摘要
目的总结恶性高血压(malignant hypertension,MHT)合并急性肾损伤(acute kidney injury,AKI)患者的临床病理特征以及肾素-血管紧张素-醛固酮系统抑制剂(renin-angiotensin-aldosterone system inhibitor,RAASi)应用情况。方法该研究为回顾性队列研究,纳入2012年1月1日至2022年7月14日北京大学第一医院的MHT合并AKI的成年住院患者。根据患者AKI发生后至出院期间是否使用RAASi将其分为RAASi组和非RAASi组,比较两组患者临床病理资料的差异,并分析RAASi应用情况。结果共179例患者被纳入该研究,年龄31(26,37)岁,男性148例(82.7%),接受透析治疗95例(53.1%)。MHT的常见病因分别为原发性高血压(125例,69.8%)、肾性高血压(39例,21.8%)和内分泌性高血压(7例,3.9%)。AKI 1级、2级、3级分别为41例(22.9%)、1例(0.5%)及137例(76.5%)。MHT患者在AKI前已使用RAASi治疗94例(52.5%),其中AKI后停用RAASi 13例(7.3%)。85例(47.5%)AKI前未使用RAASi治疗患者中,AKI后新增RAASi 68例(38.0%),其中在透析治疗支持下新增用药40例(22.3%)。与非RAASi组(n=30)比较,RAASi组(n=149)患者慢性肾脏病比例(χ^(2)=6.324,P=0.012)和AKI后高钾血症比例(χ^(2)=4.048,P=0.044)均较低,透析治疗比例(χ^(2)=5.638,P=0.018)、入院舒张压(Z=-3.609,P<0.001)及住院期间最高舒张压(Z=-1.978,P=0.048)均较高。两组患者住院期间血压控制达标率及肾功能恢复率的差异均无统计学意义(均P>0.05)。住院期间患者接受肾活检64例,其中50例(78.1%)患者有肾脏小动脉"洋葱皮"样改变等MHT典型血管病变;27例(42.2%)合并肾小球疾病,以IgA肾病最为常见(85.2%,23/27);RAASi组(n=54)肾小球缺血硬化占比、内皮细胞增生比例及肾小管急性损伤比例均低于非RAASi组(n=10),血栓比例及"洋葱皮"样改变比例均高于非RAASi组(n=10),但差异均无统计学意义(均P>0.05)。出院时肾功能恢复47例(26.3%),脱离透析26例(27.4%,26/95)。结论MHT合并AKI患者肾损伤程度重,短期肾脏预后差,RAASi使用更常见于基础肾功能好或有透析支持的患者。
Objective:To summarize the clinicopathologic characteristics of malignant hypertension(MHT)patients with acute kidney injury(AKI)and application of renin-angiotensin-aldosterone system inhibitor(RAASi).Methods:It was a retrospective cohort study.The adult patients with MHT and AKI admitted to Peking University First Hospital from January 1,2012 to July 14,2022.The patients were categorized into RAASi group and non-RAASi group based on RAASi administration from AKI onset to discharge.The clinicopathological data between the two groups were compared,and application of RAASi was analyzed.Results:A total of 179 patients were enrolled with age of 31(26,37)years and 148 males(82.7%).Ninety-five patients(53.1%)received dialysis treatment.The common causes of MHT were essential hypertension(125 patients,69.8%),renal hypertension(39 patients,21.8%)and endocrine hypertension(7 patients,3.9%).AKI severity distribution showed 41 patients(22.9%)in stage 1,1 patient(0.5%)in stage 2 and 137 patients(76.5%)in stage 3.Among MHT patients,94 patients(52.5%)had been treated with RAASi before AKI,and 13 patients(7.3%)discontinued RAASi after AKI.Among 85 patients(47.5%)without receiving RAASi treatment before AKI,68 new patients(38.0%)received RAASi treatment after AKI,and 40 patients(22.3%)were treated with the support of dialysis.Compared with non-RAASI group(n=30),proportions of chronic kidney disease(χ^(2)=6.324,P=0.012)and post-AKI hyperkalemia(χ^(2)=4.048,P=0.044)in RAASi group(n=149)were lower,and the proportion of dialysis treatment(χ^(2)=5.638,P=0.018),admission diastolic blood pressure(Z=-3.609,P<0.001)and maximum diastolic blood pressure during hospitalization(Z=-1.978,P=0.048)were higher.There were no statistically significant differences in the rates of target blood pressure control and renal function recovery between the two groups during hospitalization(all P>0.05).During hospitalization,64 patients received renal biopsies,of which 50 patients(78.1%)had typical MHT vascular lesions such as"onion skin"in renal arterioles.Twenty-seven patients(42.2%)were complicated with glomerular diseases,and IgA nephropathy was the most common type(85.2%,23/27).The proportions of glomerular ischemia and sclerosis,endothelial cell proliferation and acute renal tubular injury in RAASi group(n=54)were lower than those in non-RAASi group(n=10),and proportions of thrombosis and"onion skin"change were higher than those in RAASi group(n=10),but the differences were not statistically significant(all P>0.05).Renal function recovery occurred in 47 patients(26.3%)by discharge.Among 95 dialysis patients,26 patients(27.4%)achieved dialysis independence at discharge.Conclusions:MHT patients with AKI exhibit severe renal pathology and short-term poor prognosis.RAASi is primarily prescribed to those with relatively better kidney function or those receiving dialysis support.
作者
徐菱忆
唐灵儿
薛硕
周庆庆
蒋镭
杨莉
郑茜子
Xu Lingyi;Tang Linger;Xue Shuo;Zhou Qingqing;Jiang Lei;Yang Li;Zheng Xizi(Renal Division,Peking University First Hospital,Institute of Nephrology,Peking University,NHC Key Laboratory of Renal Disease,Key Laboratory of Chronic Kidney Disease Prevention and Treatment,Ministry of Education of China,Research Units of Diagnosis and Treatment of Immune-Mediated Kidney Diseases,Chinese Academy of Medical Sciences,Beijing 100034,China;Emergency Department,Peking University First Hospital,Beijing 100034,China)
出处
《中华肾脏病杂志》
北大核心
2025年第4期250-257,共8页
Chinese Journal of Nephrology
基金
国家自然科学基金(82300764, 82130021)
北京市科技新星计划(2021051)
首都卫生发展科研专项(首发2022-1-4071)
中央高校基本科研业务费, 北京大学临床科学家计划(BMU2023PYJH023)
北京大学临床医学+X青年专项(PKU2023LCXQ002)
中国医学科学院医学与健康科技创新工程项目(2019-I2M-5-046)
中央高水平医院临床科研业务费, 北京大学第一医院跨学科交叉研究专项(2023IR14)
北京大学第一医院青年临床研究专项(2022CR108)。
