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99Tcm-DTPA肾动态显像可以如实地显示肾脏的血流灌注及肾实质放射性核素摄取、分泌、排泄的全过程,通过定量分析分肾和总肾的肾小球滤过率(glomerular filtration rate, GFR),可全面客观地评估肾脏功能。GFR是观察肾脏功能比较灵敏的指标。目前国际上多应用GFR或以简化公式计算的方法估算GFR(estimated GFR,eGFR)来评价肾功能,并以GFR或eGFR < 60mL·min-1·(1.73m2) -1作为判断肾功能不全的标准。微小肾脏肿瘤的标准治疗方案仍需外科手术,但肾切除术是发展为慢性肾脏病的危险因素[1]。99Tcm-DTPA肾动态显像能定量测得分肾和总肾GFR,对外科手术的术前指导及术后肾脏功能不全的评估有重要意义。
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行RN的60例患者术前均行99Tcm-DTPA肾动态显像,术前总GFR<60 mL/min的4例,比例为6.7%。肿瘤直径<4cm组的总GFR为(107.04±15.97)mL/min、健侧GFR为(54.06±8.76)mL/min、患侧GFR为(52.94±8.57)ml/min;肿瘤直径≥4cm组总GFR为(95.69±20.44)ml/min、健侧GFR为(49.58±11.55)ml/min、患侧GFR为(45.78±13.27)ml/min。两组术前患侧GFR水平的差异有统计学意义(t=2.152,P<0.05);术前总GFR水平和术前健侧GFR水平的差异均无统计学意义(t=1.852、1.255,均P>0.05)。
术前总GFR减低有10例,比例为16.7%(10/60),其中年龄≥60岁有6例,GFR为(62.1±9.82)mL/min;年龄<60岁为4例,GFR为(69.91±10.32)mL/min。术前健侧GFR减低12例,比例为20%(12/60),年龄≥60岁有6例,GFR为(31.02±5.47)mL/min,年龄<60岁为6例,GFR为(36.12±2.09)mL/min。术前患侧GFR减低22例,比例为36.7%(22/60), 年龄≥60岁有9例,GFR为(30.24±6.13)mL/min,年龄<60岁为13例,GFR为(33.64±9.42)mL/min。有5例患者术前健侧GFR减低而术前患侧GFR正常,7例患者术前患侧及健侧GFR均减低。
肿瘤直径≥4 cm组和<4 cm组比较,术前患侧GFR降低的病例数的差异有统计学意义(χ2=4.512,P<0.05);术前总GFR降低、术前健侧GFR降低以及年龄、性别、伴随疾病、肿瘤良恶性的病例数比较差异均无统计学意义。
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60例行RN的患者,术前总GFR减低为10例,比例为16.7%,术前GFR<60 mL/min的4例,比例为6.7%。术后随访血肌酐水平半年,新出现eGFR<60mL·min-1·(1.73m2) -1的例数为13例, 占总比例的21.6%(13/60),其中术前健侧GFR减低的12例中有5例出现术后肾功能不全。
由表 1可知,单因素分析术后有无出现肾功能不全与术前健侧GFR减低、术前总GFR减低均有相关性(OR=4.90、6.72,均P < 0.05);与性别、年龄、术前患侧GFR减低及高血压、糖尿病无相关性。多因素分析提示,术前健侧GFR减低(OR=3.60,P < 0.05)、术前总GFR减低(OR=5.64,P=0.035)是术后肾功能不全的独立危险因素。
项目 单因素 多因素 OR (95% CI) P值 OR(95%CI) P值 性别 2.36 (0.66~8.46) 0.186 1.29(0.30~5.54) 0.735 年龄 2.50 (0.70~8.92) 0.158 1.55(0.37~6.47) 0.550 术前健侧GFR减低 4.90 (1.26~18.97) 0.021 3.60(1.04~17.68) 0.039 术前患侧GFR减低 0.43 (0.08~2.19) 0.309 - - 术前总GFR减低 6.72 (1.48~30.60) 0.014 5.64(1.13~-28.28) 0.035 合并高血压 1.57 (0.89~2.80) 0.123 - - 合并糖尿病 1.24 (0.22~7.03) 0.806 - - 肿瘤良恶性 1.27 (0.29~5.57) 0.754 - - 注: 表中, GFR: 肾小球滤过率; CI: 可变区间。 “-” 表示无此项数据。 表 1 60 例行根治性肾切除患者术后出现肾功能不全相关因素分析
Table 1. Risk factor of postoperative renal insufficiency of 60 patients with radical nephrectomy
99Tcm-DTPA肾动态显像在根治性肾切除术中的应用价值
Application value of renal dynamic imaging in radical nephrectomy
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摘要:
目的通过99Tcm-DTPA肾动态显像测定总肾及分肾肾小球滤过率(GFR),评价其在根治性肾切除术中的应用价值。 方法 60例根治性肾切除术患者术前行99Tcm-DTPA肾动态显像,定量测得总肾及分肾GFR。依据肾脏肿瘤直径大小分为≥ 4 cm组和 < 4 cm组,以了解术前患者GFR降低与肿瘤大小的相关性。采用t检验进行两组GFR水平的比较。单因素及多因素回归分析寻找术后肾功能不全的预测因子。 结果肿瘤 < 4 cm组患侧平均GFR为(52.94±8.57)mL/min,≥ 4 cm组患侧平均GFR为(45.78±13.27)mL/min,两组术前患侧GFR水平的差异有统计学意义(t=2.152,P < 0.05)。术前总GFR水平、术前健侧GFR水平的差异均无统计学意义(t=1.852、1.255,均P>0.05)。术后新出现肾功能不全的比例为21.6%,单因素及多因素logistic回归分析结果发现,术前健侧GFR降低(OR=3.6,P < 0.05)、术前总肾GFR降低(OR=5.64,P < 0.05)是术后肾功能不全的独立危险因素。 结论采用99Tcm-DTPA肾动态显像可以定量评价分肾和总肾GFR,对肾脏肿瘤患者术前指导及术后肾功能不全的预测有重要的临床意义。 Abstract:Objective To evaluate the clinical value of total and half glomerular filtration rate (GFR) measured through 99Tcm-DTPA renal dynamic imaging during radical nephrectomy. Methods The total and half GFRs of 60 patients with renal tumors were measured and analyzed through renal dynamic imaging prior to surgery. The patients were divided into two groups in accordance with renal tumor diameter (≥ 4 cm or < 4 cm). Then, the correlation between decreased preoperative GFR and tumor size was determined. Univariate and multivariate analyses were performed to detect the predictors of renal insufficiency for the evaluation of the clinical value of total and half GFRs in operated patients. Results The average GFR of the affected kidney in the group with tumors less than 4 cm in diameter was (52.94±8.57) mL/min, whereas that of the group with tumors greater than 4 cm in diameter was (45.78±13.27) mL/min. The preoperative GFR of the affected side (t=2.152, P < 0.05) of the two groups were significantly different. Meanwhile, the preoperative GFR of the unaffected side and total kidney of the two groups were not significantly different (t=1.852, 1.255, both P>0.05). The ratio of postoperative new renal insufficiency was 21.6%. Univariate and multivariate analyses showed that the decreased preoperative GFR of the unaffected side (OR=3.6, P < 0.05) and total kidney (OR=5.64, P < 0.05) are independent risk factors of postoperative renal insufficiency. Conclusion Total and half renal functions determined through renal dynamic imaging are clinically valu-able in the preoperative direction and evaluation of renal insufficiency. -
表 1 60 例行根治性肾切除患者术后出现肾功能不全相关因素分析
Table 1. Risk factor of postoperative renal insufficiency of 60 patients with radical nephrectomy
项目 单因素 多因素 OR (95% CI) P值 OR(95%CI) P值 性别 2.36 (0.66~8.46) 0.186 1.29(0.30~5.54) 0.735 年龄 2.50 (0.70~8.92) 0.158 1.55(0.37~6.47) 0.550 术前健侧GFR减低 4.90 (1.26~18.97) 0.021 3.60(1.04~17.68) 0.039 术前患侧GFR减低 0.43 (0.08~2.19) 0.309 - - 术前总GFR减低 6.72 (1.48~30.60) 0.014 5.64(1.13~-28.28) 0.035 合并高血压 1.57 (0.89~2.80) 0.123 - - 合并糖尿病 1.24 (0.22~7.03) 0.806 - - 肿瘤良恶性 1.27 (0.29~5.57) 0.754 - - 注: 表中, GFR: 肾小球滤过率; CI: 可变区间。 “-” 表示无此项数据。 -
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