超声造影技术评估糖尿病肾病肾脏血流灌注的应用价值

Application value of contrast-enhanced ultrasonography in assessing renal blood perfusion in diabetic nephropathy

摘要:

目的 探索糖尿病肾病（DN）不同阶段肾脏血流灌注状态的特征性改变及爆破-再灌注超声造影技术在DN中的临床应用价值。方法 选取2024年2月—2025年1月北京中医药大学东直门医院收治的55例糖尿病（DM）患者，依据尿微量白蛋白/肌酐比值（UACR）分为DM组（正常蛋白尿）13例、DN早期组（微量蛋白尿）28例、DN临床期组（大量蛋白尿）14例，同期选取该院6例健康受试者作为对照组。患者均行常规超声、彩色多普勒超声及爆破-再灌注超声造影。采用Pearson法进行相关性分析。采用多因素逐步Logistic回归模型分析DN的影响因素。绘制受试者工作特征（ROC）曲线分析各指标对DN的诊断价值。结果 与DM组比较，DN早期组肾动脉主干阻力指数（RI）较高（P <0.05）；与DM组比较，DN早期组、DN临床期组段动脉RI和叶间动脉RI较高（P <0.05）。相关性分析结果显示，UACR与DM病程、皮质厚、段动脉RI、叶间动脉RI、皮质平均通过时间（mTT）、肾髓质达峰时间（TTP）均呈正相关（r =0.504、0.331、0.320、0.352、0.359、0.295，P <0.05）；UACR与估计肾小球滤过率（eGFR）、肾动脉舒张期流速（Vd）、段动脉Vd、肾皮质上升斜率（WiR）、肾髓质WiR、髓质减半WiR均呈负相关（r =-0.336、-0.292、-0.301、-0.429、-0.469、-0.334，P <0.05）。eGFR与肾动脉Vd、段动脉Vd、叶间动脉Vd、皮质减半WiR、皮质WiR均呈正相关（r =0.356、0.500、0.440、0.262、0.417，P <0.05）；eGFR与DM病程、肾动脉RI、段动脉RI、叶间动脉RI、皮质TTP、皮质mTT均呈负相关（r =-0.476、-0.499、-0.438、-0.417、-0.538、-0.565，P <0.05）。多因素逐步Logistic回归分析结果显示，DM病程长［O^R=1.258（95% CI：1.088，1.454）］、皮质WiR小［O^R=0.653（95% CI：0.434，0.982）］是DN的危险因素。ROC曲线分析结果显示，DM病程、皮质WiR及两者联合诊断DN的曲线下面积分别为0.878（95% CI：0.788，0.967）、0.737（95% CI：0.608，0.866）、0.904（95% CI：0.827，0.982），敏感性分别为84.2%（95% CI：0.624，0.945）、73.7%（95% CI：0.512，0.882）、83.3%（95% CI：0.608，0.942），特异性分别为76.7%（95% CI：0.623，0.869）、71.4%（95% CI：0.564，0.828）、86.1%（95% CI：0.727，0.934）。结论 通过超声造影技术可以观察到，随着DN病情进展，血管阻力增加，血流灌注上升斜率减缓，反映了肾脏灌注能力的下降。DM病程与超声造影皮质上升斜率联合应用于DN诊断中，具有较高的诊断价值。

Abstract:

Objective To investigate characteristic changes in renal blood perfusion at different stages of diabetic nephropathy (DN) and evaluate the clinical value of contrast-enhanced ultrasonography (CEUS), specifically analyzing the wash-in rate (WiR).Methods Fifty-five diabetes mellitus (DM) patients were enrolled between February 2024 and January 2025 and categorized into DM group (normoalbuminuria, n = 13), early DN group (microalbuminuria, n = 28), and clinical DN group (macroalbuminuria, n = 14) based on urinary albumin-to-creatinine ratio (UACR). Six healthy subjects served as controls. All underwent conventional ultrasound, color Doppler, and CEUS (burst-replenishment technique). Renal artery resistive indices (RI) and CEUS parameters (cortical WiR, mean transit time [mTT], time to peak [TTP] ) were analyzed. Pearson correlation, multivariate logistic regression, and ROC analysis were performed.Results Compared to the DM group, the early DN group had significantly higher RI in the main renal artery (P < 0.05). Both early and clinical DN groups had significantly higher RI in segmental and interlobar arteries (P < 0.05). UACR correlated positively with DM duration, cortical thickness, segmental/interlobar RI, cortical mTT, and medullary TTP (P < 0.05), and negatively with eGFR, renal/segmental artery diastolic velocity (Vd), cortical WiR, and medullary WiR/half WiR (P < 0.05). eGFR correlated positively with renal/segmental/interlobar Vd and cortical half WiR/WiR (P < 0.05), and negatively with DM duration, renal/segmental/interlobar RI, cortical TTP/mTT (P < 0.05). Multivariate analysis identified longer DM duration [O^R = 1.258 (95% CI: 1.088, 1.454) ] and lower cortical WiR [O^R = 0.653 (95% CI: 0.434, 0.982) ] as independent risk factors for DN. ROC analysis showed AUCs for DM duration, cortical WiR, and their combination in diagnosing DN were 0.878 (95% CI: 0.788, 0.967), 0.737 (95% CI: 0.608, 0.866), and 0.904 (95% CI: 0.827, 0.982), with 84.2% (95% CI: 0.624, 0.945), 73.7% (95% CI: 0.512, 0.882), 83.3% (95% CI: 0.608, 0.942) in sensitivity and 76.7% (95% CI: 0.623, 0.869), 71.4% (95% CI: 0.564, 0.828), 86.1% (95% CI: 0.727, 0.934) in specificity, respectively.Conclusion CEUS reveals increasing vascular resistance and decreasing renal perfusion WiR with DN progression. Combining DM duration and cortical WiR provides high diagnostic value for DN.