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Relationship between Hepatic and Renal Function in Malignant Obstructive Jaundice Patients Undergoing Percutaneous Self-expanding Metal Biliary Stent
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摘要:
目的 探讨行经皮自膨式金属胆道支架(self-expanding metal biliary stents, SEMS)置入术重建内引流的恶性梗阻性黄疸患者肾功能相关的肝功能指标。 方法 回顾性分析2005年1月至2014年5月北京协和医院放射科采用"一步法"经皮SEMS置入术重建胆汁内引流的91例恶性梗阻性黄疸患者临床资料, 患者均于术前确诊为失去手术时机的恶性胆道梗阻, 其中男38例, 女53例; 平均年龄(67.25±13.41)岁; 平均住院时间(12.02±9.96)d。肾功能评价的主要指标之一为肌酐清除率, 并依据肾脏病膳食改良研究推荐公式法推算肾小球滤过率, 同时测定尿素氮和电解质(钠、钾、钙、氯)等相关指标。肝功能检查指标包括:总胆红素(total bilirubin, TB)、直接胆红素(direct bilirubin, DB)、丙氨酸转氨酶(alanine aminotransferase, ALT)、天冬氨酸转氨酶(aspartate aminotrans ferase, AST)、γ-谷氨酰基转移酶(gamma-glutamyl transferase, GGT)、碱性磷酸酶(alkaline phosphatase, ALP)、总蛋白(total protein, TP)和血清白蛋白(albumin, Alb)。数据来自入院后SEMS置入术前、术后出院前的肝、肾功能全自动生化分析仪检查结果。采用分位数回归分析方法研究与肾小球滤过率改变相关的影响因素。 结果 恶性梗阻性黄疸患者SEMS置入术后多项肝功能指标均较术前显著下降(P < 0.05), 其中TB、DB、ALT、AST、GGT、ALP、TP和Alb分别下降约23%、24%、36%、40%、59%、32%、25%和10%;而肾功能指标手术前后比较差异无统计学意义。通过分位数回归分析发现, 各项肝功能指标中仅DB/TB比值与肾小球滤过率显著相关(P=0.0034)。 结论 恶性梗阻性黄疸患者的DB/TB比值与肾功能明显相关, 对于DB/TB相对较高的患者应尽可能早采用"一步法"经皮SEMS置入术以恢复内引流。 Abstract:Objective To explore the hepatic function factors related to renal function in patients with malignant obstructive jaundice undergoing percutaneous self-expanding metal biliary stents (SEMS) implantation to restore internal drainage. Methods We reviewed the clinical data of 91 consecutive patients with malignant obstructive jaundice who received SEMS implantation to restore internal biliary drainage in Peking Union Medical College Hospital between January 2005 and May 2014. They were all preoperatively confirmed cases of inoperable malignant biliary obstruction, including 38 men and 53 women, with the mean age of (67.25±13.41) years and mean hospital stay of (12.02±9.96) days. Renal function was assessed by creatinine clearance rate, glomerular filtration rate (GFR) estimated using the Modification of Diet in Renal Disease (MDRD) formula, and blood urea nitrogen and electrolytes (Na, K, Ca, Cl) levels. Hepatic function was assessed by measuring levels of total bilirubin (TB), direct bilirubin (DB), alanine aminotransferase (ALT), aspartate aminotransferase(AST), gamma-glutamyl transferase (GGT), alkaline phosphatase (ALP), total protein (TP), and albumin (Alb). The data were all obtained with fully automatic biochemical analyzer before SEMS implantation, and before discharge. Quantile regression analysis was used to analyze hepatic functional factors related with GFR change. Results The hepatic function indicators significantly decreased after SEMS implantation in these patients(all P < 0.05), among which TB, DB, ALT, AST, GGT, ALP, TP, and Alb decreased by 23%, 24%, 36%, 40%, 59%, 32%, 25%, and 10%, respectively. While the renal function indicators showed no significant change after SEMS implantation. Quantile regression analysis showed that only serum DB/TB ratio was significantly correlated with GFR (P=0.0034). Conclusions DB/TB ratio in malignant obstructive jaundice may be associated with renal dysfunction. Early "one-step" percutaneous SEMS implantation is therefore recommended for patients with high DB/TB ratio to restore internal drainage. -
表 1 “一步法”SEMS置入术前后肝、肾功能生化指标比较(n=91，x±s)
时间 TB(μmol/L) DB(μmol/L) ALT(U/L) AST(U/L) GGT(U/L) ALP(U/L) TP(g/L) Alb(g/L) K(mmol/L) Na(mmol/L) Cl(mmol/L) Ca(mmol/L) BUN(μmol/L) Cr(μmol/L) GFR[ml/(min·1.73 m2)] 术前 174.06±142.38 127.64±94.48 129.94±97.55 129.70±75.65 759.00±661.06 427.78±200.11 58.54±37.77 34.06±5.22 3.87±0.39 134.72±11.27 99.70±5.11 2.66±3.26 4.24±2.29 63.38±33.93 8.23±3.19 术后 134.29±115.31 96.63±79.01 82.90±78.64 78.03±52.40 312.91±305.73 290.85±232.99 44.00±17.52 30.76±5.14 3.87±0.50 135.65±4.03 98.74±10.04 2.16±0.18 4.60±3.27 66.81±38.62 8.14±3.18 P 0.016 0.005 0.000 0.000 0.000 0.000 0.007 0.001 0.963 0.450 0.497 0.125 0.474 0.559 0.354 SEMS：自膨式金属胆道支架；TB：总胆红素；DB：直接胆红素；ALT：丙氨酸转氨酶；AST：天冬氨酸转氨酶；GGT：γ-谷氨酰基转移酶；ALP：碱性磷酸酶；TP：总蛋白；Alb：白蛋白；BUN：尿素氮；Cr：肌酐；GFR：肾小球滤过率 
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表 2 GFR与肝功能指标之间的分位数回归分析结果(α=0.5)
变量 系数 标准误 t值 P值 常数项 9.56 1.26 7.54 0.00 TB -0.01 0.01 -1.27 0.20 DB 0.00 0.01 0.35 0.72 ALT -0.01 0.01 -1.44 0.15 AST 0.01 0.01 1.29 0.20 GGT -0.00 0.00 -0.37 0.71 ALP 0.00 0.00 0.08 0.93 GFR、TB、DB、ALT、AST、GGT、ALP：同表 1
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表 3 GFR与DB/TB比值之间的分位数回归分析结果
项目 分位数 系数 标准误 t值 P值 常数项 0.10 3.06 0.63 4.82 0.00 0.20 4.34 0.67 6.45 0.00 0.30 4.24 0.63 6.69 0.00 0.40 4.27 0.69 6.18 0.00 0.50 5.35 0.82 6.47 0.00 0.60 6.72 1.03 6.52 0.00 0.70 8.52 1.11 7.65 0.00 0.80 10.54 1.08 9.72 0.00 0.90 13.06 0.84 15.47 0.00 DB/TB 0.10 2.81 0.82 3.43 0.00 0.20 2.06 0.90 2.27 0.02 0.30 2.82 0.81 3.49 0.00 0.40 3.37 0.88 3.85 0.00 0.50 3.10 1.05 2.96 0.00 0.60 2.16 1.24 1.74 0.08 0.70 1.35 1.30 1.03 0.30 0.80 0.23 1.20 0.19 0.85 0.90 -1.15 0.85 -1.35 0.15 GFR、DB、TB：同表 1
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