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中华肾病研究电子杂志

中华肾病研究电子杂志 ›› 2018, Vol. 07 ›› Issue (01) : 28 -33. doi: 10.3877/cma.j.issn.2095-3216.2018.01.007

所属专题： 文献；

论著

成人微小病变肾病综合征发生急性肾损伤的相关影响因素分析
杨琛1, 蔡广研1,†(), 陈仆1, 孟金铃1, 吴杰1, 张雪光1, 王涌1, 刘述文1, 吴镝1, 陈香美1   
  1. 1. 100853　北京，解放军总医院肾脏病科、解放军肾脏病研究所、肾脏疾病国家重点实验室、国家慢性肾病临床医学研究中心
  • 收稿日期:2017-11-19 出版日期:2018-02-28
  • 通信作者: 蔡广研
  • 基金资助:
    国家科技支撑计划课题(2015BAI12B06)

Analysis of related factors of acute kidney injury in adult minimal change nephrotic syndrome

Chen Yang1, Guangyan Cai1,†(), Pu Chen1, Jinling Meng1, Jie Wu1, Xueguang Zhang1, Yong Wang1, Shuwen Liu1, Di Wu1, Xiangmei Chen1   

  1. 1. Department of Nephrology, Chinese PLA General Hospital, Chinese PLA Institute of Nephrology, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Chronic Kidney Diseases, Beijing 100853, China
  • Received:2017-11-19 Published:2018-02-28
  • Corresponding author: Guangyan Cai
  • About author:
    Corresponding author: Cai Guangyan, Email:
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引用本文：

杨琛, 蔡广研, 陈仆, 孟金铃, 吴杰, 张雪光, 王涌, 刘述文, 吴镝, 陈香美. 成人微小病变肾病综合征发生急性肾损伤的相关影响因素分析[J/OL]. 中华肾病研究电子杂志, 2018, 07(01): 28-33.

Chen Yang, Guangyan Cai, Pu Chen, Jinling Meng, Jie Wu, Xueguang Zhang, Yong Wang, Shuwen Liu, Di Wu, Xiangmei Chen. Analysis of related factors of acute kidney injury in adult minimal change nephrotic syndrome[J/OL]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2018, 07(01): 28-33.

目的

探讨成人微小病变肾病综合征发生急性肾损伤( AKI)的相关影响因素。

方法

回顾性分析2002年1月1日至2015年12月31日在解放军总医院病理诊断为微小病变肾病，临床表现为首发肾病综合征的成年患者。记录其横断面临床及病理指标，并将其分为AKI组及非AKI组进行比较。用单因素及多元Logistic回归分析与AKI发生相关的影响因素。并对AKI相关的各影响因素进行交互作用检验。

结果

共纳入403例患者，男女比例为1∶1.13，肾活检时平均年龄为(39.5 ± 15.1)岁，其中118(29.3%)例发生了AKI。AKI组与非AKI组相比，年龄、性别、尿蛋白定量、血清白蛋白、血肌酐、血尿素氮、估算的肾小球率过滤、肾小管萎缩、肾间质病变差异均有统计学意义(P<0.05)。单因素Logistic回归分析显示高龄、男性、尿蛋白定量多、肾小管萎缩、肾间质水肿、间质纤维化及炎细胞浸润、高血压是成人微小病变肾病发生AKI的危险因素。交互作用检验表明血清白蛋白对AKI的作用受到肾间质纤维化的显著影响(P＝0.0 050)，且在调整年龄分组、性别、高血压、尿蛋白定量、肾小管萎缩、肾间质水肿、肾间质炎细胞浸润混杂因素后，其交互作用仍显著(P＝0.0 263)。从多元Logistic回归分析可见，在无肾间质纤维化的人群中，血清白蛋白水平的升高是AKI的独立保护因素(调整后的OR 0.8，95%CI 0.7～ 0.9，P<0.001)。在有肾间质纤维化人群中，血清白蛋白的升高对AKI肾脏的保护作用不显著(调整后的OR 1.0，95%CI 0.9～1.0，P＝0.0 278)。

结论

高龄、男性、尿蛋白定量多、肾小管萎缩、肾间质水肿、间质纤维化及炎细胞浸润、高血压是成人微小病变肾病综合征发生AKI的危险因素。血清白蛋白升高对AKI的保护作用受到肾间质纤维化的影响。

关键词: 急性肾损伤, 成人, 微小病变肾病, 肾病综合征, 血清白蛋白
Objective

To investigate the related factors of acute kidney injury (AKI) in adult minimal change disease (MCD).

Methods

A retrospective analysis was made in the patients (>18 years old) with first-presented nephrotic syndrome and biopsy-proven MCD from January 1, 2002 to December 31, 2015. The patients were divided into two groups: the AKI group and the non-AKI group. Univariate and multivariate logistic regression were used to analyze the influencing factors associated with the occurrence of AKI. And the interaction of AKI related factors was tested.

Results

A total of 403 patients were included. The ratio between males and females was 1∶1.13. The average age at renal biopsy was 39.5 ± 15.1 years. AKI occurred in 118 cases (29.3%) of the 403 patients. The AKI group had statistically significant differences in age, gender, urinary protein quantification, serum albumin, serum creatinine, blood urea nitrogen, estimated glomerular filtration rate (eGFR), tubular atrophy, and renal interstitial lesions compared with the non-AKI group (P<0.05). Univariate logistic regression analysis showed that the elderly age, maleness, higher urinary protein, tubular atrophy, renal interstitial edema, interstitial fibrosis, inflammatory cell infiltration, and hypertension were the risk factors for the occurrence of AKI in adult MCD. Interaction tests showed that the effect of serum albumin on AKI was significantly affected by renal interstitial fibrosis (P=0.005), and this interaction was still significant after adjustment of such factors as age group, gender, hypertension, urinary protein quantification, tubular atrophy, renal interstitial edema, and renal interstitial cell infiltration (P=0.0 263). In the non-interstitial fibrosis patients, serum albumin increase was an independent protective factor for AKI (adjusted OR, 0.8; 95%CI, 0.7-0.9, P<0.001). In the interstitial fibrosis patients, the influence of serum albumin increase on AKI was not significant (adjusted OR 1.0, 95%CI, 0.9- 1.0, P=0.0 278).

Conclusion

Elderly age, maleness, higher proteinuria, renal tubular atrophy, renal interstitial edema, renal interstitial fibrosis, inflammatory cell infiltration, and hypertension, were risk factors for the occurrence of AKI in adult MCD. The protective effect of serum albumin increase on AKI was influenced by the renal interstitial fibrosis.

Key words: Acute kidney injury, Adult, Minimal change disease, Nephrotic syndrome, Serum albumin
图1 成人微小病变肾病综合征发生急性肾损伤病例筛选流程
表1 成人微小病变肾病综合征研究人群临床及病理特点
? 非AKI组 AKI组 检验值 P值
总例数 284 118 ? ?
年龄(岁) 37.6 ± 13.5 44.1 ± 17.8 4.028 0.001
男性[例(%)] 107 (37.7 ) 82 (69.5 ) 33.873 <0.001
血清白蛋白(g/L) 21.0 ± 5.1 18.9 ± 4.4 3.899 <0.001
尿蛋白定量(g/d) 5.5 ± 3.3 6.5 ± 3.4 2.746 0.007
血尿素氮(mmol/L) 5.3 ± 2.5 10.7 ± 6.3 12.427 <0.001
血肌酐(μmol/L) 70.4 ± 18.9 148.2 ± 96.3 13.037 <0.001
eGFR[ml/(min·1.73 m2)] 104.7 ± 19.8 62.1 ± 30.4 16.604 <0.001
血红蛋白(g/L) 142.9 ± 18.7 142.6 ± 21.0 0.124 0.953
肾小管蛋白管型[例(%)] 118 (41.5 ) 60 (50.8 ) 2.921 0.087
肾小管萎缩[例(%)] 97 (34.2 ) 61 (51.7 ) 10.751 0.001
肾间质水肿[例(%)] 39 (13.9 ) 28 (23.7 ) 5.770 0.016
肾间质炎细胞浸润[例(%)] 87 (30.6 ) 67 (56.8 ) 24.114 <0.001
肾间质纤维化[例(%)] 107 (37.7 ) 63 (53.4 ) 8.434 0.004
肾小动脉透明样变性[例(%)] 27 (9.5 ) 16 (13.6 ) 1.433 0.231
肾小动脉内膜增厚[例(%)] 74 (26.1 ) 35 (29.7 ) 0.548 0.459
合并高血压[例(%)] 27 (9.5 ) 48 (40.7 ) 53.372 <0.001
合并糖尿病[例(%)] 6 (2.1 ) 4 (3.4 ) 0.560 0.454
表2 成人微小病变肾病综合征AKI发生相关危险因素的单因素Logistic回归分析
? OR (95%CI) P值
起病时年龄(岁) 1.0 (1.0～ 1.0) <0.001
年龄分组 ? ?
? 青年(<45岁) 参考 ?
? 中年(≥45岁) 1.7 (1.0～ 2.8) 0.045
? 老年(≥60岁) 3.7 (1.9～ 7.2) <0.001
男性(比女性) 3.8 (2.4～6.0) <0.001
血清白蛋白(g/L) 0.9 (0.9～1.0) <0.001
尿蛋白定量(g/d) 1.1 (1.0～1.2) 0.007
血尿素氮(mmol/L) 1.4 (1.3～1.5) <0.001
血肌酐(μmol/L) 1.1 (1.1～ 1.1) <0.001
eGFR[ml/(min·1.73 m2)] 0.9 (0.9～1.0) <0.001
血红蛋白(g/L) 1.0 (1.0～1.0) 0.901
肾小管萎缩(%) 2.1 (1.3～3.2) 0.001
蛋白管型(%) 1.5 (0.9～ 2.2) 0.088
肾间质水肿(%) 2.0 (1.1～ 3.4) 0.015
肾间质炎细胞浸润(%) 3.0 (1.9～4.6) <0.001
肾间质纤维化(%) 1.9 (1.2～2.9) 0.004
肾小动脉内膜增厚(%) 1.2 (0.7～ 1.9) 0.459
肾小动脉透明样变性(%) 1.5 (0.8～ 2.9) 0.234
合并高血压(%) 6.5 (3.8～11.2) <0.001
合并糖尿病(%) 1.6 (0.5～ 5.9) 0.458
图2 成人微小病变肾病综合征患者血清白蛋白水平与急性肾损伤发生风险的平滑曲线拟合
图3 在有或无肾间质纤维化的不同人群中，血清白蛋白水平与急性肾损伤发生风险的平滑曲线拟合
表3 血清白蛋白与AKI的发生风险在成人微小病变肾病综合征不同人群当中的多元Logistic回归关系
? 例数 无调整 模型Ⅰ 模型Ⅱ
OR(95%CI) P值 OR(95%CI) P值 OR(95%CI) P值
无肾间质纤维化 233 0.8 (0.8～ 0.9) <0.001 0.8 (0.7～ 0.9) <0.001 0.8 (0.7～ 0.9) <0.001
有肾间质纤维化 170 1.0 (0.9～1.0) 0.188 0.9 (0.9～ 1.0) 0.139 1.0 (0.9～1.0) 0.245
总体 403 0.9 (0.9～1.0) <0.001 0.9 (0.8～0.9) <0.001 0.9 (0.8～1.0) 0.001
交互作用检验a - - 0.0050 - 0.0197 - 0.0263
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