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王远龙, 刘建洪, 孙懿, 张盼. 肾细胞癌患者根治术后2~3期急性肾损伤发生危险因素研究[J]. 微创泌尿外科杂志, 2021,10(5): 331-334.
WANG Yuanlong, LIU Jianhong, SUN Yi, ZHANG Pan. Risk factors of AKI with stage 2-3 in RCC patients after radical operation. JOURNAL OF MINIMALLY INVASIVE UROLOGY,2021,10(5): 331-334.  
Doi:10.19558/j.cnki.10-1020/r.2021.05.009
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肾细胞癌患者根治术后2~3期急性肾损伤发生危险因素研究
王远龙1, 刘建洪1, 孙懿1, 张盼1
1绵阳市第三人民医院（四川精神卫生中心）泌尿外科 621000
通信作者：孙懿,103621862@qq.com
收稿日期: 2021-01-13
摘要
目的:探讨肾细胞癌（RCC）患者根治术后2~3期急性肾损伤（AKI）发生危险因素。方法:回顾性分析2010年1月–2020年9月收治的460例行根治手术治疗RCC患者的临床资料,根据是否发生2~3期AKI分为两组,采用单因素和多因素法评价RCC患者根治术后发生2~3期AKI独立危险因素。结果:460例患者中术后发生AKI 1~3期例数分别为314例、21例、5例,占比分别为68.26%、4.57%、1.09%。单因素分析结果显示,合并T2DM、高WBC计数及尿蛋白阳性均与RCC患者根治术后发生2~3期AKI有关（ P<0.05）。多因素分析结果显示,合并T2DM和高WBC计数均是RCC患者根治术后发生2~3期AKI的独立危险因素（ P<0.05）。结论:RCC患者中合并T2DM和高WBC计数人群根治术后更易发生2~3期AKI。
关键词: 肾细胞癌; 手术; 急性肾损伤; 危险因素
Risk factors of AKI with stage 2-3 in RCC patients after radical operation
WANG Yuanlong1, LIU Jianhong1, SUN Yi1, ZHANG Pan1
1Department of Urology, the Third People's Hospital of Mianyang City (Sichuan mental health center)
Corresponding author： SUN Yi, 103621862@qq.com
Abstract
Objective: To investigate the risk factors of AKI with stage 2-3 in RCC patients after radical operation.Methods: Clinical data of 460 RCC patients with HCC after radical operation were retrospectively chosen in the period from January 2010 to September 2020. All patients were grouped according to AKI with stage 2-3 or not and the independent risk factors of AKI with stage 2-3 in RCC patients after radical operation were evaluated by univariate and multivariate methods.Results: 460 patients included 314 cases with AKI stage 1 accounting for 68.26%, 4.57%, 21 cases with AKI stage 2 accounting for 4.57% and 5 cases with AKI stage 3 accounting for 1.09%respectively. Univariate analysis showed that T2DM, high WBC count and positive urine protein were associated with RCC with stage 2-3 AKI after radical resection（ P< 0.05）. Multivariate analysis showed that T2DM and high WBC count were independent risk factors for stage 2-3 AKI in RCC patients（ P< 0.05）.Conclusion: T2DM and high WBC count in patients with RCC after radical operation are more likely to occur AKI with stage 2-3.
Keyword: renal cell carcinoma; operation; acute kidney injury; risk factors

近年来肾细胞癌（renal cell carcinoma, RCC）发病率和发病例数呈上升趋势, 而外科手术被认为是肾癌患者唯一根治手段[1]。但大量研究显示, 根治性肾切除术是导致RCC患者术后慢性肾脏病（chronic kidney disease, CKD）发生独立危险因素[2, 3]; 但不同报道间患者术后远期肾功能存在诸多差异且原因尚不明确; 同时术后短期急性肾损伤（acute kidney injury, AKI）是否发生或病情严重程度已被证实与术后CKD发生独立相关; 故准确评估RCC患者术后早期肾功能对于临床预后预测具有重要意义[4]。基于以上证据, 本文回顾性分析我院2010年1月– 2020年9月收治行根治手术治疗RCC患者共460例临床资料, 根据是否发生2~3期AKI分组, 探讨RCC患者根治术后2~3期AKI发生危险因素, 现报告如下。

1 资料与方法
1.1 临床资料

研究纳入我院2010年1月– 2020年9月收治行根治手术治疗RCC患者共460例; 纳入标准：①病理组织学确诊RCC; ②顺利完成根治手术; ③年龄≥ 18岁。排除标准：①手术失败; ②住院期间死亡; ③临床资料不全。研究设计符合《赫尔辛基宣言》要求, 且患者及家属签署知情同意书。

1.2 方法

查阅病例记录性别、年龄、合并基础疾病、吸烟、实验室指标及术后AKI发生情况。AKI判定及分期标准参考KDIGO[5]：术后48 h内Cr升高> 基线水平1.5倍或绝对值升高≥ 26.5 μ mol/L; 1期指Cr水平升高达基础水平1.5~1.9倍或绝对值升高≥ 26.5 μ mol/L; 2期指Cr水平升高达基础水平2.0~2.9倍; 3期指Cr水平升高达基础水平或3倍, 或绝对值≥ 353.6 μ mol/L, 或需接受肾脏替代治疗。

1.3 统计学方法

选择SPSS 20.0软件处理数据; 正态性评估采用Kolmogorov-Smirnov检验, 符合正态分布计量资料比较采用t检验, 以x± s表示; 计数资料比较采用χ 2检验或Fisher确切概率法, 以%表示; 采用Logistic回归模型进行多因素分析; P< 0.05为差异有统计学意义。

2 结果
2.1 AKI发生情况分析

460例患者中, 术后发生AKI 1~3期例数分别为314例、21例、5例, 占比分别为68.26%、4.57%、1.09%。

2.2 RCC患者根治术后发生2~3期AKI危险因素单因素分析

根据是否发生2~3期AKI将患者分为两组, 单因素分析结果显示, 合并T2DM、高WBC计数及尿蛋白阳性均与RCC患者根治术后发生2~3期AKI发生有关（P< 0.05）, 详见表1。

表1 RCC患者根治术后发生2~3期AKI危险因素单因素分析 n
2.3 RCC患者根治术后发生2~3期AKI危险因素多因素分析

多因素分析结果显示, 合并T2DM和高WBC计数均是RCC患者根治术后发生2~3期AKI独立危险因素（P< 0.05）, 详见表2。

表2 RCC患者根治术后发生2~3期AKI危险因素多因素分析
3 讨论

对于局限期RCC患者, 外科手术切除病灶可有效改善临床预后, 有报道显示, T1~T4期符合手术指征RCC患者随访5年无复发生存率接近90%[6]; 另一项回顾性研究亦证实, 原发性肾癌患者随访5年肿瘤特异性生存率可达70%~85%[7]; 其中预后良好的肾乳头状细胞癌和嫌色细胞癌随访5年生存率为80%~90%。国外研究证实, RCC患者根治切除手术与肾部分切除术相抵, 术后肾功能损伤更为明显[8]。考虑到RCC患者术后可获得长期生存, 如何有效预测RCC患者根治术后肾功能不全发生风险并早期干预已成为医学界关注的重点问题。

本次研究结果中, 460例患者中术后发生AKI1~3期例数分别为314例, 21例, 5例, 占比分别为68.26%, 4.57%, 1.09%, 与以往报道结果相符[9, 10]; RCC患者根治切除手术创伤是导致肾功能损伤发生主要原因, 其中1期AKI多属于一过性的[11], 故本次研究未分析AKI 1期发生危险因素。单因素分析结果显示, 合并T2DM、高WBC计数及尿蛋白阳性均与RCC患者根治术后发生2~3期AKI发生有关（P< 0.05）, 但与年龄、CKD分期、BUN或UA等肾基础代谢相关指标并无相关性, 我们推测RCC患者CKD与术后2~3期AKI发生并无必然联系。但有研究证实高龄和CKD是RCC患者术后远期肾功能不全危险因素, 认为此类人群应慎重行根治性肾切除术治疗[12, 13]。

本研究多因素分析结果显示, 合并T2DM和高WBC计数均是RCC患者根治术后发生2~3期AKI独立危险因素（P< 0.05）, 而尿蛋白阳性与术后发生2~3期AKI并不独立相关。我们进一步分析数据证实, 合并T2DM患者尿蛋白阳性比例显著高于未合并T2DM患者, 推测尿蛋白阳性发生可能与T2DM有关; 而WBC计数升高且术后发生2~3期AKI患者4例多合并其他诱导WBC计数升高问题, 且术后更易出现感染加重, 这一现象可能与其术后出现2~3期AKI有关[14]; 随访发现以上人群中有2例在随访6个月内出现肾功能不全, 与我们假设相符。既往研究认为合并原发性高血压、T2DM及CKD患者术后更易出现肾功能不全[15, 16]。本次研究结果证实, T2DM是RCC患者根治术后发生2~3期AKI的独立危险因素, 但原发性高血压与2~3期AKI发生并无相关性。本次研究因纳入样本量少, 未进一步针对分级和血压控制情况进行亚组分析。

本次研究亦存在一定不足：①纳入样本量少、且属于单中心回顾性报道, 无法完全排除混杂因素影响; ②研究中6 h和12 h尿量难以获得, 故研究中未通过尿量计算来诊断术后AKI。

综上所述, RCC患者中合并T2DM和高WBC计数人群根治术后更易发生2~3期AKI; 但需要注意本次研究属于小样本单中心回顾性报道, 无法完全排除混杂因素影响, 所得结论仍有待后续研究进一步确证。

参考文献
[1] 王林辉, 时佳子. 肾癌肾部分切除术的指征应该怎么把握. 中华泌尿外科杂志, 2018, 39(6): 403-406. [本文引用:1]
[2] ROBSON CJ, CHURCHILL BM, ANDERSON W. The results of radical nephrectomy for renal cell carcinoma. J Urol, 2017, 197(2, S): S111-S113. [本文引用:1]
[3] KIM WH, SHIN KW, JI SH, et al. Robust association between acute kidney injury after radical nephrectomy and long-term renal function. J Clin Med, 2020, 9(3): 619. [本文引用:1]
[4] ZARGAR H, MIR MC, AUTORINO R. Partial nephrectomy versus radical nephrectomy for clinical t1b and t2 renal tumors: a systematic review and meta-analysis of comparative studies. BJU Int, 2017, 119(2, SI): 74-75. [本文引用:1]
[5] FUKUSHIMA H, INOUE M, KIJIMA T, et al. Incidence and risk factors of hypertension following partial nephrectomy in patients with renal tumors: a cross-sectional study of postoperative home blood pressure and antihypertensive medications. Clin Genitourin Cancer, 2020, 18(5): e619-e628. [本文引用:1]
[6] 李欣, 吴晓静, 张暮寅, 等. 肾癌患者单侧根治性肾切除术后肾功能的变化. 肾脏病与透析肾移植杂志, 2019, 28(1): 24-29. [本文引用:1]
[7] MCINTOSH AG, PARKER DC, EGLESTON BL, et al. Prediction of significant estimated glomerular filtration rate decline after renal unit removal to aid in the clinical choice between radical and partial nephrectomy in patients with a renal mass and normal renal function. BJU Int, 2019, 124(6): 999-1005. [本文引用:1]
[8] ANTONELLI A, ALLINOVI M, COCCI A, et al. The predictive role of biomarkers for the detection of acute kidney injury after partial or radical nephrectomy: a systematic review of the literature. Eur Urol Focus, 2020, 6(2): 344-353. [本文引用:1]
[9] HUR M, PARK SK, YOO S, et al. The association between intraoperative urine output and postoperative acute kidney injury differs between partial and radical nephrectomy. Sci Rep, 2019, 9(1): 760. [本文引用:1]
[10] ELLIS RJ, DEL VECCHIO SJ, NG KL, et al. Factors associated with acutely elevated serum creatinine following radical tumour nephrectomy: the Correlates of Kidney Dysfunction-Tumour Nephrectomy Database study. Transl Androl Urol, 2017, 6(5): 899-909. [本文引用:1]
[11] KIM NY, CHAE D, LEE J, et al. Development of a risk scoring system for predicting acute kidney injury after minimally invasive partial and radical nephrectomy: a retrospective study. Surg Endosc, 2021, 35(4): 1626-1635. [本文引用:1]
[12] HAMRAHIAN SM, FALKNER B. Hypertension in chronic kidney disease Adv Exp Med Biol, 2017, 956(10): 307-325. [本文引用:1]
[13] ANDERS HJ, HUBER TB, ISERMANN B, et al. CKD in diabetes: diabetic kidney disease versus nondiabetic kidney disease. Nat Rev Nephrol, 2018, 14(6): 361-377. [本文引用:1]
[14] XU L, LI C, ZHAO L, et al. Acute kidney injury after nephrectomy: a new nomogram to predict postoperative renal function. BMC Nephrol, 2020, 21(1): 181. [本文引用:1]
[15] MIZOTA T, DONG L, TAKEDA C, et al. Transient acute kidney injury after major abdominal surgery increases chronic kidney disease risk and 1-year mortality. J Crit Care, 2019, 50(8): 17-22. [本文引用:1]
[16] BHINDI B, LOHSE CM, SCHULTE PJ, et al. Predicting renal function outcomes after partial and radical nephrectomy. Eur Urol, 2019, 75(5): 766-772. [本文引用:1]