【作者】 王云华；

【导师】 刘瑞洪；

【作者基本信息】 中南大学 ， 内科学， 2008， 博士

【摘要】 第一部分肾脏64层螺旋CT灌注成像技术的参数组合、正常灌注表现及其影响因素的研究目的:①探讨64层螺旋CT(Spiral CT,SCT)肾脏灌注成像的技术方法;②测定正常肾脏皮质、髓质的各项灌注参数;③分析正常肾脏皮质、髓质灌注值与年龄、性别、左右侧的相关性。材料和方法:应用SIEMENS Sensation 64层螺旋CT扫描仪,对30例健康志愿者先行肾脏CT平扫,确定肾门层面为灌注层面,而后以6ml/s速度注射非离子对比剂碘海醇(300mgI/ml)50ml,在肾门层面行同层动态扫描,扫描延时时间为6s。每个病人的扫描分3个序列,每个序列的扫描时间为30s,间隔10s让患者呼吸换气,然后接着下一个序列扫描。每个序列的球管曝光时间为0.5s,间隔时间分别为0.5s、2.5s、4.5s。在西门子工作站上用Body Perfusion软件包中的Kindey分析软件处理数据。测定正常肾脏的各项灌注参数值,应用配对t检验及两样本t检验分别比较左右侧及男女各灌注参数有无显著性差异。根据年龄将其分为三组,应用方差分析分别比较三组间肾脏皮质、髓质灌注参数值有无显著性差异,从而分析年龄是否对各灌注参数产生影响。结果:①探讨出理想的64层螺旋CT灌注参数组合。②28例正常肾脏64层CT灌注成像表现为双侧肾脏皮质TDC曲线(time-densitycurve)和双侧肾髓质TDC曲线对称,基本重合。肾皮质BF为301.56±68.79ml/100ml/min,BV为38.86±5.83 ml/100ml,TTP为11.17±1.12s,PS为42.85±10.88ml/100ml/min,PBV为67.53±10.25ml/100ml;肾髓质BF为157.78±34.58 ml/100ml/min,BV为28.53±3.90 ml/100ml,TTP为12.38±1.15s,PS为75.59±22.68ml/100ml/min,PBV为28.24±0.94ml/100ml。③双侧肾脏皮质、髓质灌注值之间无统计学差异(肾皮质BF、BV、TTP、PS、PBV的P值分别为0.55、0.73、0.60、0.16、0.68;肾髓质BF、BV、TTP、PS、PBV的P值分别为0.09、0.72、0.60、0.09、0.65。P值均＞0.05);男、女肾脏皮髓质灌注值之间无明显统计学差异(肾皮质BF、BV、TTP、PS、PBV的P值分别为0.29、0.50、0.40、0.72、0.31;肾髓质BF、BV、TTP、PS、PBV的P值分别为0.45、0.38、0.11、0.45、0.75。P值均＞0.05);但年龄因素对肾脏皮髓质灌注参数有影响,年龄＜40岁组、40—60岁组、＞60岁组三组比较肾皮质BF、BV、TTP、PS三组间差别有统计学意义,肾髓质BV、PS三组间差别有统计学意义,组间比较时,P均＜0.05。结论:①64层螺旋CT灌注成像技术能测量正常肾脏皮质、髓质各灌注值,能定量分析其血流动力学变化。②肾脏皮髓质的灌注值与年龄相关,而与性别、左右侧无关。第二部分肾脏64层螺旋CT灌注成像对梗阻性肾积水积水肾脏单肾功能的评价目的:①探讨梗阻性肾积水患者积水肾64层螺旋CT灌注成像表现(灌注参数值的变化与灌注图的变化);②探讨64层螺旋CT肾灌注成像对单肾功能损害及其分级的的评估价值;③64层螺旋CT肾脏各灌注参数值与单光子发射计算机体层成像(SPECT)肾动态显像测定的GFR进行比较,分析两者间的相关性。材料与方法:36例梗阻性肾积水患者,均对其进行64层螺旋CT灌注扫描和单光子发射计算机体层成像(SPECT)肾动态显像检查。①将积水组(48个肾脏)各灌注参数位与第一部分测定的正常组对照分析;②根据SPECT测定的肾小球滤过率(GFR)把72个肾脏分为正常组、肾功能轻度受损组、肾功能重度受损组,分别测量3组肾皮质和髓质的64层螺旋CT血流灌注参数,比较三者之间的差异;③将各灌注参数与单侧肾脏GFR进行pearson相关性分析。结果:①36例梗阻性肾积水患者的CT灌注成像表现为双侧TDC曲线不对称,积水侧肾皮质、髓质的TDC斜率与峰高降低。积水肾的肾皮质BF为203.20±44.93ml/100ml/min,BV为27.61±3.90 ml/100ml,PS为30.68±6.48 ml/100ml/min,PBV为46.49±10.85 ml/100ml;肾髓质BF为99.89±24.08 ml/100ml/min,BV为18.32±4.32ml/100ml,PS为51.80±12.09 ml/100ml/min,PBV为21.3l±2.95ml/100ml。与第一部分正常肾脏各灌注参数值相比均下降(P值均＜0.05)。②肾功能受损组肾皮质和肾髓质各血流灌注值均下降,与正常组比较有显著性差异(P＜0.05)。正常组、肾功能轻度受损组、肾功能重度受损组3组间肾皮质和肾髓质血流灌注值均有显著性差异(P＜0.05)。三组间肾皮质、肾髓质各血流灌注参数组间两两比较,也均有显著性差异,P值＜0.05。③肾皮质和髓质的各灌注参数与单侧肾脏肾小球滤过率(GFR)有良好的相关性。其中肾皮质BF相关性最好,相关系数r=0.852。结论:①64层螺旋CT肾脏灌注成像能对积水肾肾皮质和髓质的血流灌注状态与肾功能损害进行定量评估;②64层螺旋CT灌注成像能对受损肾功能进行分级;③64层螺旋CT肾灌注成像测定的肾皮质、髓质的各灌注参数值与SPECT测定的GFR有良好的相关性。因此64层螺旋CT肾脏灌注成像对评价肾积水时肾血流变化情况及预测单侧肾脏功能有一定的临床价值。第三部分肾脏皮髓质分界、肾皮髓质对比度及皮髓质CT峰值与单肾功能相关性的64层螺旋CT研究目的:观察64层螺旋CT灌注扫描中正常肾与梗阻性肾积水时积水肾肾脏皮髓质分界(CMD)、肾皮髓质对比度(CMC)及皮髓质CT峰值的变化规律,并进一步探讨其与单肾功能的相关性。材料与方法:选择36名梗阻性肾积水患者,均对其进行64层螺旋CT灌注扫描和单光子发射计算机体层成像(SPECT)肾动态显像检查,并将患者按SPECT测定的肾小球滤过率(GFR)水平分为正常组(24个)和轻度肾功能降低组(21个)与重度肾功能减退组(27个)。并分别以肾皮髓质分界清晰、模糊、部份可见与消失将CMD分为四种不同程度;分别测量皮质峰值时刻的皮质及髓质CT值,计算皮髓质对比度(CMC),分别测量髓质峰值;探讨正常组、轻度肾功能降低组与重度肾功能减退组之间CMD、CMC与皮髓质CT峰值的差异;分别将上述CMC及肾皮质及髓质CT峰值与GFR进行相关分析。结果:(1) CMD:正常组(24个),24个(100%)CMD清晰;轻度肾功能降低组(21个):14个(66.67%)CMD清晰,2个(9.52%)CMD模糊但仍可见,5个(23.81%)CMD部分可见;重度肾功能减退组(27个):7个(25.93%)CMD清晰,5个(18.52%)CMD模糊但仍可见,15个(55.56%)CMD部分可见。(2) CMC值及其与GFR相关性:正常组CMC为0.616±0.203,肾功能轻度受损组CMC为0.517±0.140,肾功能重度受损组CMC为0.367±0.110。CMC与GFR呈正相关(r=0.536,P＜0.05)。(3)肾皮质及髓质CT峰值及与GFR相关性:正常组肾皮质CT峰值为132.95±21.99Hu,肾髓质CT峰值104.07±16.15Hu;肾功能轻度受损组肾皮质CT峰值为90.97±29.32Hu,肾髓质CT峰值75.90±24.70 Hu;肾功能重度受损组肾皮质CT峰值为68.45±24.09Hu,肾髓质CT峰值56.90±21.31Hu。肾皮质CT峰值与GFR呈正相关(r=0.672,P＜0.05),肾髓质CT峰值与GFR呈正相关(r=0.623,P＜0.05)。结论:(1)梗阻性肾积水患者积水肾功能减退时CMD半定量化与量化指标CMC及肾皮髓质CT峰值均降低。(2)梗阻性肾积水肾脏CMC、与肾皮质及髓质CT峰值改变与GFR具有正相关关系,因而其对预测单侧肾脏功能有一定的临床价值。第四部份肾脏皮质厚度、皮层容积大小与单肾功能相关性的64层SCT研究目的:研究肾脏皮质厚度、肾皮质容积大小与单肾功能的关系。材料与方法:36例梗阻性肾积水患者,在对其进行64层螺旋CT灌注扫描后进行全肾CT增强扫描,并于2天内行单光子发射计算机体层成像(SPECT)肾动态显像检查。根据SPECT检测的肾小球滤过率(GFR)把72个肾脏分为正常组、肾功能轻度受损组、肾功能重度受损组,分别测量三组病例的肾脏皮质厚度、肾皮质容积大小均值;比较三组间64层SCT测量的肾脏皮质厚度、肾皮质容积大小的差异,分析肾脏皮质厚度、肾皮层容积大小与同侧肾GFR值的相关性,从而探讨64层SCT测量肾脏皮质厚度、肾皮层容积大小对单肾功能的评价价值。结果:肾功能正常组、轻度受损组、重度受损组三组间肾脏皮质厚度分别为0.51±0.1、0.37±0.12、0.23±0.80(cm),三组间肾脏皮质容积大小分别为74.26±11.92、55.28±15.19、27.57±7.02(cm~3)。三组之间肾脏皮质厚度及容积大小差异均有统计学意义(F值分别为51.60,77.01,P值均＜0.01)。肾脏皮质厚度、皮质容积大小与肾脏GFR均有良好的相关性(相关系数分别为r=0.778与r=0.815,P值均＜0.01)。结论:64层SCT增强扫描及相关后处理软件测量的肾脏皮质厚度与皮层容积大小能在一定程度上反映单肾功能,可以作为64层SCT评价单肾功能的有用参数。更多还原

【Abstract】 PartⅠ:The Research of Perfusion Imaging Parameter, normal Perfusion Performance and The Influencing Factors in 64—Slice Spiral CT Kidney Perfusion ImagingObjective:①To investigate the methods of MSCT perfusion imaging of the kidney;②To measure all the cortex and medulla perfusion parameters of the nomal kidney;③These perfusion parameters were compared to determine whether there were significant diference between right and left,male and femal.And the correlation between age and perfusion parameters was analyzed.Methods:28 healthy volunteers were studied in this group with SIEMENS Sensation 64-slice spiral CT.A conventional kidney CT plain scan was obtained as a routine to locate the renal hili.Dynamic scans were performed at the location of the renal hili with 50ml nonionic contrast administration(300 mgI/ml) at the speed of 6 ml/s.There are three separate scan sequences for each patient with 30 seconds scan duration respectively.The patient was asked to breathe in and out during the 10s interval of each scan sequence.For each scan sequence,the rotation time is 0.5s,and scan interval is 0.5s、2.5s and 4.5s, respectively.Data postprocessing was performed on Siemens workstation using kidney analyzing software in the package of Body Perfusion.To measure all the cortex and medulla perfusion parameters of the nomal kidney.The perfusion parameters were then compared using the paired t-test and two-sample t-test,to determine whether there were significant diference between right and left,male and femal.And the correlation between age and perfusion parameters was analyzed. Result:①To explore the ideal 64-slice spiral CT kidney perfusion parameter combination.②The time-density curves of 28 bilateral normal renal cortex and medulla are symmetric,even coincident.The mean BF、BV、TTP、PS、PBV of renal cortex were 301.56±68.79ml/100ml/min、38.86±5.83 ml/100ml、11.17±1.12s、42.85±10.88ml/100ml/min、67.53±10.25 ml/100ml respectively.and the mean BF、BV、TTP、PM、PBV of renal medulla were 157.78±34.58 ml/100ml/min、28.53±3.90 ml/100ml、12.38±1.15s、75.59±22.68 ml/100ml/min、28.24±0.94 ml/100ml.③Using analysis of variance,there were no gender and right or left differences in the perfusion parameters(The P value of the BF、BV、TTP、PS、PBV of renal cortex were 0.55、0.73、0.60、0.16、0.68; The P value of the BF、BV、TTP、PS、PBV were 0.09、0.72、0.60、0.09、0.65.P＞0.05),but the perfusion parameters of cortex and medulla was lower in the elder(P＜0.05).Conclusion:①It can measure the cortex and medulla perfusion parameters of the nomal kidney with 64—slice spiral CT perfusion imaging.It can quantitatively evaluate the haemodynamics change in the normal renal tissue..②There were no gender and right or left differences in all the perfusion parameters of the normal kidney,but there were relationship between age with all the perfusion parameters. PartⅡ:64—Slice Spiral CT Perfusion Imaging in the Single Renal Functional Assessment of Hydronephrotic kidneyObjective:The purpose of this study was to evaluate the diagnostic value of MSCT perfusion imaging in assessment of single renal function of hydronephrotic kidney,and to compare the results with GFR which were obtained with SPECTMethods:64-slice spiral CT perfusion were performed in 36 obstructive nephrohydrosis patients whose split renal glomerular filtration rate(GFR) were measured by SPECT renal dynamic imaging.①To compared the perfusion parameters of the renal cortex and renal medulla of the Hydronephrotic kidney with the normal kidney studied in the primary part.②The 72 kidneys were divided into normal renal function,mild and severe renal impairment groups according to renal function.Differences between the groups respect to all the mean perfusion parameters of the renal cortex and renal medulla were assesses by ANOVA.③Using Pearsons correlation test,the correlation between all the mean perfusion.parameters of the renal cortex and renal medulla and renal GFR were examined.Result:①The time-density curves of bilateral normal renal cortex and medulla are not symmetric.The mean BF、BV、PS、PBV of renal cortex were 203.20±44.93ml/100ml/min、27.61±3.90 ml/100ml、30.68±6.48 ml/100ml/min、46.49±10.85 ml/100ml;and the mean BF、BV、PM、PBV of renal medulla were 99.89±24.08 ml/100ml/min、18.32±4.32 ml/100ml、51.80±12.09 ml/100ml/min、21.31±2.95ml/100ml.The mean Perfusion parameters of the cortex and medulla of obstructed kidney were lower compared to that of normal kidney.②There were significant differences of all the perfusion parameters of the renal cortex and medulla between three groups(P＜0.05).③The perfusion parameters of the renal cortex and medulla had positive linear corelation with GFR.The best correlatin was the blood flow of the cortex of kidney.The correlation coefficient r=0.852.Conclusion:①It can quantitatively evaluate the haemodynamics condition and functional lesion of the kidney using 64—slice spiral CT perfusion imaging;②It can classify the impaired kidney function;③The perfusion parameters of the renal cortex and medulla had positive linear corelation with GFR.So it is of certain value in evaluating the half renal function of hydronephrosis. PartⅢ:The 64-slice Spiral CT Study of Relationship between Renal Corticomedullary Differentiation,Contrast Between Renal Cortex and Medulla(CMC),Renal Cortex and Medulla Peak Value with the Single Renal Functional of Hydronephrotic kidneyObject:To observe 64-slice spiral CT perfusion imaging features about renal corticomednllary differentiation,differentiation contrast between renal cortex and medulla(CMC),renal cortex and medulla CT peak value in normal and hydronephrotic kidney,and to explore the relationgship between them with the single renal functional.Material and methods:64-slice spiral CT perfusion were performed in 36 obstructive nephrohydrosis patients whose split renal glomerular filtration rate(GFR) were measured by SPECT renal dynamic imaging. The 72 kidneys were divided into normal renal function,mild and severe renal impairment groups according to GFR.Renal corticomedullary diferentiation on CT images were divided into clear group,obscure group,part clear group and vanish group according to the level of CMD. The CT intensity of cortex and medulla was measured in order to calculate contrast between renal cortex and medulla(CMC),Using Pearsons correlation test,the correlation between them and renal GFR were examined.Results:①The 24 kidneys of normal group,24(100%) kidneys showed clear CMD.The 21 kidneys of mild renal impairment group, 14(66.67%)kidneys showed clear CMD,2(9.52%)showed obscure CMD and 5(23.81%) showed part clear of CMD;The 27 kidneys severe renal impairment group,7(25.93%)kidneys showed clear CMD,5(18.52 %)showed obscure CMD and 15(55.56%)showed part clear of CMD;②The normal group CMC was 0.616±0.203,The mild renal impairment group CMC was 0.517±0.140,The severe renal impairment group CMC was 0.367±0.110.The CMC had positive linear corelation with GFR,The correlation coefficient r=0.536.③The renal cortex and medulla CT peak value of normal group were 132.95±21.99Hu and 104.07±16.15Hu;The renal cortex and medulla CT peak value of mild renal impairment group were 90.97±29.32Hu and 75.90±24.70Hu;The renal cortex and medulla CT peak value of severe renal impairment group 68.45±24.09Hu and 56.90±21.31Hu.The renal cortex CT peak value had positive linear corelation with GFR,The correlation coefficient r=0.672, The renal medulla CT peak value had positive linear corelation with GFR,The correlation coefficient r=0.623.Conclusion:①The CMC and the renal cortex and medulla CT peak value all degrade when the kidney functiong decrease of obstructive nephrohydrosis patients.Hypofunction.②The CMC and the renal cortex CT peak value of obstructive nephrohydrosis had positive linear corelation with GFR.So they are of certain value in evaluating the single renal function of hydronephrosis. PartⅣRelationship between renal cortex thickness or volume and split renal function:study with CT measurementObjective To study the relationship between renal cortex thickness or volume and renal function,and to assess the value of CT as a criterion to grade renal function.Methods Enhancement CT were performed in 36 nephrohydrosis patients whose split renal glomerular filtration rate(GFR) were measured by SPECT renal dynamic imaging.The 72 kidneys were divided into normal renal function,mild and severe renal impairment groups according to renal function.Differences between the groups respect to the mean cortex thickness and volume were assesses by ANOVA.Using Pearson’s correlation test,the corelation between the renal cortex thicknesses,volume and renal GFR were examined.Results The renal cortex thicknesses of normal renal function,mild and severe renal impairment groups were(0.51±0.1)、(0.37±0.12)、(0.23±0.80) cm respectively,and the renal cortex volume were (74.26±11.92)、(55.28±15.19)、(27.57±7.02)cm~3.There were significant differences of renal cortex thickness and volume between three groups (cortex thickness F=51.60,P＜0.01:cortex cortex F=77.01,P＜0.01),The thicknesses of renal cortex(r=0.778 P＜0.01),the volume of renal cortex (r=0.815 P＜0.01)had positive linear corelation with renal function.Conclusion The thicknesses and volume of renal cortex measured by CT can reflect renal function.CT was a supplementary method to a ssess renal function.更多还原