[NEJM最新论文]:和肽素诊断尿崩症 | 中国病理生理学会危重病医学专业委员会
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[NEJM最新论文]:和肽素诊断尿崩症
2018年08月10日 时讯速递, 进展交流 暂无评论

ORIGINAL ARTICLE

A Copeptin-Based Approach in the Diagnosis of Diabetes Insipidus

Wiebke Fenske, Julie Refardt, Irina Chifu, et al

N Engl J Med 2018; 379:428-439

DOI: 10.1056/NEJMoa1803760

Abstract

BACKGROUND 背景

The indirect water-deprivation test is the current reference standard for the diagnosis of diabetes insipidus. However, it is technically cumbersome to administer, and the results are often inaccurate. The current study compared the indirect water-deprivation test with direct detection of plasma copeptin, a precursor-derived surrogate of arginine vasopressin.

间接限水试验是目前诊断尿崩症的标准方法。然而,这种方法技术上非常复杂,结果经常不准确。本研究对间接限水试验与直接测定血浆和肽素(一种精氨酸血管加压素前体)进行了测定。

METHODS 方法学

From 2013 to 2017, we recruited 156 patients with hypotonic polyuria at 11 medical centers to undergo both water-deprivation and hypertonic saline infusion tests. In the latter test, plasma copeptin was measured when the plasma sodium level had increased to at least 150 mmol per liter after infusion of hypertonic saline. The primary outcome was the overall diagnostic accuracy of each test as compared with the final reference diagnosis, which was determined on the basis of medical history, test results, and treatment response, with copeptin levels masked.

2013年至2017年间,我们在11家医学中心入选了156名低张尿患者,并进行了限水试验及输注高张盐水试验。在输注高张盐水试验后,当血钠水平升高到至少150 mmol/L时,我们测定了血浆和肽素。主要预后终点为每种试验诊断的总体准确性(与最终参照诊断相比,后者根据病史、检查结果及治疗反应综合确定,且不考虑和肽素水平)。

RESULTS 结果

A total of 144 patients underwent both tests. The final diagnosis was primary polydipsia in 82 patients (57%), central diabetes insipidus in 59 (41%), and nephrogenic diabetes insipidus in 3 (2%). Overall, among the 141 patients included in the analysis, the indirect water-deprivation test determined the correct diagnosis in 108 patients (diagnostic accuracy, 76.6%; 95% confidence interval [CI], 68.9 to 83.2), and the hypertonic saline infusion test (with a copeptin cutoff level of >4.9 pmol per liter) determined the correct diagnosis in 136 patients (96.5%; 95% CI, 92.1 to 98.6; P<0.001). The indirect water-deprivation test correctly distinguished primary polydipsia from partial central diabetes insipidus in 77 of 105 patients (73.3%; 95% CI, 63.9 to 81.2), and the hypertonic saline infusion test distinguished between the two conditions in 99 of 104 patients (95.2%; 95% CI, 89.4 to 98.1; adjusted P<0.001). One serious adverse event (desmopressin-induced hyponatremia that resulted in hospitalization) occurred during the water-deprivation test.

共有144名患者完成了两项试验。82名患者(57%)被诊断为原发性多尿,59名患者(41%)诊断为中枢性尿崩症,3名患者(2%)诊断为肾性尿崩症。在纳入分析的141名患者中,间接限水试验对108名患者得到正确诊断(诊断准确率76.6%; 95% 可信区间 [CI], 68.9 to 83.2),高张盐水输注试验(和肽素临界值> 4.9 pmol/L)对136名患者得到正确诊断(96.5%; 95% CI, 92.1 to 98.6; P<0.001)。在105名患者中,间接限水试验能够正确鉴别77名原发性多尿与部分中枢性尿崩症 (73.3%; 95% CI, 63.9 to 81.2),高张盐水输注试验能够对104名患者中的99名进行正确鉴别(95.2%; 95% CI, 89.4 to 98.1;校正后P < 0.001)。在限水试验期间发生1例严重不良事件(醋酸去氨加压素诱导的低钠血症导致患者住院治疗)。

CONCLUSIONS 结论

The direct measurement of hypertonic saline–stimulated plasma copeptin had greater diagnostic accuracy than the water-deprivation test in patients with hypotonic polyuria.

对于低张尿患者,直接测定高张盐水刺激的血浆和肽素水平的诊断准确性优于限水试验。

(Funded by the Swiss National Foundation and others; ClinicalTrials.gov number, NCT01940614.)

 

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