糖皮质激素在血液病患者粒细胞缺乏伴PSI评分中高危肺炎中的治疗效果  

Therapeutic effects of glucocorticoids in patients with hematologic diseases with neutropenia and severe pneumonia classified by the PSI scores

作　　者：薛述芳 任金华 陈力津[6] 赵小琴 杨婷 胡建达[1,5,8] Xue Shufang;Ren Jinhua;Chen Lijin;Zhao Xiaoqin;Yang Ting;Hu Jianda(Fujian Institute of Hematology,Fujian Medical University Union Hospital,Fuzhou 350001,China;Department of Hematology-Oncology,Fujian Children's Hospital,Fuzhou 350014,China;Department of Hematology,National Regional Medical Center,Binhai Campus of the First Affiliated Hospital,Fujian Medical University,Fuzhou 350209,China;Department of Hematology,the First Affiliated Hospital,Fujian Medical University,Fuzhou 350005,China;Institute of Precision Medicine,Fujian Medical University,Fuzhou 350122,China;Department of Oncology,Quanzhou First Hospital Affiliated to Fujian Medical University,Quanzhou 362000,China;Department of Hematology,Fujian Medical University Union Hospital,Pingtan Hospital,Pingtan 350128,China;Department of Hematology,the Second Affiliated Hospital,Fujian Medical University,Quanzhou 362000,China)

机构地区：[1]福建医科大学附属协和医院血液科,福建省血液病重点实验室,福建省血液病研究所,福州350001 [2]福建省儿童医院血液肿瘤科,福州350014 [3]福建医科大学附属第一医院滨海院区、国家区域医疗中心血液科&血液移植中心,福州350209 [4]福建医科大学附属第一医院血液科,福州350005 [5]福建医科大学精准医学研究院,福州350122 [6]福建医科大学附属泉州第一医院肿瘤内科,泉州362000 [7]福建医科大学附属协和医院平潭医院血液科,平潭350128 [8]福建医科大学附属第二医院,泉州362000

出　　处：《中华血液学杂志》2024年第11期1035-1042,共8页Chinese Journal of Hematology

摘　　要：目的探索糖皮质激素在血液病患者粒细胞缺乏(粒缺)合并肺炎严重指数(pneumonia severity index,PSI)中高危肺炎中的治疗价值。方法回顾性分析2016年10月1日至2018年12月31日福建医科大学附属协和医院血液科收治的粒缺合并PSI中高危肺炎的534例血液病患者资料,利用倾向性评分(PSM)调整激素组与非激素组之间基础资料的差异,比较两组患者治疗过程中炎症因子的变化,治疗失败率、死亡率、到达临床稳定状态时间、抗菌药物使用天数及不良反应发生率。结果176例患者接受了激素治疗,而358例患者未使用激素。激素组患者炎症因子水平、合并症比例及PSI评分更高。PSM共匹配125对病例。匹配后激素组和非激素组之间的合并症差异减小,但激素组的炎症因子水平仍然较高,接受激素治疗的患者病情较重,而在后续的治疗过程中炎症因子水平的下降更为显著。激素组晚期治疗失败率高于非激素组(39.2%对24.8%,P=0.015),但主要体现在影像学进展,而呼吸衰竭、机械通气、脓毒性休克等严重并发症的发生率差异无统计学意义。Logistic回归分析显示,糖皮质激素可降低治疗失败率(OR=0.367,95%CI 0.165~0.818,P=0.014)。PSI评分高增加治疗失败率(OR=1.028,95%CI 1.007~1.049,P=0.008)。激素组与非激素组30 d死亡率差异无统计学意义(8.0%对7.2%,P=0.811)。PSI评分是30 d死亡的危险因素(OR=1.077,95%CI 1.032~1.123,P=0.001)。激素组PSIⅤ级患者30 d生存率与PSIⅣ级患者比较差异无统计学意义[(87.8±5.1)%对(94.0±2.6)%,P=0.216]。糖皮质激素并不增加血糖升高、消化道出血和30 d内再感染发生率。结论糖皮质激素在血液病患者粒缺合并PSI中高危肺炎的治疗中有助于控制炎症因子水平,可降低PSIⅤ级患者治疗失败率及死亡率。Objective This study aimed to investigate the clinical value of glucocorticoids in patients with neutropenic severe pneumonia at moderate to high risk according to the Pneumonia Severity Index(PSI)in patients with hematologic diseases.Methods Clinical data were collected from 534 patients at the Fujian Medical University Union Hospital from October 2016 to December 2018.We evaluated the changes in inflammatory cytokines,treatment failure,in-hospital mortality,and other outcomes,adjusting for potential confounders through propensity score matching.Results Patients were categorized into glucocorticoids(n=176)and control(n=358)groups.The glucocorticoid group demonstrated higher levels of C-reactive protein,procalcitonin,and interleukin-6,alongside higher PSI scores.The differences in comorbidities diminished,except for inflammatory cytokine levels,with a notable reduction in inflammatory cytokines observed in the glucocorticoid group,after matching 125 pairs based on propensity scores.Late treatment failure was more prevalent in the glucocorticoid group(39.2%vs 24.8%,P=0.015),but this was primarily caused by radiographic progression.The incidences of respiratory failure,mechanical ventilation,and septic shock were similar between the groups.Logistic regression analyses revealed that glucocorticoids reduced the risk of treatment failure(OR=0.367,95%CI 0.165–0.818,P=0.014).The 30-day in-hospital mortality rates were comparable(8.0%in glucocorticoids vs 7.2%in controls,P=0.811),with indications that glucocorticoids may exert a protective effect on mortality.The PSI score was determined as the sole independent risk factor for 30-day in-hospital mortality(OR=1.077,95%CI 1.032–1.123,P=0.001).No evidence indicated that glucocorticoids increased the incidence of hyperglycemia,gastrointestinal bleeding,or 30-day infection recurrence.Conclusion Glucocorticoids reduce inflammatory cytokine levels and are potentially related to decreased treatment failure and mortality in patients with neutropenic pneumonia classified as PS

关 键 词：糖皮质激素 粒细胞缺乏 肺炎严重指数 重症肺炎 

分 类 号：R552[医药卫生—血液循环系统疾病] R563.1[医药卫生—内科学]