CD14~+/人白细胞DR抗原测定在原位肝移植术患者感染监测中的作用

目的 探讨原位肝移植术后CD14~+单核细胞人白细胞DR抗原(CD14~+/HLA-DR)表达率的变化及其在术后感染监测中的作用.方法 按照美国胸科医师协会/危重病医学会(ACCP/SCCM)的感染性休克定义,将63例肝移植术后患者分为非感染组(47例)、感染组(10例)、感染性休克组(6例);用流式细胞仪动态监测患者移植前后CD14~+/HLA-DR表达率,并进行受试者工作特征曲线(ROC曲线)分析,评价其在感染监测中的价值.结果 感染组和感染性休克组术后CD14~+/HLA-DR表达率均显著低于非感染组(感染组;(29.6±7.2)%,感染性休克组:(16.3±10.5)%比(62.3±18.3)%,均P＜0.01],但两组间差异元统计学意义(P=0.128).CD14~+/HLA-DR表达率对感染预测的ROC曲线下面积为0.965,在最佳截断点(cut off)值为36.35%时敏感性和特异性分别为100.0%和93.6%,CD14~+/HLA-DR表达率对感染性休克预测的ROC曲线下面积为0.968,在最佳截断点值为31.97%时敏感性和特异性分别为100.0%和87.7%.3组患者移植前后不同时间点比较发现,感染发生时,感染组、感染性休克组CD14~+/HLA-DR表达率较非感染组移植后显著下降(P＜0.05和P＜0.01),在感染最重时两组CD14~+/HLA-DR表达率均降到最低值(感染组:(29.6±7.2)%,感染性休克组:(16.3±0.5)%,均P＜0.01].结论 对高危或可疑感染的肝移植术后患者,动态监测CD14~+/HLA-DR表达率可作为病情判断及预后的良好指标,CD14~+/HLA-DR≤36.35%可作为肝移植术后发生感染的预警值;CD14~+/HLA-DR≤31.97%可作为判断合并感染性休克的警戒指标.

Role of assessment and monitoring of human leucocyte antigen-DR on CD14~+ monocyte in postoperative infection in patients after orthotopic liver transplantation

Objective To investigate the changes in expression level of human leucocyte antigen-DR (HLA-DR) on CD14~+ monocyte (CD14~+/HLA-DR) in the patients after orthotopic liver transplantation,and its role in monitoring postoperative infection.Methods Sixty-three patients with liver transplantation were divided into three groups,non-infection group with 47 cases,infection group with 10 cases and septic shock group with 6 cases[according to the definition of septic shock of American College of Chest Physicians/Society for Critical Care Medicine (ACCP/SCCM)].CD14~+/HLA-DR expression ratio was assessed with flow cytometer,and its clinical implication was evaluated by receiver operating characteristic (ROC) curve assay.Results CD14~+/HLA-DR expression ratio in infection group[(29.6±7.2)%]and septic shock group[(16.3±10.5)%]were significantly lower than that in non-infection group[(62.3±18.3)%,both P＜0.01],but no significant difference of CD14~+/HLA-DR expression ratio was found between infection group and septic shock group(P=0.128).Total area under ROC curve of CD14~+/HLA-DR expression ratio for the infection was 0.965,its sensitivity and specificity at 36.35% cut off were 100.0% and 93.6%,respectively.Total area under ROC curve of CD14~+/HLA-DR expression ratio to predict septic shock was 0.968,its sensitivity and specificity at 31.97% cut off were 100.0% and 87.7%,respectively.Comparing the change of CD14~+/HLA-DR expression,it was lower in the infection group and septic shock group (P＜0.05 and P＜0.01),and the expression rate was lowest during period of serious infection in the two groups [infection group : (29.6±7.2)%,septic shock group : (16.3±0.5)%,all P＜0.01].Conclusion For the patients with possible infection after liver transplantation,sequential assessment of CD14~+/HLA-DR expression ratio would be a good marker for the judgment of patient's conditions and outcome.CD14~+/HLA-DR expression ratio below 36.35% could be used as the prewarning value for the diagnosis of postoperative infection,and 31.97% could be used as the critical value for the diagnosis of septic shock.