应用凝血标志物诊断创伤骨科术后静脉血栓形成的病例对照研究  

Blood coagulation biomarkers for postoperative venous thromboembolism diagnosis in orthopedic traumatic patients： a case control study

作　　者：孟英[1] 刘宁[2] 薛冰蓉[3] 刘建龙[4] 卢山[1] 王旭[1] 赵慧茹[1] 文梦 吴俊[1] 

机构地区：[1]北京积水潭医院检验科,100035 [2]北京大学人民医院检验科 [3]绵阳市中心医院检验科 [4]北京积水潭医院血管外科

出　　处：《中华检验医学杂志》2016年第10期751-755,共5页Chinese Journal of Laboratory Medicine

基　　金：首都特色临床医疗项目,吴阶平基金（Z141107006614012）;教育部留学归国人员科研启动基金（教外司留[2013]693号）;人社部留学人员科技活动项目（[2015]192）;北京市卫生系统第五批215高层次人才培养计划

摘　　要：目的 评价创伤骨科术后凝血标志物的变化，分析其对静脉血栓形成的诊断价值。方法 病例对照研究。选取创伤骨科手术患者108例（其中术后血栓形成组54例，术后非血栓形成组54例）。术后第3～4天检测常规凝血指标及血栓调节蛋白（TM）、凝血酶抗凝酶复合物（TAT）、组织型纤溶酶原激活抑制复合物（t－PAIC）、纤溶酶－抗纤溶酶复合物（PIC）、纤维蛋白降解产物（FDP）、D－二聚体。比较组间上述指标的差异，绘制ROC曲线，确定诊断切点及诊断效能。结果 创伤骨科手术后患者各项凝血指标显著升高，其中术后血栓组TM（9.04±2.06）IU/ml，t－PAIC（10.15±4.23）ng/ml, PIC（1.15±0.70）μg/ml, D－二聚体（5.31±5.10）ng/ml高于术后非血栓组TM（7.50±1.70）IU/ml, t－PAIC （6.97±2.56）ng/ml, PIC（0.93±0.84）μg/ml，D二聚体（2.35±2.12）ng/ml，P值分别为0.000 2、〈0.000 1、〈0.000 1、〈0.000 1；术后血栓组TAT（4.79±4.32）ng/ml, FDP（8.87±7.68）μg/ml与非血栓组TAT（6.51±5.92）ng/ml，FDP（4.91±4.67）μg/ml差异无统计学意义，P＝0.212 3，0.050 8。TM、t－PAIC、PIC、D二聚体诊断术后静脉血栓ROC曲线下面积为0.718 5、0.741 6、0.648 0、0.670 0, P值分别为〈0.000 1，〈0.000 1, 0.009 3，0.004 1; cut－off值为11.15（IU/ml）, 10.65（ng/ml）, 1.36（μg/ml）, 7.69（ng/ml）；阳性似然比分别为9.00，11.29，3.66，14.60；特异性分别为98.15%、96.23%、90.20%、97.96%,诊断率分别为20.3%、46.3%、35.8%、25.9%。结论 创伤骨科患者术后存在凝血及纤溶系统活化，TM、t－PAIC、PIC、D－二聚体对术后静脉血栓具有良好的辅助诊断价值，TAT由于受术后抗凝影响，不宜作为诊断指标。Objective To evaluate the value of blood coagulation biomarkers in orthopaedic traumatic patients after surgery and analyze its diagnostic values for venous thrombosis embolism. Methods In thisease control study, we consecutive enrolled 108 traumatic patients after surgery. 54 patients have thrombosis and other 54 patients have no thrombosis. Blood was taken 3 - 4 days after surgery. Routine coagulation screening test , FDP（ fibrinogen/fibrin degradation products ） , D dimer and new item such as TM （thrombomodulin） , TAT（ thrombin-anti-tbrombin complex） , t-PAIC （ tissue- type plasminogen activator- plasminogen activator inhibitor complex ）, PIC （ plasmin-anti-plasmin complex ） were tested. The difference between groups of these biomarkers was compared, and then the receiver operation curve （ROC） was drew to determine the diagnostic cut-off point and diagnostic performance. Results ALL blood coagulation biomarkers in orthopaedic traumatic patients after surgery were significantly increased. The group of patients with thrombosis have higher TM （9.04 ± 2.06 ） IU/ml, t-PAIC （ 10.15 ± 4.23 ） ng/ml, PIC （ 1.15 ± 0.70 ）μg/ml, D dimer（5.31 ± 5. 10） ng/ml than group without thrombosis TM（7.50 ±1.70） IU/ml, t-PAIC （ 6.97 ±2.56） ng/ml, PIC （0.93± 0.84） μg/ml, D dimer （ 2.35± 2.12） ng/ml, and P = 0. 000 2, 〈 0. 000 1, 〈 0. 000 1, 〈0.000 1, respectively. However, TAT（4.79 ± 4.32）ng/ml, （6.51 ± 5.92）ng/ml, FDP （8.87 ± 7.68）μg/ml, （4.91 ± 4.67）μg/ml showed no difference between thrombosis groupand no thrombosis group, （P = 0.212 3,0.050 8 ; respectively）. The area under the ROC curve of TM, t-PAIC, PIC and D-dimer were 0. 718 5,0. 741 6,0. 648 0,0. 670 0, respectively; P values were 〈0. 000 1, 〈 0. 000 1, 0. 009 3,0.004 1, respectively; cut-off values were 11.15 IU/ml, 10.65 ng/ml, 1.36μg/ml, 7.69 ng/ml, respectively; positive likelihood ratios were 9.00,11.29,3.66,14.60, respectively; specificity were 98.15% ,96.23% , 90.20%

关 键 词：手术后并发症 静脉血栓形成 生物学标记 血栓调节蛋白 组织型纤溶酶原激活物 纤维蛋白纤维蛋白原降解物 

分 类 号：R687.3[医药卫生—骨科学] R446.1[医药卫生—外科学]