Herget-Rosenthal Stefan, Poppen Dennis, Hüsing Johannes, Marggraf Günter, Pietruck Frank, Jakob Heinz-Günther, Philipp Thomas, Kribben Andreas
Department of Nephrology, University Hospital, Essen, Germany.
Clin Chem. 2004 Mar;50(3):552-8. doi: 10.1373/clinchem.2003.027763. Epub 2004 Jan 6.
Acute tubular necrosis (ATN) has high mortality, especially in patients who require renal replacement therapy (RRT). We prospectively studied the diagnostic accuracy of the urinary excretion of low-molecular-weight proteins and enzymes as predictors of a need for RRT in ATN.
In 73 consecutive patients with initially nonoliguric ATN, we measured urinary excretion of alpha(1)- and beta(2)-microglobulin, cystatin C, retinol-binding protein, alpha-glutathione S-transferase, gamma-glutamyltransferase, lactate dehydrogenase, and N-acetyl-beta-D-glucosaminidase early in the course of ATN.
Twenty-six patients (36%) required RRT a median of 4 (interquartile range, 2-6) days after detection of proteinuria and enzymuria. Patients who required RRT had higher urinary cystatin C and alpha(1)-microglobulin [median (interquartile range), 1.7 (1.2-4.1) and 34.5 (26.6-45.1) g/mol of creatinine] than patients who did not require RRT [0.1 (0.02-0.5) and 8.0 (5.0-17.5) g/mol of creatinine]. Urinary excretion of cystatin C and alpha(1)-microglobulin had the highest diagnostic accuracies in identifying patients requiring RRT as indicated by the largest areas under the ROC curves: 0.92 (95% confidence interval, 0.86-0.96) and 0.86 (0.78-0.92), respectively. Sensitivity and specificity were 92% (95% confidence interval, 83-96%) and 83% (73-90%), respectively, for urinary cystatin C >1 g/mol of creatinine, and 88% (78-93%) and 81% (70-88%) for urinary alpha(1)-microglobulin >20 g/mol of creatinine.
In nonoliguric ATN, increased urinary excretion of cystatin C and alpha(1)-microglobulin may predict an unfavorable outcome, as reflected by the requirement for RRT.
急性肾小管坏死（ATN）死亡率很高，尤其是在需要肾脏替代治疗（RRT）的患者中。我们前瞻性地研究了低分子量蛋白质和酶的尿排泄量作为ATN患者是否需要RRT的预测指标的诊断准确性。
在73例最初为非少尿型ATN的连续患者中，我们在ATN病程早期测量了α（1）-微球蛋白、β（2）-微球蛋白、胱抑素C、视黄醇结合蛋白、α-谷胱甘肽S-转移酶、γ-谷氨酰转移酶、乳酸脱氢酶和N-乙酰-β-D-氨基葡萄糖苷酶的尿排泄量。
26例（36%）患者在检测到蛋白尿和酶尿后中位4（四分位间距，2 - 6）天需要RRT。需要RRT的患者尿胱抑素C和α（1）-微球蛋白水平更高[肌酐的中位数（四分位间距），1.7（1.2 - 4.1）和34.5（26.6 - 45.1）g/mol]，而不需要RRT的患者分别为[0.1（0.02 - 0.5）和8.0（5.0 - 17.5）g/mol肌酐]。如ROC曲线下最大面积所示，胱抑素C和α（1）-微球蛋白的尿排泄量在识别需要RRT的患者方面具有最高的诊断准确性：分别为0.92（95%置信区间，0.86 - 0.96）和0.86（0.78 - 0.92）。对于尿胱抑素C>1 g/mol肌酐，敏感性和特异性分别为92%（95%置信区间，83 - 96%）和83%（73 - 90%），对于尿α（1）-微球蛋白>20 g/mol肌酐，敏感性和特异性分别为88%（78 - 93%）和81%（70 - 88%）。
在非少尿型ATN中，胱抑素C和α（1）-微球蛋白尿排泄量增加可能预示不良预后，这通过是否需要RRT反映出来。
