基于NGAL的模型在肝硬化急性肾损伤早期诊断和鉴别诊断中的意义

摘要/Abstract

摘要： 目的明确早期检测NGAL对诊断肝硬化急性肾损伤的意义以及基于NGAL的模型在鉴别肝硬化急性肾损伤类型中的意义。方法对住院的肝硬化(失代偿期)患者按照入排标准进行前瞻性观察,一旦发生AKI,根据ICA-AKI新指南进行诊断和治疗,在诊断AKI的24 h内检测晨起的卧位醛固酮和血管紧张素Ⅱ、收集晨起尿液离心取上清检测uNGAL,评估NGAL对AKI诊断的意义,并根据收集到的数据设计早期鉴别诊断系统。结果纳入研究的肝硬化(失代偿期)患者共804例,住院期间并发AKI或入院时即存在AKI的患者为213例。肝硬化AKI患者uNGAL水平比未发生AKI的肝硬化患者高(t=11.439,P=0.000);不同类型的AKI患者uNGAL的表达水平不同,PRA、HRS、ATN分别为(323.08±106.93)、(486.27±164.67)和(882.43±440.92) ng/mL,差异有统计学意义(F=48.774,P<0.01)。uNGAL对AKI 2期以上的鉴别诊断有意义,特别是对ATN的鉴别,ROC曲线中根据约登指数确定的阈值为522.72 ng/mL,敏感度为0.938,特异度为0.655,采用621.73 ng/mL阈值(敏感度为0.750,特异度为0.800)更符合临床的需要。醛固酮和血管紧张素Ⅱ在不同类型的AKI中表达有差异,但组间分析和多因素分析显示对鉴别HRS和ATN意义不大。结论 uNGAL作为新型标志物,可以作为肝硬化急性肾损伤患者诊断AKI的依据,早期检测对于鉴别ATN型AKI的有较大的意义。

关键词: 肝硬化急性肾损伤, 中性粒明胶酶酯质转运体, 鉴别诊断

Abstract: Objective To clarify the significance of early detection of neutrophil gelatinase-associated lipocalin (NGAL) in the diagnosis of acute kidney injury (AKI) in cirrhotic patients and the significance of NGAL-based model in differentiating the types of AKI. Methods A total of 804 patients with decompensated cirrhosis were included in the study. 213 patients (26.5%) were hospitalized with AKI or had AKI at admission. Once AKI occurred, the patients were diagnosed and treated according to the new ICA(International-Club of Ascites)-AKI guidelines. Blood aldosterone and angiotensin Ⅱ levels of the patients in the lying position in the morning were detected within 24 hours after the diagnosis of AKI. Urine NGAL (uNGAL) level was detected in the supernatant of centrifuged morning urine. The significance of NGAL in the diagnosis of AKI was evaluated and data were collected to develop an early differential diagnosis system. Results The uNGAL of cirrhotic patients with AKI was higher than that of decompensated cirrhotic patients without AKI (t=11.439, P=0.000); the levels of uNGAL were significantly different within pre-azotemia (PRA,323.08±106.93), hepatorenal syndrome (HRS,486.27±164.67) and acute tubular necrosis patients(ATN,882.43±440.92 ng/mL) (F=48.774,P=0.000). After further stratification with AKI stage, uNGAL was found to be meaningful in differentiating AKI above stage 2,especially ATN. The threshold determined by Yoden index under receiver operating characteristic curve(ROC)is 522.72ng/mL (sensitivity: 0.938, specificity: 0.655).The threshold of 621.73ng/mL (sensitivity: 0.750, specificity: 0.800) showed a higher sensitivity and was more fit for clinical requirement. The expression levels of aldosterone and angiotensin II were different in different types of AKI (P=0.000), but the intergroup analysis and multivariate analysis showed little significance for differentiating HRS from ATN. Conclusion As a new marker, uNGAL is useful for diagnosing AKI in cirrhotic patients. Early detection of uNGAL is of greater significance for differentiating ATN-type AKI.

Key words: Acute kidney injury in cirrhosis, Neutrophil gelatinase ester transporter, Differential diagnosis

尹伟, 李成忠. 基于NGAL的模型在肝硬化急性肾损伤早期诊断和鉴别诊断中的意义[J]. 肝脏, 2021, 26(3): 247-251.

YIN Wei, LI Cheng-zhong. Significance of NGAL-based model in early diagnosis and differential diagnosis of acute kidney injury in cirrhotic patients[J]. Chinese Hepatolgy, 2021, 26(3): 247-251.

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