北京大学学报(医学版) ›› 2019, Vol. 51 ›› Issue (5): 863-869. doi: 10.19723/j.issn.1671-167X.2019.05.012

• 论著 • 上一篇    下一篇

急性肾梗死的临床特征:单中心52例临床分析

张志刚,刘新民()   

  1. 北京大学第一医院老年病科, 北京 100034
  • 收稿日期:2017-08-13 出版日期:2019-10-18 发布日期:2019-10-23
  • 通讯作者: 刘新民 E-mail:lxm2128@163.com

Clinical characteristics of patients with acute renal infarction: an analysis of 52 patients in a single center

Zhi-gang ZHANG,Xin-min LIU()   

  1. Department of Geriatrics, Peking University First Hospital, Beijing 100034, China
  • Received:2017-08-13 Online:2019-10-18 Published:2019-10-23
  • Contact: Xin-min LIU E-mail:lxm2128@163.com

摘要:

目的:分析急性肾梗死的临床特征,探讨急性肾梗死并发血尿的相关临床及实验室因素。方法:回顾性分析经影像证实的52例急性肾梗死患者的临床资料,包括人口学数据、危险因素、临床表现、实验室检查、诊断、治疗及预后情况,并比较并发血尿患者与无血尿患者上述指标的差异。结果:52例急性肾梗死患者,其中34例男性、18例女性,平均年龄(56.3±14.8)岁。左、右肾及双肾受累比例分别为44.2%、34.6%和21.2%。局灶性、多灶性及大面积梗死的比例分别为36.5%、50.0%和13.5%。38.5%的患者同时合并其他脏器血栓栓塞事件,44.2%的患者合并心房颤动。常见症状包括胁腹痛(71.2%)、恶心(55.8%)、腰痛(53.9%)、呕吐(48.1%)、发热(48.1%)和腹泻(21.2%)。肾区叩痛是最常见的体征(40.4%)。血清乳酸脱氢酶、血白细胞计数及C-反应蛋白升高的患者比例分别为86.5%、67.3%和54.5%。38.5%的患者在就诊时并发血尿。血清D-二聚体升高仅见于56.5%的患者。就诊至确诊的中位时间为41.5 h(2~552 h)。47例患者(90.4%)经增强计算机断层显像明确诊断、5例患者(9.6%)经肾动脉造影明确诊断。抗凝治疗是最常采用的治疗方法。所有患者平均随访(39.4±35.8)个月,大多数患者肾功能稳定,4例需要持续透析治疗,1例死于心力衰竭。血尿患者的血清乳酸脱氢酶显著高于无血尿患者[773.5 IU/L (153.0~3 159.0 IU/L) vs. 488.0 IU/L (137.0~3 370.0 IU/L),P=0.041],其他临床表现、诊断、治疗及预后情况组间差异无统计学意义。结论:心源性血栓栓塞是急性肾梗死最常见的病因,对于持续腰腹痛、血乳酸脱氢酶升高且存在危险因素的患者宜进行腹部增强计算机断层显像以助早期诊断。血尿并非常见的临床表现且与预后无关,其出现与否可能取决于梗死的严重程度。

关键词: 急性肾梗死, 血栓栓塞, 血尿, 增强计算机断层显像, 乳酸脱氢酶

Abstract:

Objective:To investigate the clinical characteristics of patients with acute renal infarction (ARI) and explore the possible clinical and/or laboratory parameters relative to hematuria. Methods: Medical records of 52 patients hospitalized with radiologic proven ARI were retrospectively reviewed. Clinical characteristics, including demographic data, risk factors for thromboembolism, initial clinical presentations, laboratory data, diagnosis, treatment programs and outcomes were evaluated and compared between hematuria(+) and hematuria(-) patients. Results: The mean age of the patients (34 men and 18 women) was (56.3±14.8) years. The left, right, and bilateral kidneys were involved in 44.2%, 34.6% and 21.2% of the patients, respectively. Focal, multiple and massive infarctions were involved in 36.5%, 50.0% and 13.5% of the patients. The prevalence of concurrent thromboembolic events was 38.5%. Atrial fibrillation was complicated in 44.2% of the patients. ARI often presented with non-specific symptoms, including abdominal/flank pain (71.2%), nausea (55.8%), lumbar pain (53.9%), vomiting (48.1%), fever (48.1%), and diarrhea (21.2%). Percussion tenderness over kidney region was the most common sign (40.4%). The levels of serum lactate dehydrogenase, white blood cell count and C-reactive protein were elevated in 86.5%, 67.3%, and 54.5% of cases, respectively. Hematuria was detected in only 38.5% of the cases on admission. Elevation of serum D-dimer was only noted in 56.5% of the patients. The median duration from hospital presentation to diagnosis was 41.5 h (range: 2-552 h). Contrast-enhanced computed tomography was diagnostic in 47 (90.4%) cases. Angiography was positive in the other 5 (9.6%) cases. Anticoagulation was the most common therapy. During a mean follow-up of (39.4±35.8) months, renal functions of most patients were stable. Four patients needed permanent dialysis and one patient died of heart failure. There was no statistical significance between hematuria(+) group and hematuria(-) group for all the parameters except the level of serum lactate dehydrogenase, which was higher in hematuria(+) group [773.5 IU/L (range: 153.0-3 159.0 IU/L) vs. 488.0 IU/L (range: 137.0-3 370.0 IU/L), P=0.041]. Conclusion: Thromboembolism due to heart disease is the main etiology of ARI. Early contrast-enhanced computed tomography scan should be considered for high-risk patients with persisting abdominal or lumbar pain and elevated serum level of lactate dehydrogenase. Hematuria is not a sensitive clue for diagnosis and is not relative to prognosis. Whether it is present may be determined by the severity of infarction.

Key words: Acute renal infarction, Thromboembolism, Hematuria, Contrast-enhanced computed tomography, Lactate dehydrogenase

中图分类号: 

  • R692.2

表1

急性肾梗死患者的临床特征"

Items Total (n=52) Hematuria(+) (n=20) Hematuria(-) (n=32) Statistics P
Age/years 56.3±14.8 55.9±14.7 56.6±15.1 0.18 0.86
Male 34 (65.4) 13 (65.0) 21 (65.6) 0 0.96
BMI/(kg/m2) 24.1±3.8 23.7±4.1 24.2±3.8 0.34 0.74
Time from symptom presentation to
urinanalysis/h
24 (1, 360) 24 (1, 360) 24 (2, 288) 1.12 0.27
Symptoms/signs
Abdominal/flank pain 37 (71.2) 14 (70.0) 23 (71.9) 0.02 0.89
Lumbar pain 28 (53.9) 10 (50.0) 18 (56.3) 0.19 0.66
No pain 4 (7.7) 3 (15.0) 1 (3.1) - 0.29*
Nausea 29 (55.8) 11 (55.0) 18 (56.3) 0.01 0.93
Vomiting 25 (48.1) 11 (55.0) 14 (43.8) 0.62 0.43
Fever 25 (48.1) 13 (65.0) 12 (37.5) 3.73 0.05
Diarrhea 11 (21.2) 3 (15.0) 8 (25.0) - 0.50*
Oliguria 9 (17.3) 2 (10.0) 7 (21.9) - 0.45*
Fatigue 6 (11.5) 2 (10.0) 4 (12.5) - 1.00*
Percussion tenderness over
kidney region
21 (40.4) 9 (45.0) 12 (37.5) 0.29 0.59
Laboratory data
ALT/(IU/L) 42.0 (3.0, 201.0) 52.5 (13.0, 201.0) 39.5 (3.0, 127.0) -1.76 0.08
AST/(IU/L) 38.5 (12.0, 308.0) 40.5 (14.0, 308.0) 35.0 (12.0, 118.0) 0.55 0.14
LDH/(IU/L) 511.0 (137, 3 370) 773.5 (153.0, 3 159.0) 488.0 (137.0, 3 370.0) -2.13 0.04
Creatinine/(μmol/L) 118.0 (63.5, 824.8) 123.5 (77.0, 526.0) 114.5 (63.5, 824.8) -0.56 0.57
eGFR/[mL/(min·1.73 m2)] 56.8±27.2 53.1±29.5 59.0±26.0 0.74 0.46
UA/(μmol/L) 355.8±116.3 351.6±105.5 358.1±123.7 0.18 0.86
TG/(mmol/L) 1.06 (0.20, 4.08) 1.05 (0.40, 4.08) 1.08 (0.20, 2.56) -0.01 0.99
TCHO/(mmol/L) 4.15±1.05 4.15±1.23 4.15±0.94 -0.03 0.98
LDL-C/(mmol/L) 2.62±0.88 2.54±0.93 2.67±0.86 0.48 0.63
WBC/(×103/μL) 11.9 (2.7, 32.2) 12.3 (6.5, 25.6) 10.8 (2.7, 32.2) -1.60 0.12
Plt/(×104/μL) 20.5 (7.4, 49.7) 20.9 (10.1, 32.0) 20.1 (7.4, 49.7) 0.70 0.49
CRP/(mg/dL) 30.3 (0.5, 249.0) 69.0 (1.8, 249.0) 5.7 (0.5, 189.4) -1.84 0.07
Fibrinogen/(g/L) 4.6±1.8 4.3±1.8 4.7±1.8 0.63 0.54
D-dimer > normal upper limit 26/46 (56.5) 12/17 (70.6) 14/29 (48.3) 2.17 0.14
Left 23 (44.2) 9 (45.0) 14 (43.8)
Right 18 (34.6) 5 (25.0) 13 (40.6) 0.35
Bilateral 11 (21.2) 6 (30.0) 5 (15.6)
Focal infarction 19 (36.5) 5 (25.0) 14 (43.8)
Multiple infarction 26 (50.0) 12 (60.0) 14 (43.8) 0.39
Global ARI 7 (13.5) 3 (15.0) 4 (12.5)
Items Total (n=52) Hematuria(+) (n=20) Hematuria(-) (n=32) Statistics P
Concurrent thromboembolism 20 (38.5) 7 (35.0) 13 (40.6) 0.16 0.69
Splenic infarction 11 (21.2) 4 (20.0) 7 (21.9) - 1.00*
Lower extremity arterial embolism 5 (9.6) 0 (0) 5 (15.6) - 0.14*
Mesenteric arterial embolism 4 (7.7) 2 (10.0) 2 (6.3) - 0.63*
Iliaic artery embolism 1 (1.9) 1 (5.0) 0 (0) - 0.39*
Cerebral infarction 5 (9.6) 3 (15.0) 2 (6.3) - 0.36*
Liver infarction 1 (1.9) 1 (5.0) 0 (0) - 0.39*
Pulmonary thromboembolism 1 (1.9) 1 (5.0) 0 (0) - 0.39*
Pancreatic infarction 1 (1.9) 1 (5.0) 0 (0) - 0.39*

表2

急性肾梗死的危险因素和可能的病因"

Items Total (n=52) Hematuria(+) (n=20) Hematuria(-) (n=32) Statistics P
Risk factors for ARI
Atrial fibrillation 23 (44.2) 9 (45.0) 14 (43.8) 0.01 0.93
Malignancy 2 (3.8) 2 (10.0) 0 (0) - 0.14*
Hyperlipidemia 15 (28.8) 5 (25.0) 10 (31.3) 0.23 0.63
Homocysteinemia 5/6 (83.3) 3/3 (100.0) 2/3 (66.7) - 1.00*
Diabetes mellitus 4 (7.7) 1 (5.0) 3 (9.4) - 1.00*
Hypertension 26 (50.0) 13 (65.0) 13 (40.6) 2.92 0.09
Valvular heart disease 30 (57.7) 12 (60.0) 18 (56.3) 0.07 0.79
Aortic mural thrombus 6 (11.5) 2 (10.0) 4 (12.5) - 1.00*
Aortic dissection 2 (3.8) 1 (5.0) 1 (3.1) - 1.00*
Congestive heart failure 5 (9.6) 2 (10.0) 3 (9.4) - 1.00*
Coronary artery disease 12 (23.1) 5 (25.0) 7 (21.9) 0.07 0.8
Antiphospholipid syndrome 1 (1.9) 1 (5.0) 0 (0) - 0.39*
Smoking (current/exsmoker) 20 (38.5) 9 (45.0) 11 (34.4) 0.59 0.44
Renal artery stenosis 17 (32.7) 4 (20.0) 13 (40.6) 2.38 0.12
Cerebrovascular disease 3 (5.8) 2 (10.0) 1 (3.1) - 0.55*
Obesity 6/35 (17.1) 1/11(9.1) 5/24 (20.8) - 0.64*
Cardiomyopathy 3 (5.8) 1 (5.0) 2 (6.3) - 1.00*
Etiologies of ARI
Thromboembolism 30 (57.7) 10 (50.0) 20 (62.5) 0.79 0.38
In situ thrombosis 5 (9.6) 2 (10.0) 3 (9.4) - 1.00*
Coagulation dysfunction 6 (11.5) 4 (20.0) 2 (6.3) - 0.19*
Idiopathic 0 (0) 0 (0) 0 (0) - -
Unknown 11 (21.2) 4 (20.0) 7 (21.9) - 1.00*

表3

急性肾梗死患者的诊断、治疗和预后"

Items Total
(n=52)
Hematuria(+)
(n=20)
Hematuria(-)
(n=32)
Statistics P
Time from hospital presentation to diagnosis/h 41.5 (2.0, 552.0) 24.0 (2.0, 552.0) 48.0 (2.0, 408.0) 0.39 0.70
Diagnostic methods
Contrast-enhanced CT 47 (90.4) 19 (95.0) 28 (87.5) - 0.64*
Ultrasound 0 (0) 0 (0) 0 (0) - -
MRI 0 (0) 0 (0) 0 (0) - -
Angiography 5 (9.6) 1 (5.0) 4 (12.5) - 0.64*
Treatment
Anticoagulation 25 (48.1) 10 (50.0) 15 (46.9) 0.05 0.83
Antiplatelet 2 (3.8) 0 (0) 2 (6.3) - 0.52*
Systemic thrombolysis+anticoagulation 9 (17.3) 6 (30.0) 3 (9.4) - 0.07*
Catheter-directed thrombolysis+anticoagulation 7 (13.5) 2 (10.0) 5 (15.6) - 0.69*
Interventional therapy+anticoagulation 1 (1.9) 0 (0) 1 (3.1) - 1.00*
Interventional therapy+antiplatelet 4 (7.7) 1 (5.0) 3 (9.4) - 1.00*
Surgery+anticoagulation 0 (0) 0 (0) 0 (0) - -
No 4 (7.7) 1 (5.0) 3 (9.4) - 1.00*
Prognosis
Duration of symptom after treatment/d 3 (1, 12) 4 (1, 12) 3 (1, 9) -0.81 0.43
Median time of hospital stay/d 13 (2, 64) 18 (3, 64) 11 (2, 42) -1.35 0.18
Inhospital mortality 0 (0) 0 (0) 0 (0) - -
Creatinine/(μmol/L), discharge 102.0 (60.0, 1 043.0) 111.0 (66.0, 896.0) 99.0 (60.0, 1 043.0) -1.46 0.15
eGFR/[mL/(min·1.73 m2)], discharge 64.6±29.3 57.4±30.6 68.8±28.2 1.25 0.22
Dialysis-dependent, follow-up 4 (7.7) 2 (10.0) 2 (6.3) - 0.63*
Creatinine/(μmol/L), follow-up 116.6±20.9 118.8±23.4 113.7±18.5 0.47 0.65
eGFR/[mL/(min·1.73 m2)], follow-up 52.8±15.3 52.3±14.7 53.4±17.2 -0.14 0.90
[1] Saeed K . Renal infarction[J]. Int J Nephrol Renovasc Dis, 2012,5:119-123.
[2] Ma YC, Zuo L, Chen JH , et al. Modified glomerualr filtration rate estimating equation for Chinese patients with chronic kidney disease[J]. J Am Soc Nephrol, 2006,17(10):2937-2944.
[3] Suzer O, Shirkhoda A, Jafri SZ , et al. CT features of renal infarction[J]. Eur J Radial, 2002,44(1):59-64.
[4] Nagasawa T, Matsuda K, Takeuchi Y , et al. A case series of acute renal infarction at a single center in Japan[J]. Clin Exp Nephrol, 2016,20(3):411-415.
[5] Yang J, Lee JY, Na YJ , et al. Risk factors and outcomes of acute renal infarction[J]. Kidney Res Clin Pract, 2016,35(2):90-95.
[6] Vermond RA, Geelhoed B, Verweij N , et al. Incidence of atrial fibrillation and relationship with cardiovascular events, heart failure, and mortality: a community-based study from the Netherlands[J]. J Am Coll Cardiol, 2015,66(9):1000-1007.
[7] Frost L, Engholm G, Johnsen S , et al. Incident thromboembolism in the aorta and the renal, mesenteric, pelvic, and extremity arteries after discharge from the hospital with a diagnosis of atrial fibrillation[J]. Arch Intern Med, 2001,161(2):272-276.
[8] Oh YK, Yang CW, Kim YL , et al. Clinical characteristics and outcomes of renal infarction[J]. Am J Kidney Dis, 2016,67(2):243-250.
[9] Antopolsky M, Simanovsky N, Stalnikowicz R , et al. Renal infarction in the ED: 10-year experience and review of the literature[J]. Am J Emerg Med, 2012,30(7):1055-1060.
[10] Adam SS, Key NS, Greenberg CS . D-dimer antigen: current concepts and future prospects[J]. Blood, 2009,113(13):2878-2887.
[11] de la Iglesia F, Asensio P, Diaz A , et al. Acute renal infarction as a cause of low-back pain[J]. South Med J, 2003,96(5):497-499.
[12] Miyoshi T, Okayama H, Hiasa G , et al. Contrast-enhanced ultrasound for the evaluation of acute renal infarction[J]. J Med Ultrasonics, 2016,43(1):141-143.
[13] Yun WS . Long-term follow-up results of acute renal embolism after anticoagulation therapy[J]. Ann Vasc Surg, 2015,29(3):491-495.
[14] Hsiao PJ, Wu TJ, Lin SH . Cortical rim sign and acute renal infarction[J]. CMAJ, 2010,182(8):E313.
[15] Mesiano P, Rollino C, Beltrame G , et al. Acute renal infarction: a single center experience[J]. J Nephrol, 2017,30(1):103-107.
[16] Silverberg D, Menes T, Rimon U , et al. Acute renal artery occlusion: presentation, treatment and outcome[J]. J Vasc Surg, 2016,64(4):1026-1032.
[17] Rhee H, Song SH, Lee DW , et al. The significance of clinical features in the prognosis of acute renal infrction: single center experience[J]. Clin Exp Nephrol, 2012,16(4):611-616.
[1] 朱冯赟智,邢晓燕,汤晓菲,李依敏,邵苗,张学武,李玉慧,孙晓麟,何菁. 肌炎合并血栓栓塞患者的临床及免疫学特征[J]. 北京大学学报(医学版), 2020, 52(6): 995-1000.
[2] 张玮,张培训. 老年髋部骨折患者围手术期血栓预防时限分析[J]. 北京大学学报(医学版), 2019, 51(3): 501-504.
[3] 顾婕昱,陆翠,石慧,杨程德. 14例恶性抗磷脂综合征病例报道及临床分析[J]. 北京大学学报(医学版), 2018, 50(6): 1033-1038.
[4] 于路平,赵卫红,刘士军,李清,徐涛. 先天性肾动静脉瘘伴肾动脉多支畸形病例分析[J]. 北京大学学报(医学版), 2018, 50(4): 722-728.
[5] 吴静静, 杨莉. 278例静脉血栓栓塞症医疗保险患者住院费用分析[J]. 北京大学学报(医学版), 2013, 45(03): 437-442.
[6] 郭晓玥, 魏瑗, 张立华, 贺豪杰, 王妍, 赵扬玉. 剖宫产术后左侧卵巢静脉血栓1例报告[J]. 北京大学学报(医学版), 2012, 44(3): 492-494.
[7] 于峥嵘, 李淳德, 邑晓东, 林景荣, 刘宪义, 刘洪, 卢海霖. 脊柱手术后静脉血栓栓塞的预防[J]. 北京大学学报(医学版), 2011, 43(5): 661-665.
[8] 于芳, 赵晶, 唐朝枢, 耿彬, . 自行合成硫化氢缓释供体GYY4137对细胞活力的影响及其释放的硫化氢在小鼠体内的分布[J]. 北京大学学报(医学版), 2010, 42(5): 493-497.
[9] 李振荣, 张捷, 王天成, 李国权. 对乳酸脱氢酶同工酶谱的异常区带和增高的乳酸脱氢酶1组织来源的分析[J]. 北京大学学报(医学版), 2004, 36(5): 552-553.
[10] 张立, 蔡钦林, 党耕町, 刘忠军. Frankel-A型急性颈脊髓损伤后继发的低钠血症[J]. 北京大学学报(医学版), 2000, 32(4): 369-373.
Viewed
Full text


Abstract

Cited

  Shared   
  Discussed   
[1] 田增民, 陈涛, Nanbert ZHONG, 李志超, 尹丰, 刘爽. 神经干细胞移植治疗遗传性小脑萎缩的临床研究(英文稿)[J]. 北京大学学报(医学版), 2009, 41(4): 456 -458 .
[2] 郭岩, 谢铮. 用一代人时间弥合差距——健康社会决定因素理论及其国际经验[J]. 北京大学学报(医学版), 2009, 41(2): 125 -128 .
[3] 成刚, 钱振华, 胡军. 艾滋病项目自愿咨询检测的技术效率分析[J]. 北京大学学报(医学版), 2009, 41(2): 135 -140 .
[4] 卢恬, 朱晓辉, 柳世庆, 郑杰, 邱晓彦. 白细胞介素2促进宫颈癌细胞系HeLaS3免疫球蛋白G的表达[J]. 北京大学学报(医学版), 2009, 41(2): 158 -161 .
[5] 袁惠燕, 张苑, 范田园. 离子交换型栓塞微球及其载平阳霉素的制备与性质研究[J]. 北京大学学报(医学版), 2009, 41(2): 217 -220 .
[6] 徐莉, 孟焕新, 张立, 陈智滨, 冯向辉, 释栋. 侵袭性牙周炎患者血清中抗牙龈卟啉单胞菌的IgG抗体水平的研究[J]. 北京大学学报(医学版), 2009, 41(1): 52 -55 .
[7] 董稳, 刘瑞昌, 刘克英, 关明, 杨旭东. 氯诺昔康和舒芬太尼用于颌面外科术后自控静脉镇痛的比较[J]. 北京大学学报(医学版), 2009, 41(1): 109 -111 .
[8] 祁琨, 邓芙蓉, 郭新彪. 纳米二氧化钛颗粒对人肺成纤维细胞缝隙连接通讯的影响[J]. 北京大学学报(医学版), 2009, 41(3): 297 -301 .
[9] 李宏亮*, 安卫红*, 赵扬玉, 朱曦. 妊娠合并高脂血症性胰腺炎行血液净化治疗1例[J]. 北京大学学报(医学版), 2009, 41(5): 599 -601 .
[10] 李伟军, 邢晓芳, 曲立科, 孟麟, 寿成超. PRL-3基因C104S位点突变体和CAAX缺失体的构建及表达[J]. 北京大学学报(医学版), 2009, 41(5): 516 -520 .