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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

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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
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