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中华医学超声杂志（电子版）

中华医学超声杂志（电子版） ›› 2024, Vol. 21 ›› Issue (05) : 491 -499. doi: 10.3877/cma.j.issn.1672-6448.2024.05.007

泌尿生殖系统超声影像学

声触诊弹性成像联合脉冲多普勒超声成像参数与早期慢性肾脏病分期的相关性及临床价值
唐小清1, 何萍1, 杨友1, 罗霞1, 张菊英1, 杨鑫1, 余进洪1,†()   
  1. 1. 637000　川北医学院附属医院超声科
  • 收稿日期:2023-11-16 出版日期:2024-05-01
  • 通信作者: 余进洪

Correlation of sound touch elastography combined with pulsed wave Doppler ultrasound imaging parameters with stage of early chronic kidney disease and their clinical significance

Xiaoqing Tang1, Ping He1, You Yang1, Xia Luo1, Juying Zhang1, Xin Yang1, Jinhong Yu1,†()   

  1. 1. Department of Ultrasound, Affiliated Hospital of North Sichuan Medical College, Nanchong 637000, China
  • Received:2023-11-16 Published:2024-05-01
  • Corresponding author: Jinhong Yu
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引用本文：

唐小清, 何萍, 杨友, 罗霞, 张菊英, 杨鑫, 余进洪. 声触诊弹性成像联合脉冲多普勒超声成像参数与早期慢性肾脏病分期的相关性及临床价值[J]. 中华医学超声杂志（电子版）, 2024, 21(05): 491-499.

Xiaoqing Tang, Ping He, You Yang, Xia Luo, Juying Zhang, Xin Yang, Jinhong Yu. Correlation of sound touch elastography combined with pulsed wave Doppler ultrasound imaging parameters with stage of early chronic kidney disease and their clinical significance[J]. Chinese Journal of Medical Ultrasound (Electronic Edition), 2024, 21(05): 491-499.

目的

分析声触诊弹性成像（STE）联合脉冲多普勒（PW）超声成像参数与早期慢性肾病（CKD）改变及其分期的相关性，探讨2种超声成像参数对CKD早期预测、发现及分期诊断的临床意义。

方法

收集2022年9月至2023年4月川北医学院附属医院收治的按肾小球滤过率分期为1~3期的CKD患者共82例作为病例组，将病例组分成CKD 1期、CKD 2期、CKD 3期3组，另选择同期健康体检者35名作为对照组，病例组和对照组分别进行PW、STE检查并记录相关参数，PW参数包括肾门处肾动脉（MRA）、肾窦部段动脉（SRA）、肾锥体叶间动脉（IRA）的收缩期血液峰值流速（PSV）、舒张末期流速（EDV）以及血流阻力指数（RI），STE参数包括肾皮质杨氏模量值的最大值（Emax）、平均值（Emean）、最小值（Emin）。比较病例组与对照组之间超声参数的差异，通过二元Logistic回归分析诊断早期CKD的影响因素，绘制受试者操作特征（ROC）曲线，评估发现早期CKD改变有统计学意义的参数指标以及这些参数对早期CKD联合诊断的价值；分析4组间各个超声参数指标的差异，运用多分类Logistic回归分析，计算各组超声参数的异常检出率，评估对早期CKD分期的诊断价值。

结果

Logistic回归分析显示，MRA-PSV、MRA-EDV、Emean、Emax对预测早期CKD差异具有统计学意义（OR=0.952、0.893、1.687、1.416，P=0.001、=0.002、=0.001、<0.001），其中Emax是诊断早期CKD的独立影响因素，截断值为11.01 kPa。在单因素诊断中，Emax对早期CKD诊断的ROC曲线下面积（AUC）最大（AUC=0.740）；上述4项指标联合诊断的AUC=0.792，高于各个单项参数。4组间对比提示，MRA-PSV、MRA-EDV对CKD 2期检出率最高，且MRA-EDV检出率高于MRA-PSV（55.6% vs 51.9%）；SRA-PSV、SRA-EDV、Emax对CKD 3期检出率最高（60.9% vs 52.2% vs 43.5%），其中SRA-PSV检出率最高；Emean对CKD 1期检出率最高（37.5%）；联合诊断方式在早期CKD分期中显著提高了CKD 1期的检出率（50.0%）。

结论

MRA-PSV、MRA-EDV、Emean、Emax可作为预测可能发生早期CKD的超声诊断参数，且对早期CKD初步分期具有一定的诊断价值，PW联合STE提高了早期CKD检出及分期的诊断效能，PW联合STE有望成为早期CKD发现、分期、评估及随访的有效影像学检查方式。

关键词: 慢性肾病, 脉冲多普勒, 声触诊弹性成像
Objective

To analyze the correlation of parameters of sound touch elastography (STE) combined with pulsed wave (PW) Doppler imaging with early changes and stage of chronic kidney disease (CKD), and to explore the clinical significance of the parameters of the two ultrasound imaging modalities for early prediction, detection, and staging of chronic kidney disease.

Methods

Eighty-two patients with stages 1-3 CKD classified by glomerular filtration rate from September 2022 to April 2023 at the Affiliated Hospital of North Sichuan Medical College were collected as cases. These cases were divided into three groups according to CKD stage: CKD stage 1, CKD stage 2, and CKD stage 3. Thirty-five healthy individuals in the same period were selected as controls. Both the case group and control group underwent PW and STE examinations to record relevant parameters. PW parameters included peak systolic blood flow velocity (PSV), end diastolic blood flow velocity (EDV), and blood flow resistance index (RI) of the renal artery at the renal hilum (MRA), the renal sinus segmental artery (SRA), and the renal pyramidal interlobular artery (IRA). STE parameters included the maximum (Emax), average (Emean), and minimum (Emin) values of the renal cortex Young's modulus. The differences in these parameters were compared between the case group and the control group, and binary logistic regression analysis was performed to identify the parameters that had statistical significance for detecting early chronic kidney disease changes, and receiver operating characteristic (ROC) curve analysis was performed to assess the value of these parameters for the diagnosis of early chronic kidney disease. The differences in ultrasound parameters were compared among the four groups, multi-class logistic regression analysis was performed to calculate the abnormal detection rate by ultrasound parameters in each group, and their diagnostic value for early CKD staging was evaluated.

Results

Compared with the control group, the differences in MRA-PSV, MRA-EDV, Emean, and Emax in predicting early CKD in the case group were statistically significant (odds ratio=0.952, 0.893, 1.687, and 1.416; P=0.001, =0.002, =0.001, and <0.001, respectively). Emax was an independent factor for the diagnosis of early CKD, with a cutoff value of 11.01 kPa. In univariate diagnosis, Max had the largest area under the ROC curve (AUC=0.740) for the diagnosis of early CKD. The AUC of joint diagnosis (0.792) was higher than that of each individual parameter. The comparison between the four groups indicated that MRA-PSV and MRA-EDV had the highest detection rate for CKD stage 2, and the detection rate by MRA-EDV was higher than that by MRA-PSV (55.6% vs 51.9%). SRA-PSV, SRA-EDV, and Emax had the highest detection rate for CKD stage 3 (60.9% vs 52.2% vs 43.5%), with SRA-PSV having the highest detection rate. Emean had the highest detection rate for CKD stage 1 (37.5%). The joint diagnosis significantly improved the detection rate of CKD stage 1 (50.0%) in early CKD staging.

Conclusion

MRA-PSV, MRA-EDV, Emean, and Emax can be used as ultrasound diagnostic parameters to predict the possible occurrence of early CKD, and have appreciated diagnostic value for the initial staging of early CKD. PW combined with STE improves the diagnostic performance of early CKD detection and staging. PW combined with STE is expected to become a reliable and effective imaging examination method for early CKD detection, staging, evaluation, and follow-up.

Key words: Chronic kidney disease, Pulsed wave Doppler, Sound touch elastography
表1 慢性肾病患者估计肾小球滤过率与PW、STE超声参数相关性分析
变量 r值 P值
MRA-PSV 0.502 <0.001
MRA-EDV 0.416 <0.001
MRA-RI 0.155 0.162
SRA-PSV 0.415 <0.001
SRA-EDV 0.566 <0.001
SRA-RI 0.102 0.363
IRA-PSV 0.110 0.326
IRA-EDV 0.096 0.389
IRA-RI 0.110 0.326
Emax -0.214 0.053
Emean -0.193 0.083
Emin -0.053 0.633
表2 慢性肾脏病患者血肌酐与PW、STE超声参数相关性分析
变量 r值 P值
MRA-PSV -0.415 <0.001
MRA-EDV -0.256 0.015
MRA-RI -0.258 0.019
SRA-PSV -0.394 <0.001
SRA-EDV -0.429 <0.001
SRA-RI -0.208 0.061
IRA-PSV -0.157 0.160
IRA-EDV -0.058 0.604
IRA-RI -0.223 0.044
Emax 0.151 0.175
Emean 0.160 0.150
Emin 0.024 0.831
表3 慢性肾病患者与健康体检者的2种超声成像参数比较
变量 病例组（n=82） 对照组（n=35） 统计值 P值
MRA-PSV[cm/s，M（QR）] 54.82（43.21，62.80） 63.32（57.87，79.07） Z=-4.009 <0.001
MRA-EDV[cm/s，M（QR）] 19.52（16.09，23.37） 23.41（20.95，26.83） Z=-3.786 <0.001
MRA-RI（） 0.62±0.06 0.63±0.07 t=-0.643 0.522
SRA-PSV[cm/s，M（QR）] 37.20（30.88，47.66） 39.78（34.39，44.33） Z=-1.057 0.291
SRA-EDV[cm/s，M（QR）] 15.55（13.75，17.76） 17.14（14.76，19.07） Z=-2.09 0.037
SRA-RI[M（QR）] 0.56（0.52，0.62） 0.58（0.52，0.61） Z=-0.086 0.931
IRA-PSV[cm/s，M（QR）] 28.09（22.34，31.93） 26.87（24.28，30.47） Z=-0.274 0.784
IRA-EDV[cm/s，M（QR）] 12.37（10.70，14.61） 12.30（11.43，14.28） Z=-0.601 0.548
IRA-RI（） 0.54±0.07 0.53±0.04 t=0.888 0.377
Emax[kPa，M（QR）] 11.71（10.52，14.18） 10.37（7.16，11.29） Z=-3.536 <0.001
Emean[kPa，M（QR）] 7.33（6.23，8.29） 6.37（5.26，7.00） Z=-4.107 <0.001
Emin[kPa，M（QR）] 4.48（3.66，5.31） 4.34（3.65，5.35） Z=-0.408 0.683
图1 慢性肾病（CKD）患者脉冲多普勒和声触诊弹性成像图像。图a~d分别为对照组、CKD 1期、CKD 2期、CKD 3期脉冲多普勒声像图；图e~h分别为对照组、CKD 1期、CKD 2期、CKD 3期弹性成像图
表4 影响诊断早期慢性肾病的超声成像参数的单因素Logistic回归分析
变量 B值 SE值 Wald值 P值 OR值 95%CI
MRA-PSV -0.049 0.014 11.641 0.001 0.952 0.926~0.979
MRA-EDV -0.113 0.037 9.368 0.002 0.893 0.831~0.960
SRA-EDV -0.054 0.049 1.256 0.262 0.947 0.861~1.042
Emean 0.523 0.156 11.307 0.001 1.687 1.244~2.289
Emax 0.348 0.093 14.025 <0.001 1.416 1.180~1.698
表5 影响诊断早期慢性肾病的超声成像参数的多因素Logistic回归分析
因素 B值 SE值 Wald值 P值 OR值 95%CI
MRA-PSV -0.037 0.022 2.731 0.098 0.964 0.923~1.007
MRA-EDV -0.018 0.059 0.090 0.765 0.983 0.876~1.103
Emean 0 0.262 0 0.999 1.000 0.598~1.672
Emax 0.307 0.149 4.260 0.039 1.359 1.016~1.818
表6 超声成像参数MRA-PSV、MRA-EDV、Emean、Emax及四项联合对早期慢性肾病的诊断效能
检验结果变量 P值 AUC 截断值 约登指数 敏感度（%） 特异度（%） 准确性（%）
MRA-PSV（cm/s） <0.001 0.735 57.03 0.402 82.9 57.3 72.6
MRA-EDV（cm/s） <0.001 0.722 19.35 0.431 48.8 94.3 70.1
Emean（kPa） <0.001 0.707 7.71 0.406 54.9 84.7 69.2
Emax（kPa） <0.001 0.740 11.01 0.438 64.5 74.3 70.9
联合 <0.001 0.792 - 0.470 75.6 71.4 74.4
图2 肾门处肾动脉（MRA）-收缩期血液峰值流速（PSV）、MRA-舒张末期流速（EDV）、杨氏模量平均值（Emean）、杨氏模量最大值（Emax）及四项联合诊断早期慢性肾病的受试者操作特征曲线
表7 CKD各病例组与对照组的2种超声成像参数变化比较
变量 对照组（n=35） CKD 1期（n=32） CKD 2期（n=27） CKD 3期（n=23） 统计值 P值
MRA-PSV（cm/s，） 66.59±12.60 63.53±15.39 48.41±9.33ab 48.41±9.33ab F=18.138 <0.001
MRA-EDV[cm/s，M（QR）] 23.41（20.95，26.83） 23.35（18.87，27.70） 18.57（16.91，20.24）ab 15.8（12.38，21.51）ab H=32.261 <0.001
MRA-RI（） 0.63±0.07 0.63±0.06 0.62±0.06 0.62±0.07 F=0.613 0.608
SRA-PSV[cm/s，M（QR）] 39.78（34.39，44.33） 42.54（36.36，50.96） 35.87（31.35，42.37） 31.42（24.76，39.34）ab H=17.656 0.001
SRA-EDV[cm/s，M（QR）] 17.14（14.76，19.07） 17.59（15.72，19.92） 15.55（14.72，16.9）b 13.81（11.43，14.88）ab H=32.044 <0.001
SRA-RI[M（QR）] 0.58（0.52，0.61） 0.58（0.52，0.63） 0.56（0.54，0.62） 0.55（0.51，0.66） H=0.584 0.900
IRA-PSV[cm/s，M（QR）] 26.87（24.28，30.47） 29.81（22.69，32.78） 28.07（22.38，30.47） 27.61（21.9，32.85） H=1.018 0.797
IRA-EDV[cm/s，M（QR）] 12.30（11.43，14.28） 12.58（10.73，14.76） 11.90（10.95，14.28） 11.90（10.47，15.24） H=1.157 0.763
IRA-RI（） 0.53±0.04 0.53±0.06 0.54±0.06 0.53±0.08 F=0.481 0.696
Emax[kPa，M（QR）] 10.37（7.16，11.29） 11.23（9.90，13.42） 11.85（11.12，13.96）a 12.34（10.57，17.74）a H=20.918 <0.001
Emean（kPa，） 6.20±1.26 6.71±1.34 7.59±1.57a 8.10±2.28ab F=7.671 <0.001
Emin[kPa，M（QR）] 4.34（3.65，5.35） 4.31（3.48，5.20） 4.54（3.76，5.35） 4.56（3.71，5.52） H=0.958 0.811
表8 超声参数对早期CKD 1~3期各期的异常检出率[例（%）]
分组 例数 MRA-PSV MRA-EDV SRA-PSV SRA-EDV Emax Emean 联合
CKD1期 32 0（0） 0（0） 15（46.9） 10（31.2） 9（28.1） 12（37.5） 16（50.0）
CKD2期 27 14（51.9） 15（55.6） 0（0） 2（0.07） 3（11.1） 7（25.9） 14（51.9）
CKD3期 23 9（39.1） 8（34.8） 14（60.9） 12（52.2） 10（43.5） 8（34.8） 13（56.5）
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