高渗高血糖综合征引发横纹肌溶解综合征的关联因素分析及临床防治探讨

程雅欣; 李佳; 李永恒; 刘明玉; 谭文彬

doi:10.12435/j.issn.2095-5227.2023.155

高渗高血糖综合征引发横纹肌溶解综合征的关联因素分析及临床防治探讨

Factors associated with rhabdomyolysis caused by hyperosmolar hyperglycemic syndrome and its clinical management

摘要

摘要:
背景横纹肌溶解症(rhabdomyolysis，RM)可引起高钾血症、心律失常、肌红蛋白尿，对肾小管造成损害，导致急性肾功能损伤，甚至危及患者生命。然而，在临床上糖尿病高渗高血糖综合征(hyperosmolar hyperglycemic syndrome，HHS)引发的横纹肌溶解症症状常隐匿，容易被忽视。
目的分析南部战区总医院HHS患者合并RM的临床特点和关联因素，并对其防治方法进行探讨。
方法回顾性分析南部战区总医院2009年2月—2021年7月收治住院的HHS患者病历资料，根据是否患有RM，将患者分为HHS合并RM组和HHS组。比较两组患者的临床特征和生化指标，并采用Pearson检验分析双变量间的相关性，使用多重线性回归分析方法确定导致HHS患者肌酸激酶水平上升的关联因素。分析经补液、降糖、纠正电解质和抗感染等治疗后不同患者的转归情况。
结果本研究共纳入31例HHS患者，其中合并RM者9例。与HHS组相比，HHS合并RM组患者平均年龄(P=0.011)、急性肾损伤患病率(P=0.037)、谷草转氨酶(P=0.011)、血钠(P=0.003)、血浆有效渗透压(P=0.001)、肌酐(P=0.004)和尿素氮(P=0.001)水平更高，差异均有统计学意义。肌酸激酶水平与肌酸激酶同工酶(r=0.442，P=0.018)、谷草转氨酶(r=0.389，P=0.031)、血氯(r=0.395，P=0.028)、血钠(r=0.537，P=0.002)、有效血浆渗透压(r=0.830，P=0.001)、肌酐(r=0.513，P=0.003)和尿素氮(r=0.772，P=0.001)水平呈正相关，与血钙水平呈负相关(r=-0.448，P=0.011)。多重线性回归分析发现，谷草转氨酶(β=0.503，P=0.010)、有效血浆渗透压(β=0.356，P=0.026)、肌酐(β=0.709，P=0.023)和尿素氮(β=-0.862，P=0.013)水平是导致HHS患者肌酸激酶水平上升的独立关联因素。经治疗后共29例好转出院，HHS合并RM组5例肌酸激酶、肌红蛋白降至正常。
结论 HHS引发RM与血浆有效渗透压、肌酐水平密切相关，临床收治HHS患者时若发现相关指标升高时应高度警惕。

Abstract:
Background Rhabdomyolysis (RM), characterized by myoglobinuria, hyperkalemia, and cardiac arrhythmias, poses a risk to renal tubules, leads to acute kidney injury and potentially life-threatening consequences. However, the symptoms of RM triggered by hyperosmolar hyperglycemic syndrome (HHS) in clinical practice often remain concealed and easily be overlooked.
Objective To analyze the clinical characteristics and factors associated with HHS combined RM in our hospital, and explore its preventive and treatment strategies.
Methods A retrospective analysis was conducted on medical records of HHS patients admitted to our hospital from February 2009 to July 2021. Patients were divided into HHS with RM group and HHS group based on the presence of RM. Clinical features and biochemical indicators were compared between the two groups, and Pearson test was used to analyze the correlation between variables. Additionally, multiple linear regression analysis was employed to identify factors contributing to elevated levels of creatine kinase (CK) in HHS patients. Finally, the outcomes of different patients after treatment, including fluid resuscitation, glycemic control, electrolyte correction, and anti-infective therapy, were analyzed.
Results A total of 31 HHS patients were included in this study, of which 9 had concurrent RM. Compared with the HHS group, patients in the HHS combined with RM group had higher mean age (P=0.011), prevalence of acute kidney injury (P=0.037), AST level (P=0.011), blood sodium level (P=0.003), plasma effective osmolality (P=0.001), creatinine (P=0.004), and urea nitrogen (P=0.001) levels, and the differences were all statistically significant. Creatine kinase level was positively correlated with CK-MB (r=0.442, P=0.018), AST (r=0.389, P=0.031), blood chloride (r=0.395, P=0.028), blood sodium (r=0.537, P=0.002), effective plasma osmolality (r=0.830, P=0.001), creatinine (r=0.513, P=0.003) and urea nitrogen levels (r=0.772, P=0.001), and while it was negatively correlated with blood calcium levels (r=-0.448, P=0.011). Multiple linear regression analysis revealed that AST (β=0.503, P=0.010), effective plasma osmolality (β=0.356, P=0.026), creatinine level (β=0.709, P=0.023) and urea nitrogen (β=-0.862, P=0.013) were independent correlates leading to an increase in creatine kinase level in HHS patients. A total of 29 cases were discharged with improvement after treatment, and creatine kinase and myoglobin decreased to normal in 5 cases in the HHS combined RM group.
Conclusion The development of RM in HHS patients is closely associated with plasma osmolality and creatinine levels. Therefore, heightened vigilance is warranted when encountering elevated indicators in HHS patients during clinical management.

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