尿白蛋白肌酐比增高预测急性缺血性卒中短期预后的临床研究

doi:10.3969/j.issn.1673-5765.2019.11.002

摘要/Abstract

摘要：

目的观察急性缺血性卒中（acute ischemic stroke，AIS）患者的临床特点及入院时的尿白蛋白肌酐比（albumin-to-creatinine ratio，ACR）和估算的肾小球滤过率（evaluated glomerular filtration rate，eGFR）对患者3个月预后的影响。方法本研究为前瞻性研究，连续性纳入北京医院2017年3月27日-11月16日住院治疗的AIS患者作为研究对象。收集患者一般资料、血管危险因素、ACR、eGFR和其他相关实验室检查结果，评估患者入院时NIHSS评分，随访3个月时的mRS评分。按照患者是否有肾功能障碍分为肾功能障碍组和肾功能正常组，比较两组的临床特点；按照患者3个月的mRS评分，分为预后良好组（mRS评分0～2分）和预后不良组（mRS评分3～6分），比较两组的上述临床特点，并分析3个月预后不良的独立危险因素。结果共纳入115例患者，AIS患者的肾功能障碍患病率为44.3%（51/115）。与肾功能正常组相比，肾功能障碍组平均年龄较高（P =0.009）；糖尿病（P =0.001）、冠状动脉粥样硬化性心脏病（P =0.026）、心房颤动（P =0.003）的发病率较高；入院时NIHSS评分（P =0.013）、入院后的血糖（P =0.001）、血浆纤维蛋白原（P =0.008）及D -二聚体（P =0.001）水平较高。与预后良好组相比，预后不良组的平均年龄较高（P =0.007）；既往卒中史（P =0.002）、心房颤动患病率（P =0.040）、血浆纤维蛋白原（P =0.004）及D-二聚体水平（P <0.001）较高；入院时NIHSS评分（P <0.001）较高。高血压、糖尿病、血脂代谢异常、冠状动脉粥样硬化性心脏病、吸烟史在预后良好组及预后不良组的差异无统计学意义。与预后良好组相比，预后不良组ACR更高（P <0.001），而eGFR（P =0.030）更低。多因素分析显示入院时NIHSS评分≥8分（OR 27.05，95%CI 3.75～178.18，P=0.001）、ACR≥3 mg/mmo（l OR 35.50， 95%CI 4.79～262.94，P＜0.001）、卒中史（OR 20.48，95%CI 2.35～178.18，P =0.006）是3个月预后不良的独立危险因素。结论 AIS患者的肾功能障碍患病率较高，入院时ACR增高的AIS患者3个月预后较差。

文章导读： 急性缺血性卒中患者的肾功能障碍患病率较高，且入院尿白蛋白肌酐比增高时，其3个月预后较差。多因素分析显示，入院时白蛋白肌酐比≥3 mg/mmol是急性缺血性卒中患者3个月预后不良的危险因素，其对3个月预后不良的预测作用优于估算的肾小球滤过率。

关键词: 急性缺血性卒中; 肾功能障碍; 尿白蛋白肌酐比; 肾小球滤过率; 预后

Abstract:

Objective To investigate the clinical characteristics of acute ischemic stroke (AIS) patients, and the effect of urinary albumin-to-creatinine ratio (ACR), the evaluated glomerular filtration rate (eGFR) at admission on the functional outcome at 90 days in AIS patients. Methods This was a prospective study which enrolled consecutive AIS patients who were hospitalized in Department of Neurology, Beijing Hospital from March 27, 2017 to November 16, 2017. Data of general information, vascular risk factors, ACR, eGFR, and related laboratory tests, NIHSS score on admission were collected. The outcome was evaluated by a mRS score at 3 months. Based on renal function state, all patients were divided into renal dysfunction group and normal renal function group, and the clinical characteristics between the two groups were compared. Based on the mRS at 3 months, all patients were divided into good prognosis group (mRS: 0-2) and poor prognosis group (mRS: 3-6), the clinical characteristics between the two groups were compared and independent risk factors for poor prognosis at 3 months were analyzed. Results A total of 115 patients were included in this study. The prevalence of renal dysfunction in AIS patients was 44.3% (51/115). Compared with normal renal function group, renal dysfunction group had a higher mean age (P =0.009), and higher incidence of diabetes (P =0.001), coronary heart disease (P =0.026) and atrial fibrillation (P =0.003), and a higher NIHSS score (P =0.013) on admission, and higher levels of blood glucose (P =0.001), plasma fibrinogen (P =0.008) and D-dimer (P =0.001) on admission. Compared with good prognosis group, poor prognosis group had a higher mean age (P =0.007), a higher rate of history of stroke (P =0.002), a higher incidence of atrial fibrillation (P =0.040), higher levels of plasma fibrinogen (P =0.004) and D-dimer (P <0.001), higher NIHSS (P <0.001) score on admission. There were no statistical difference in hypertension, diabetes, abnormal lipid metabolism, coronary atherosclerotic heart disease, and smoking history between the good prognosis and poor prognosis groups. Compared with the good prognosis group, the poor prognosis group had higher ACR (P <0.001) and lower eGFR (P =0.030). Multivariate analysis showed that the NIHSS score≥8 on admission (OR 27.05, 95%CI 3.75-178.18, P =0.001), ACR≥3 mg/mmol (OR 35.50, 95%CI 4.79-262.94, P <0.001), history of stroke (OR 20.48, 95%CI 2.35- 178.18, P =0.006) were independent risk factors for poor prognosis at 3 months. Conclusions AIS patients had a higher prevalence of renal dysfunction. The AIS patients with high ACR at admission had a poorer outcome at 3 months.

Key words: Acute ischemic stroke; Renal dysfunction; Urinary albumin creatinine ratio;Glomerular filtration rate; Prognosis

申致远, 陈玉辉, 龚涛. 尿白蛋白肌酐比增高预测急性缺血性卒中短期预后的临床研究[J]. 中国卒中杂志, 2019, 14(11): 1083-1088.

SHEN Zhi-Yuan, CHEN Yu-Hui, GONG Tao. The Prediction Value of High Urinary Albumin Creatinine Ratio for Short-term Functional Outcome in Acute Ischemic Stroke[J]. Chinese Journal of Stroke, 2019, 14(11): 1083-1088.

参考文献

[1] STEVENS P E，LEVIN A，Kidney Disease：

Improving Global Outcomes Chronic Kidney Disease

Guideline Development Work Group Members.

Evaluation and management of chronic kidney disease：

synopsis of the kidney disease：improving global

outcomes 2012 clinical practice guideline[J]. Ann

Intern Med，2013，158（11）：825-830.

[2] 中华人民共和国卫生部. 中华人民共和国卫生行业

标准：WS 319-2010[S]. 北京：中国标准出版社，2010：

1-8.

[3] 中国高血压防治指南修订委员会. 中国高血压防治

指南（2010年修订版）[J]. 中国实用乡村医生杂志，

2012，19（12）：1-15.

[4] 中华医学会糖尿病学分会. 中国2型糖尿病防治指南

（2010年版）[J]. 中国糖尿病杂志，2012，20（1）：54-

109.

[5] 中华医学会神经病学分会，中华医学会神经病学分

会脑血管病学组. 中国急性缺血性脑卒中诊治指南

2014[J]. 中华神经科杂志，2015，48（4）：246-257.

[6] 中华医学会心电生理和起搏分会，中国医师协会心

律学专业委员会心房颤动防治专家工作委员会. 心房

颤动：目前的认识和治疗建议-2015[J]. 中国心脏起

搏与心电生理杂志，2015，19（5）：377-434.

[7] 中国成人血脂异常防治指南修订联合委员会. 中国

成人血脂异常防治指南（2016年修订版）[J]. 中国循

环杂志，2016，31（10）：937-950.

[8] DEGRABA T J，HALLENBECK J M，PETTIGREW

K D，et al. Progression in acute stroke：value of the

initial NIH stroke scale score on patient stratification

in future trials[J]. Stroke，1999，30（6）：1208-1212.

[9] KASNER S E. Clinical interpretation and use of

stroke scales[J]. Lancet Neurol，2006，5（7）：603-

612.

[10] LEVEY A S，STEVENS L A，SCHMID C H，et

al. A new equation to estimate glomerular filtration

rate[J]. Ann Intern Med，2009，150（9）：604-612.

[11] BROSIUS F C 3rd，HOSTETTER T H，

KELEPOURIS E，et al. Detection of chronic

kidney disease in patients with or at increased

risk of cardiovascular disease：a science advisory

from the American Heart Association Kidney And

Cardiovascular Disease Council；the Councils on High Blood Pressure Research，Cardiovascular

Disease in the Young，and Epidemiology and

Prevention；and the Quality of Care and Outcomes

Research Interdisciplinary Working Group：

developed in collaboration with the National Kidney

Foundation[J]. Hypertension，2006，48（4）：751-755.

[12] JHA V，GARCIA-GARCIA G，ISEKI K，et al.

Chronic kidney disease：global dimension and

perspectives[J]. Lancet，2013，382（9888）：260-272.

[13] ZHANG L，WANG F，WANG L，et al. Prevalence

of chronic kidney disease in China：a cross-sectional

survey[J]. Lancet，2012，379（9818）：815-822.

[14] FABJAN T H，HOJS R. Ischemic stroke：the impact

of renal dysfunction on 1-year mortality[J]. Wien Klin

Wochenschr，2015，127（Suppl 5）：S175-S180.

[15] LIN S W，WENG W C，HUANG Y H，et al.

Association between renal dysfunction and 3-year

mortality in patients with acute first-ever ischemic

stroke[J/OL]. Clin Neurol Neurosurg，2015，137：15-21.

https：//doi.org/10.1016/j.clineuro.2015.06.008.

[16] YEH S J，JENG J S，TANG S C，et al. Low estimated

glomerular filtration rate is associated with poor

outcomes in patients who suffered a large artery

atherosclerosis stroke[J]. Atherosclerosis，2015，239

（2）：328-334.

[17] WATANABE Y，SUDA S，KANAMARU T，et al.

High urinary albumin/creatinine ratio at admission

predicts poor functional outcome in patients with acute

ischemic stroke[J]. Nephrology（Carlton），2016，22

（3）：199-204.

[18] HAYDEN D，MCCARTHY C，AKIJIAN L，et

al. Renal dysfunction and chronic kidney disease

in ischemic stroke and transient ischemic attack：a

population-based study[J]. Int J Stroke，2017，12（7）：

761-769.

[19] MASSON P，WEBSTER A C，HONG M，et al.

Chronic kidney disease and the risk of stroke：a

systematic review and meta-analysis[J]. Nephrol Dial

Transplant，2015，30（7）：1162-1169.

[20] HSIEH Y T，KUO J F，SU S L，et al. Subnormal

estimated glomerular filtration rate strongly predict

incident cardiovascular events in type 2 diabetic

Chinese population with normoalbuminuria[J/OL].

Medicine（Baltimore），2016，95（2）：e2200.

https：//doi.org/10.1097/MD.0000000000002200.

[21] KUWASHIRO T，KAMOUCHI M，AGO T，et al.

The factors associated with a functional outcome after

ischemic stroke in diabetic patients：the Fukuoka

Stroke Registry[J]. J J Neurol Sci，2012，313（1-2）：

110-114.

[22] KUMAI Y，KAMOUCHI M，HATA J，et al.

Proteinuria and clinical outcomes after ischemic

stroke[J]. Neurology，2012，78（24）：1909-1915.

[23] HUANG Y C，WU Y L，LEE M H，et al. Association

of renal biomarkers with 3-month and 1-year outcomes

among critically ill acute stroke patients[J/OL]. PloS

one，2013，8（9）：e72971. https：//doi.org/10.1371/

journal.pone.0072971.

[24] MATSUSHITA K，CORESH J，SANG Y，et al.

Estimated glomerular filtration rate and albuminuria for

prediction of cardiovascular outcomes：a collaborative

meta-analysis of individual participant data[J]. Lancet

Diabetes Endocrinol，2015，3（7）：514-525.

[25] BABER U，MANN D，SHIMBO D，et al. Combined

role of reduced estimated glomerular filtration rate

and microalbuminuria on the prevalence of peripheral

arterial disease[J]. Am J Cardiol，2009，104（10）：

1446-1451.

[26] NAKAYAMA M，METOKI H，TERAWAKI H，et

al. Kidney dysfunction as a risk factor for first

symptomatic stroke events in a general Japanese

population--the Ohasama study[J]. Nephrol Dial

Transplant，2007，22（7）：1910-1915.

[27] NINOMIYA T. Risk of stroke in kidney disease[J/

OL]. Contrib Nephrol，2013，179：58-66. https：//doi.

org/10.1159/000346724.

[28] TSURUOKA S，KAI H，USUI J，et al. Effects of

irbesartan on inflammatory cytokine concentrations

in patients with chronic glomerulonephritis[J]. Intern

Med，2013，52（3）：303-308.

[29] CHO B H，KIM J T，CHANG J，et al. Prediction of

hemorrhagic transformation in acute ischaemic stroke

by micro- and macroalbuminuria after intravenous

thrombolysis[J]. Eur J Neurol，2013，20（8）：1145-

1152.

[30] ZAHRAN M，NASR F M，METWALY A A，et

al. The role of hemostatic factors in atherosclerosis

in patients with chronic renal disease[J]. Electron

Physician，2015，7（5）：1270-1276.

[31] GANSEVOORT R T，CORREA-ROTTER R，

HEMMELGARN B R，et al. Chronic kidney disease

and cardiovascular risk：epidemiology，mechanisms，

and prevention[J]. Lancet，2013，382（9889）：339-352.