complications in these patients include low body mass index,reduced eGFR,decreased platelet count,elevated serum albumin,and increased urinary protein level.
作者
黄浩成
郦俊
杨小兵
Huang Haocheng;Li Jun;Yang Xiaobing(Division of Nephrology,Nanfang Hospital,Southern Medical University,Guangzhou 510515,China)
出处
《中华肾脏病杂志》
CAS
CSCD
北大核心
2024年第11期851-857,共7页
Chinese Journal of Nephrology
基金
国家自然科学基金面上项目(81970666)
南方医科大学南方医院临床研究专项(2023CR004)。
