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Distribution and Diagnostic Value of Pancreatic Enzymes in Dialysis Patients
在透析病人診斷急性胰臟炎的最佳胰臟酵素值
摘要
背景：由於腎臟對胰臟酵素排泄能力下降，尿毒症病人血清中胰臟酵素值在一般狀態下是偏高的。臨床上，這常造成在尿毒症病人診斷急性胰臟炎的困難。所以我們在本研究分析透析病患血中胰臟酵值的分佈並討論不同的胰臟酵素診斷標準值在尿毒病患診斷急性胰臟炎的價值。 方法：我們選擇39位腹膜透析，76位血液透析，以及266位正常腎功能病人，測量其血清中胰臟酵素數值，並藉由醫院住院病歷資訊系統交集尿毒與急性胰臟炎診斷而得到21位發生急性胰臟炎的尿毒症病人，取其住院療程中血清胰臟酵素最高值來分析，並用統計方法比較不同的cut-off值。 結果：透析病患血清中胰臟酵素明顯高於腎功能正常的人，最高可達正常值之5-7倍。在115透析病患中，有67位(58%)之澱粉酶值高於正常，而其中有2位(2%)高於三倍正常；另外有87位(74%)的脂酶值高於正常，而其中有17位(15%)高於三倍正常值。患有胰臟炎及沒有兩族群的胰臟酵素有明顯重疊。ROC曲線分析顯示如果以澱粉釀247 U/L以及脂酶631 U/L來做為尿毒病患診斷急性胰臟炎的標準，會有最佳的敏感度和特異性之平衡。若以傳統的三倍當標準，脂酶有尚不錯的敏感度和特異性之平衡。但澱粉酶則不佳。如果採用正常值七倍當標準則在澱粉酶與脂酶都會有1.0的特異性。 結論：透析病患在平常狀態就可能有5~7倍高的胰臟酶值，所以要在這個族群診斷急性胰臟炎要很小心，不能以胰臟酵素值的高低做為唯一標準，一定要配合臨床及影像證據。傳統的脂酶三倍標準提供了可被接受的敏感度和特異性，但澱粉酶則不佳。在我們醫院我們建議採用澱粉酶247 U/L及脂酶621U/L當診斷標準。然而只有在胰臟酵素值高於七倍正常值時才能絕對確認胰臟炎的診斷。
並列摘要
Purpose: As serum levels of pancreatic enzyme are elevated in dial sis patients, clinicians ma encounter difficulty in diagnosing pancreatitis among dialysis patients with abdominal pain. In this work, we analyze the distrtbution of pancreatic enzyme levels in dialysis patients and compared different cut-off values in establishing diagnosis of acute pancreatitis in dialysis population. Patients and Methods: Serum levels of amylase and lipase were measured in 39 peritoneal dialysis (PD) patients, 76 hemodialysis (HD) patients and 266 people with normal renal function. Another 21 dialysis patients with pancreatitis cross-referenced from tile hospital computer database were also included in the analysis. Distribution of pancreatic enzymes between different groups was analyzed, and sensitivity/specificity of different cut-off values was compared using SPSS software. Results: Mean serum amylase and lipase level were higher in HD as well as PD patients thou in the normal controls (p＜0.05). In total, 67 of tile 115 (58%) asymptomatic dialysis patients had an anylase level higher than the upper normal limit with 2 (2%) was higher than 3 times tile normal. Eighty-five of 115 (74%) patients had a lipase level higher than the normal with 17 (15%) higher than 3 times the normal. The highest level of amylase was 5.3 times and lipase was 6.7 times the upper normal limit. When contracting pancreatitis, dialysis patients had further rise in amylase and lipase levels (p＜0.05 for both). However, significant overlapping in pancreatic enzyme levels existed between those with and without pancreatitis. ROC curve analysis revealed that the cut-off value providing the best balance between sensitivity and specificity was 247 U/L for amylase (0.714/0.839), and 631 U/L for lipase (0.905/0.902). When using the traditional 3 times the normal as the cut-off value, the sensitivity/specificity of amylase criterion of 420 U/L was 0.333/0.982 while that of lipase criterion of 570 U/L was 0.952/0.857. Alternatively, using 7 tunes rile upper normal limit as the cut-oft value provides a specificity of 1.0 for both amylase amid lipase criteria. Conclusion: Asymptomatic dialysis patients might have highly elevated pancreatic enzyme levels which overlap severely with patients with pancreatitis. Thus, diagnosis of acute pancreatitis should be made with care. A cut-off value of 3 times the upper normal limit provided an acceptable balance between sensitivity and specificity criteria for lipase hut not for amylase. A cut-off value of 247 U/L for amylase and 621 U/L for lipase is a the preferred criterion in our hospital. However, only the application of 7 times the upper normal limit as a the cut-off value could guarantee correct diagnosis of pancreatitis in dialysis population.