南方医科大学学报

南方医科大学学报 ›› 2020, Vol. 40 ›› Issue (10): 1518-1524.doi: 10.12122/j.issn.1673-4254.2020.10.20

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COVID-19患者肺外多器官早期损害的临床分析

范景如，张永海，潘泽群，王良玉，洪旭伟，吴令杰，郭舜奇   


  • 出版日期:2020-10-20 发布日期:2020-10-20

Clinical analysis of early damage in multiple extra-pulmonary organs in COVID-19

  • Online:2020-10-20 Published:2020-10-20

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摘要： 目的 分析COVID-19患者病程中合并早期心脏、肝脏和肾脏损害的临床表现，探讨可识别COVID-19心、肝、肾早期损害的指标。 方法 收集2020年1月20日~2月20日，我院收治的12例COVID-19患者病程中发热、畏寒、咳嗽、乏力等临床特征、存在的相关基础疾病，入院后第2天的血常规、电解质、血脂、止凝血功能中的主要指标及相关感染指标。收集并分析患者的肌酶激酶MB同工酶（CK-MB）、肌钙蛋白 （I aTnI）、B型钠尿肽（BNP）、心率、心电图新发改变（通过心电图检查获取）、左心室射血分数（LVEF，%）及左室总体纵向应变（GLS）（通过心脏彩超检查获取）；通过动态复查患者白蛋白（ALB）、谷丙转氨酶（ALT）、谷草转氨酶（AST）、谷氨酰转肽酶（GGT）、直接胆红素（DBIL）、总胆红素（TBIL）等肝功能生化指标的动态变化；记录血尿素（BUN）、
尿肌酐（UCR），通过计算肾小球滤过率（eGFR）、内生肌酐清除率（Ccr）及尿微量白蛋白/尿肌酐比值（UACR），评估早期肾损害发病情况,损害的发生情况, 并通过检测尿微量白蛋白（MA）、α1-微球蛋白（A1M）、尿免疫球蛋白 G（IGU）及尿转铁蛋白（TRU）水平。综合分析COVID-19肺外器官早期损伤的情况。结果 12例 COVID-19患者包括2例重型、8例普通型和2例轻型。肌钙
蛋白I（aTNI）、左心室射血分数均无明显异常的情况下观察到窦性心动过速、心电图新发改变及GLS的异常率均为33.3%，CKMB与BNP的异常率均为8.3%；入院第1、3天，未见谷丙转氨酶（ALT）、谷草氨酶（AST）、谷氨酰转肽酶（GGT）升高；第7天，观察到重症COVID-19患者出现肝功能损伤，表现为ALT、AST升高；患者血肌酐、血尿素均无明显异常情况下仍观察到eGFR、
Ccr 及 UACR 的异常率分别为 66.7%、41.7%、41.7%，尿液蛋白中 MA、A1M、IGU、TRU 异常升高率分别为 33.3%、33.3%、41.7%、16.7%。结论 COVID-19患者中：在aTNI、LVEF未见异常的，可通过观察患者的心电图的是否存在窦速、新发异常改变、GLS的异常，早期识别其心脏损害；早期肝损伤不明显，但仍应重视特别是重症患者肝功能指标的动态监测；在血肌酐、血尿素正常的情况下，可通过计算eGFR、Ccr 及 UACR及检测尿液蛋白联合早期识别肾损伤。

关键词: COVID-19, 早期心脏损害, 早期肝损害, 早期肾损害

Abstract: Objective To analyze the clinical manifestations of heart, liver and kidney damages in the early stage of COVID-19 to identify the indicators for these damages. Methods We analyzed the clinical features, underlying diseases, and indicators of infection in 12 patients with COVID-19 on the second day after their admission to our hospital between January 20 and February 20, 2020. The data including CK-MB, aTnI, BNP, heart rate, changes in ECG, LVEF (% ), left ventricular general longitudinal strain (GLS, measured by color Doppler ultrasound) were collected. The changes of liver function biochemical indicators were dynamically reviewed. BUN, UCR, eGFR, Ccr, and UACR and the levels of MA, A1M, IGU, and TRU were recorded. Results The 12 patients included 2 severe cases, 8 common type cases, and 2 mild cases. Four of the patients presented with sinus tachycardia, ECG changes and abnormal GLS in spite of normal aTNI and LVEF; 1 patient had abnormal CKMB and BNP. On the first and third days following admission, the patients had normal ALT, AST and GGT levels. On day 7, hepatic function damage occurred in the severe cases, manifested by elevated ALT and AST levels. Abnormalities of eGFR, Ccr and UACR occurred in 8, 5 and 5 of the patients, respectively. Abnormal elevations of MA, A1M, IGU and TRU in urine protein were observed in 4, 4, 5, and 2 of the patients, respectively. Conclusion In patients with COVID-19, heart damage can be identified early by observing the GLS and new abnormalities on ECG in spite of normal aTNI and LVEF. Early liver injury is not obvious in these patients, but dynamic monitoring of the indicators of should be emplemented, especially in severe cases. In cases with normal CR and BUN, kidney damage can be detected early by calculating eGFR, Ccr and UACR and urine protein tests.

Key words: COVID-19, early heart damage, early liver damage, early kidney damage