本文選題：竹葉青蛇 + 烙鐵頭蛇��； 參考：《福建中醫(yī)藥大學(xué)》2016年碩士論文

【摘要】：目的：探討中性粒細(xì)胞明膠酶相關(guān)脂質(zhì)運(yùn)載蛋白(NGAL)、肝型脂肪酸結(jié)合蛋白(L-FABP)和腎損傷分子-1(KIM-1)對(duì)血循毒蛇咬傷所致急性腎損傷(AKI)早期診斷及預(yù)后的作用,進(jìn)一步推進(jìn)蛇傷的防治及AKI早期診斷的研究工作。方法：病例來(lái)源為2015年1月至2015年12月本院急診科留觀病房及蛇傷科住院病房并符合納入和排除標(biāo)準(zhǔn)的毒蛇咬傷患者。通過(guò)全自動(dòng)生化分析儀檢測(cè)患者蛇傷后24小時(shí)、48小時(shí)、72小時(shí)、7天和10天的血清肌酐(sCr)、血尿素氮(BUN)和尿酸(UA)水平變化,選用2004年急性透析質(zhì)量倡議(ADQI)工作組提出的RIFLE分級(jí)診斷標(biāo)準(zhǔn),將病例歸為蛇傷AKI組和非AKI組進(jìn)行隊(duì)列觀察。酶聯(lián)免疫吸附試驗(yàn)(ELISA)檢測(cè)患者入院時(shí)收集的尿液中NGAL、L-FABP和KIM-1水平,比較其組間差異性,再用ROC曲線分析三者的診斷特性,并行Logistic回歸分析,明確三者對(duì)蛇傷AKI患者死亡率的影響。結(jié)果：最后納入觀察的對(duì)象達(dá)49例,涉及蛇種包括烙鐵頭蛇和竹葉青蛇,其例數(shù)分別達(dá)23和26。蛇傷AKI組例數(shù)為24,其sCr變化符合2004年ADQI工作組提出的RIFLE分級(jí)診斷標(biāo)準(zhǔn),分級(jí)屬風(fēng)險(xiǎn)期或損傷期,個(gè)別病例可達(dá)衰竭期。非AKI組例數(shù)為25。兩組的BUN和UA雖部分有差異,但都在正常參考值范圍內(nèi)波動(dòng)。24例發(fā)生AKI的蛇傷患者中有2名病情危重,雖然予積極轉(zhuǎn)移至重癥病房進(jìn)一步行腎替代及其他綜合治療,但最終都在傷后72小時(shí)內(nèi)死亡,而未發(fā)生AKI者,死亡人數(shù)為0,均痊愈出院,兩組死亡率差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。蛇傷AKI組的尿NGAL (uNGAL)、尿L-FABP (uL-FABP)和尿KIM-1 (uKIM-1)水平較非AKI組升高,差異具有統(tǒng)計(jì)學(xué)意義(P0.01),但三者在不同蛇種所致AKI患者間進(jìn)行比較后未發(fā)現(xiàn)顯著差異(P0.05)。通過(guò)ROC曲線分析可見(jiàn),uNGAL、uKIM-1和uL-FABP的ROC曲線下面積(AUC-ROC)均0.7(P0.01)。uL-FABP的AUC-ROC最大(0.952),其最佳診斷界值為27.5ng/ml,各項(xiàng)診斷性評(píng)價(jià)指標(biāo)結(jié)果均位于三者中的中位。經(jīng)過(guò)Logistic回歸分析,發(fā)現(xiàn)NGAL、L-FABP和KIM-1與蛇傷AKI患者死亡率的Logistic回歸方程的總體檢驗(yàn)存在統(tǒng)計(jì)學(xué)意義(P0.05),但分別針對(duì)上述各標(biāo)志物回歸系數(shù)進(jìn)行檢驗(yàn)時(shí)未發(fā)現(xiàn)統(tǒng)計(jì)學(xué)意義(P0.05)。結(jié)論：尿液中NGAL、L-FABP和KIM-1的含量可作為竹葉青蛇和烙鐵頭蛇傷所致AKI早期診斷的標(biāo)志物,其中L-FABP診斷能力最優(yōu)秀。但三者對(duì)蛇傷AKI患者的預(yù)后作用尚待進(jìn)一步證實(shí)。
[Abstract]:Objective: to investigate the early diagnosis and prognosis of neutrophil gelatinase-associated lipid carrier protein NGALL (L-FABP) and renal injury molecule (-1) KIM-1 in acute renal injury induced by blood-borne snake bite. To further promote the prevention and treatment of snake injury and the early diagnosis of AKI. Methods: from January 2015 to December 2015, the patients in the emergency department and the serpentine department in our hospital met the criteria of inclusion and exclusion of venomous snake bite. The serum creatinine (Cr), blood urea nitrogen (bun) and uric acid (UAA) levels were measured by automatic biochemical analyzer at 24 hours, 48 hours, 72 hours, 7 days and 10 days after snake injury. The RIFLE grading diagnostic criteria proposed by the AHD quality Initiative (ADQI) working group in 2004 were used to classify the cases into snake wound AKI group and non-AKI group for cohort observation. Elisa was used to detect the levels of NGALL-FABP and KIM-1 in urine collected from patients at admission, and to compare their differences. The diagnostic characteristics of the three groups were analyzed by ROC curve, and Logistic regression analysis was performed to determine the effect of the three on the mortality of AKI patients with snake injury. Results: 49 cases were included in the study. The number of snake species involved were 23 and 26, respectively. The number of patients with snake injury in AKI group was 24. The change of sCr was in accordance with the diagnostic criteria of RIFLE classification proposed by ADQI working group in 2004. The classification was a risk period or injury stage, and individual cases could reach the stage of exhaustion. The number of non-AKI cases was 25. Although there were some differences in BUN and UA between the two groups, two of the 24 snake injury patients with AKI were in critical condition, although they were actively transferred to the intensive care unit for further renal replacement and other comprehensive treatment. However, all of them died within 72 hours after injury, but no AKI occurred, the number of deaths was 0, all of them were cured and discharged. There was no significant difference in mortality between the two groups (P 0.05). The levels of urinary NGAL uNGALP, urinary L-FABP uL-FABPand urinary KIM-1 uKIM-1) in snake injury AKI group were higher than those in non-AKI group, and the difference was statistically significant (P 0.01), but no significant difference was found among the patients with AKI caused by different serpent species. From the analysis of ROC curve, we can see that the area under ROC curve of uL-FABP and ROC curve of uL-FABP are the AUC-ROC maximum of 0.7(P0.01).uL-FABP 0.952, and the best diagnostic limit is 27.5 ng / ml. The results of each diagnostic evaluation index are all in the median of the three. By Logistic regression analysis, it was found that the overall test of Logistic regression equation between NGALL-FABP and KIM-1 and AKI patients with snake injury had statistical significance (P 0.05), but no statistical significance was found when the regression coefficients of the above markers were tested. Conclusion: the levels of NGALL-FABP and KIM-1 in urine can be used as markers for the early diagnosis of AKI caused by Bamboo leaf green snake and Tiantou snake wound, among which L-FABP is the best in diagnosis. However, the prognostic effects of these three factors on AKI patients with snake injury need to be further confirmed.
【學(xué)位授予單位】：福建中醫(yī)藥大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2016
【分類號(hào)】：R646

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