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摘要: 目的 分析重庆及周边地区蛇咬伤患者发生急性肾损伤的危险因素。 方法 纳入2018年1月—2023年1月医院急诊科治疗的蛇咬伤患者156例，平均年龄为(51±16)岁。按照患者是否发生急性肾损伤，分为急性肾损伤组(26例)与非急性肾损伤组(130例)。收集并分析两组患者的临床资料，包括年龄、性别、院前时间、咬伤部位、白细胞计数、血红蛋白、肌红蛋白、心肌酶谱、肝功能、凝血功能等，并使用logistic逻辑回归模型分析与急性肾损伤相关的风险因素。 结果 急性肾损伤组与非急性肾损伤组患者在院前时间、血红蛋白、肌酸激酶同工酶、性别、谷丙转氨酶、谷草转氨酶、凝血酶原时间、活化部分凝血活酶时间、肝功能异常、凝血功能异常方面进行比较，差异有统计学意义(均P＜0.05)；但两组患者在年龄、白细胞计数、血肌红蛋白、肌酸激酶及咬伤部位比较，差异无统计学意义(均P>0.05)。急性肾损伤组患者的院前时间较非急性肾损伤组患者长，差异有统计学意义(P＜0.05)；急性肾损伤组患者的肝功能和凝血功能异常情况相对较高，白细胞计数值均高于非急性肾损伤组患者，差异均有统计学意义(P＜0.05)；单因素logistic逻辑回归分析显示，性别、院前时间、白细胞计数、血红蛋白、肝功能及凝血功能差异均有统计学意义(P＜0.05)，多因素logistic回归分析显示在院前时间、肝功能异常及凝血功能异常均差异有统计学意义(P＜0.05)。 结论 性别、院前时间、白细胞计数、血红蛋白、肝功能及凝血功能是蛇咬伤诱发急性肾损伤的危险因素，而院前时间、肝功能异常及凝血功能异常是蛇咬伤诱发急性肾损伤的独立危险因素。Abstract: Objective To analyze the risk factors associated with acute kidney injury in patients with snakebites in Chongqing and surrounding areas. Methods From January 2018 to January 2023, 156 cases of snakebite patients treated in the emergency department of our hospital were included in the study. The average age of patients with snakebites was (51±16) years. The patients were divided into the acute kidney injury group(26 cases)and the non-acute kidney injury group(130 cases)based on whether acute kidney injury occurred. A comparative analysis was conducted on gender, age, pre-hospital time, bite site, leukocyte count, hemoglobin levels, myohaemoglobin, cardiac enzyme profile, liver function and coagulation function between the two groups. Additionally, logistic regression models were employed to analyze the relevant risk factors associated with acute kidney injury. Results Between the acute kidney injury group and non-acute kidney injury group, hemoglobin, creatine kinase isoenzyme, gender, alanine aminotransferase, aspartate aminotransferase, prothrombin time, activated partial thromboplastin time, abnormal liver function and coagulation function (P < 0.05). However, the two groups showed no difference in age, leukocyte count, haemoglobin, creatine kinase and bite site (P> 005).The pre-hospital time of patients with acute kidney injury was longer than that of patients with non-acute kidney injury (P < 0.05). Acute kidney injury patients exhibited relatively higher rates of abnormal liver and coagulation function, as well as elevated leukocyte count, all with statistical significance(P < 0.05). logistic regression analysis showed that gender, treatment time, leukocyte count, hemoglobin, liver function, and coagulation function were found to be statistical significance(P < 0.05). Pre-hospital time, abnormal liver function, and coagulation function were found to be statistical significance(P < 0.05). Conclusion Gender, pre-hospital time, leukocyte count, hemoglobin, liver function, and coagulation function are risk factors for the development of acute kidney injury induced by snakebites. Furthermore, pre-hospital time, abnormal liver function and abnormal coagulation function are independent risk factors for acute kidney injury following snakebites.
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Key words:
- snake bites /
- acute kidney injury /
- risk factors
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表 1 两组患者的临床数据比较
X±S 项目 急性肾损伤组(26例) 非急性肾损伤组(130例) P 年龄/岁 55.04±17.21 51.18±16.88 0.251 性别/例(%) 0.029 男 9(34.6) 78(60.0) 女 17(65.4) 52(40.0) 咬伤部位/例(%) 0.115 上肢 10(38.5) 32(24.6) 下肢 16(61.5) 98(75.4) 院前时间/h 14.31±13.90 9.36±6.81 0.009 白细胞计数/(×109/L) 11.19±5.10 9.37±3.59 0.122 血红蛋白/(g/L) 135.19±27.28 145.88±16.00 0.045 肌红蛋白/(ng/mL) 308.62±128.85 263.66±73.33 0.519 肌酸激酶/(U/L) 1 551.65±623.69 453.58±317.58 0.132 肌酸激酶同工酶/(ng/mL) 54.47±25.59 16.11±11.03 0.014 ALT/(IU/L) 33.09±14.42 25.15±11.95 0.003 AST/(IU/L) 31.70(24.55，54.43) 26.95(22.30，33.00) 0.025 PT/s 11.78±1.71 10.96±1.82 0.036 APTT/s 36.47±10.40 30.44±8.48 0.009 肝功能异常/例(%) 0.001 是 9(34.6) 10(7.7) 否 17(65.4) 120(92.3) 凝血功能异常/例(%) 0.003 是 14(53.8) 30(23.1) 否 12(46.2) 100(76.9) 注：院前时间为蛇咬伤到入院院前时间；肝功异常为肝功能检查中ALT、AST中任意一项升高并超出正常值上限，伴或不伴总胆红素(TBIL)、碱性磷酸酶(ALP)、谷氨酰转肽酶(GGT)升高；凝血功能异常表现为PT、APTT、TT和FIB等指标超出正常范围。 
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表 2 单因素分析蛇咬伤后肾功能异常的影响因素
项目 OR 95%CI Wald χ2 P 年龄 1.015 0.988~1.042 1.116 0.291 性别 2.833 1.174~6.837 5.370 0.020 咬伤部位 0.522 0.216~1.266 2.067 0.151 院前时间 1.054 1.019~1.092 9.069 0.003 白细胞计数 1.111 1.007~1.227 4.401 0.036 血红蛋白 0.970 0.947~0.993 6.252 0.012 肌红蛋白 1.001 0.999~1.002 0.778 0.378 肌酸激酶 1.000 1.000~1.001 2.570 0.109 肌酸激酶同工酶 1.015 0.999~1.031 3.597 0.058 ALT 1.043 1.011~1.075 7.240 0.007 AST 1.020 1.004~1.036 6.230 0.013 PT 1.240 1.008~1.524 4.162 0.041 APTT 1.069 1.023~1.117 8.857 0.003 肝功能异常 6.353 2.259~17.865 12.285 0.000 凝血功能异常 3.889 1.625~9.304 9.311 0.002
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表 3 多因素分析蛇咬伤后肾功能异常的影响因素
项目 OR 95%CI Wald χ2 P 性别 2.380 0.705~8.027 1.953 0.162 院前时间 1.057 1.014~1.101 6.947 0.008 白细胞计数 1.092 0.956~1.247 1.682 0.195 血红蛋白 0.974 0.939~1.009 2.102 0.147 肝功能异常 10.275 2.647~39.885 11.333 0.001 凝血功能异常 4.261 1.491~12.176 7.322 0.007
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表 4 预测模型的预测价值
项目 AUC 95%CI P 治疗间隔时间 0.660 0.538~0.783 0.010 肝功能异常 0.638 0.508~0.768 0.026 凝血功能异常 0.653 0.531~0.775 0.014 预测模型 0.805 0.724~0.886 ＜0.001
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