早期临床免疫学监测在脓毒症患者预后评估中的价值探讨  

Value of early clinical immunological monitoring in the evaluation of prognosis in patients with sepsis

作　　者：张苜[1] 甯议万 范晶[1] 林时辉[1] 杨远征[2] 徐昉[1] Zhang Mu;Ning Yiwan;Fan Jing;Lin Shihui;Yang Yuanzheng;Xu Fang(Department of Emergency Medicine and Critical Illness Medicine,The First Affiliated Hospital of Chongqing Medical University;Department of Intensive Care ,Affiliated Hospital of Hainan Medical College)

机构地区：[1]重庆医科大学附属第一医院急诊医学科重症医学科,重庆400016 [2]海南医学院附属医院重症医学科,海口570102

出　　处：《重庆医科大学学报》2019年第1期80-84,共5页Journal of Chongqing Medical University

基　　金：国家自然科学基金资助项目(编号:81873928;81760341);重庆市科委社会事业与民生保障科技创新专项资助项目(编号:cstc2017shmsA130072);重庆市卫生和计划生育委员会医学科研计划资助项目(编号:2015MSXM015;2017ZDXM007;2017MSXM017)

摘　　要：目的:分析脓毒症患者细胞免疫、体液免疫指标与病情严重程度及预后的关系。方法:选择71名脓毒症患者为研究对象;按病情严重程度分为脓毒症组(37例)和脓毒性休克组(34例);根据28 d转归分为生存组(58例)和死亡组(13例)。记录患者入ICU时APACHEⅡ评分和SOFA评分,检测免疫学指标,统计分析脓毒症组、脓毒性休克组间上述指标的差异;ROC曲线分析上述指标对患者预后评估的临床价值。结果:脓毒性休克组APACHEⅡ评分、SOFA评分、CD4+/CD8+及C4浓度明显高于脓毒症组,具有统计学差异(P<0.05)。脓毒性休克组T淋巴细胞百分比、C3浓度低于脓毒症组,具有统计学差异(P<0.05)。死亡组APACHEⅡ评分及SOFA评分明显高于生存组,死亡组CD4+/CD8+、C3的浓度低于生存组,具有统计学差异(P<0.05)。多因素logistic回归分析提示SOFA和C3浓度是预测脓毒症患者病情严重程度的影响指标。根据受试者工作特征曲线(ROC曲线)分析,CD4+/CD8+、APACHEⅡ评分和SOFA评分的AUC分别为0.807、0.843、0.853(P<0.05);CD4+/CD8+最佳临界值为21.9%时,预测脓毒症死亡的敏感度为69.2%,特异度为86.2%;APACHEⅡ最佳临界值为22分时,预测脓毒症死亡的敏感度为76.9%,特异度为79.3%;SOFA最佳临界值为17.5分时,预测脓毒症死亡的敏感度为76.9%,特异度为79.3%。结论:T淋巴细胞百分比、CD4+/CD8+、补体C3和C4浓度与脓毒症严重程度具有相关性,对判断脓毒症严重程度具有潜在价值。C3浓度是预测脓毒症患者病情严重程度的独立指标。CD4+/CD8+能够反映脓毒症患者的预后。Objective:To analyze the association of cellular and humoral immunity indices with the severity of disease and prognosis in patients with sepsis. Methods:A total of 71 patients with sepsis included in the study were divided into sepsis group(37 cases) and septic shock group(34 cases) according to the severity of disease,and into survival group(58 cases) and death group(13 cases) according to the 28-day outcome. The Acute Physiology and Chronic Health Evaluation Ⅱ(APACHE Ⅱ) score and the Sequential Organ Failure Assessment(SOFA) score were determined when the patients were admitted to the ICU,and their immunological in-dices were measured. The differences in the above indices between the sepsis group and the septic shock group were statistically analyzed. The receiver operating characteristic(ROC) curve was used to analyze the clinical value of the above indicators in evaluating the prognosis of the patients. Results:Compared with the sepsis group,the septic shock group had significantly higher APACHE Ⅱ score,SOFA score,CD4^+/CD8^+,and complement 4(C4) level(P<0.05),but significantly lower T lymphocyte percentage and complement 3(C3) level(P<0.05). Compared with the survival group,the death group had significantly higher APACHE Ⅱ score and SOFA score(P<0.05),but significantly lower CD4^+/CD8^+ and C3 level(P<0.05). A multivariate logistic regression analysis suggested that SOFA score and C3 level were predictors of the severity of sepsis. According to the results of ROC curve analysis,the areas under the ROC curve for CD4^+/CD8^+,APACHE Ⅱ score,and SOFA score were 0.807,0.843,and 0.853,respectively(P<0.05);in predicting sepsis-induced death,CD4^+/CD8^+ had a sensitivity of 69.2% and a specificity 86.2% at the optimal cut-off value of 21.9%,APACHEⅡ score had a sensitivity of 76.9% and a specificity of 79.3% at the optimal cut-off value of 22,and SOFA score had a sensitivity of 76.9% and a specificity of 79.3% at the optimal cut-off value of 17.5. Conclusion:T lymphocyte percentage,CD4^+/CD8^+,C3,and C4

关 键 词：脓毒症 细胞免疫 体液免疫 严重程度 预后 

分 类 号：R446.11[医药卫生—诊断学]