小儿糖尿病酮症酸中毒合并急性肾损伤时的尿中性粒细胞明胶酶相关脂质运载蛋白系列检测
Serial urinary neutrophil gelatinase associated lipocalin in pediatric diabetic ketoacidosis with acute kidney injury.
作者信息
Williams Vijai, Jayashree Muralidharan, Nallasamy Karthi, Dayal Devi, Rawat Amit, Attri Savita Verma
机构信息
Division of Pediatric Intensive Care, Department of Critical Care, Sheikh Khalifa Medical City (SKMC), Abu Dhabi, United Arab Emirates.
Division of Pediatric Emergency and Intensive Care, Department of Pediatrics, Advanced Pediatrics Centre, Post Graduate Institute of Medical Education & Research, Chandigarh, India.
出版信息
Clin Diabetes Endocrinol. 2021 Nov 1;7(1):20. doi: 10.1186/s40842-021-00133-8.
BACKGROUND
Acute kidney injury (AKI) due to Diabetic Ketoacidosis (DKA) is rather common. Novel biomarkers to diagnose AKI are being increasingly used in different settings. The use of urinary Neutrophil Gelatinase-Associated Lipocalin (uNGAL) in predicting persistent AKI in pediatric DKA cases is still not thoroughly investigated.
METHODS
This was a secondary analysis of Saline versus Plasma-Lyte in Ketoacidosis (SPinK) trial data; 66 children (> 1 month-12 years) with DKA, defined by the International Society for Pediatric and Adolescent Diabetes (ISPAD), were analyzed. Children with cerebral edema, chronic kidney disease and those who received pre-referral fluids and/or insulin were excluded. uNGAL and urine NGAL-creatinine ratio (uNCR) at 0 and 24 h were measured in all. Persistent AKI was defined as a composite outcome of continuance of AKI defined by the Kidney Disease Improving Global Outcomes (KDIGO) stage 2 or 3 beyond 48 h from AKI onset, progression of AKI from either KDIGO stage 0 or 1 to a worse stage, need of renal replacement therapy or death.
MAIN OUTCOMES
Thirty-five (53%) children had AKI at admission; 32 (91.4%) resolved within 48 h. uNGAL was significantly higher in the AKI group at admission [79.8 ± 27.2 vs 54.6 ± 22.0, p = 0.0002] and at 24 h [61.4 ± 28.3 vs 20.2 ± 14.5, p = 0.0003]. Similar trend was observed with uNCR at admission [6.7 ± 3.7 vs 4.1 ± 2.6, p = 0.002] and at 24 h [6.3 ± 2.5 vs 1.2 ± 1.0, p = 0.01]. Furthermore, uNGAL at admission showed a moderate positive linear correlation with serum creatinine. Additionally, elevated uNGAL at 0 and 24 h correlated with corresponding KDIGO stages. Admission uNGAL >88 ng/ml and uNCR of >11.3 ng/mg had a sensitivity of 66% and 67%, specificity of 76% and 95%, and Area under the receiver operating characteristic curve (AUC) of 0.78 and 0.89 respectively for predicting persistent AKI at 48 h.
CONCLUSIONS
Majority of AKI resolved with fluid therapy. While uNGAL and uNCR both correlated with serum creatinine and AKI stages, serial uNCR was a better predictor of persistent AKI than uNGAL alone. However, feasibility of routine uNGAL measurement to predict persistent AKI in DKA needs further elucidation.
TRIAL REGISTRATION
This was a secondary analysis of the data of SPinK trial [CTRI/2018/05/014042 ( ctri.nic.in )].
背景
糖尿病酮症酸中毒（DKA）所致急性肾损伤（AKI）颇为常见。用于诊断AKI的新型生物标志物在不同情况下的应用日益广泛。尿中性粒细胞明胶酶相关脂质运载蛋白（uNGAL）在预测儿童DKA病例持续性AKI中的应用仍未得到充分研究。
方法
这是一项对酮症酸中毒中生理盐水与平衡液（SPinK）试验数据的二次分析；对66例由国际儿童和青少年糖尿病学会（ISPAD）定义的DKA患儿（年龄大于1个月至12岁）进行了分析。排除患有脑水肿、慢性肾脏病以及那些在转诊前接受过补液和/或胰岛素治疗的患儿。对所有患儿在0小时和24小时时测定uNGAL和尿NGAL-肌酐比值（uNCR）。持续性AKI被定义为一个复合结局，即根据改善全球肾脏病预后组织（KDIGO）标准，AKI在起病48小时后持续处于2期或3期，或从KDIGO 0期或1期进展至更严重阶段，或需要肾脏替代治疗或死亡。
主要结局
35例（53%）患儿入院时存在AKI；其中32例（91.4%）在48小时内缓解。AKI组患儿入院时uNGAL显著更高[79.8±27.2 vs 54.6±22.0，p = 0.0002]，24小时时也更高[61.4±28.3 vs 20.2±14.5，p = 0.0003]。uNCR在入院时[6.7±3.7 vs 4.1±2.6，p = 0.002]和24小时时[6.3±2.5 vs 1.2±1.0，p = 0.01]也呈现类似趋势。此外，入院时uNGAL与血清肌酐呈中度正线性相关。另外，0小时和24小时时uNGAL升高与相应的KDIGO分期相关。入院时uNGAL>88 ng/ml和uNCR>11.3 ng/mg对于预测48小时时的持续性AKI，敏感性分别为66%和67%，特异性分别为76%和95%，受试者工作特征曲线下面积（AUC）分别为0.78和0.89。
结论
大多数AKI通过补液治疗得以缓解。虽然uNGAL和uNCR均与血清肌酐及AKI分期相关，但连续测定uNCR比单独测定uNGAL能更好地预测持续性AKI。然而，常规测定uNGAL以预测DKA中持续性AKI的可行性仍需进一步阐明。
试验注册
这是对SPinK试验数据的二次分析[CTRI/2018/05/014042（ctri.nic.in）]。
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