外周血可溶性Fas蛋白及其配体、髓过氧化物酶水平对重症肺炎患儿预后不良的预测价值

目的观察重症肺炎患儿外周血可溶性Fas蛋白（sFas）、可溶性Fas蛋白配体（sFasL）和髓过氧化物酶（MPO）水平变化，并探讨三者对重症肺炎预后不良的预测价值。 方法选取四川中医药高等专科学校绵阳富临医院2016年2月至2020年5月收治的182例重症肺炎、196例轻症肺炎患儿和178例健康儿童，分别为重症组、轻症组和对照组；重症组患儿再根据预后分为预后不良组（29例）和预后良好组（153例）。采用单因素方差分析比较重症组、轻症组治疗前和对照组外周血sFas、sFasL和MPO水平；采用单因素和多因素Logistic回归分析重症组患儿预后不良的影响因素，采用受试者工作特征（ROC）曲线评价外周血sFas、sFasL和MPO水平以及联合指标预测重症组患儿预后不良的价值。 结果三组研究对象的性别、年龄和体重，重症组与轻症组患儿病原微生物分布、肺炎分期差异均无统计学意义（P均> 0.05）。重症组患儿治疗前外周血sFas、sFasL和MPO水平分别为（104.63 ± 19.75）ng/L、（1 062.36 ± 179.85）ng/L和（1 020.26 ± 59.71）U/L，轻症组患儿分别为（80.52 ± 13.66）ng/L、（703.57 ± 127.66）ng/L和（796.75 ± 43.02）U/L，对照组儿童分别为（58.78 ± 10.16）ng/L、（577.83 ± 121.22）ng/L和（632.59 ± 38.71）U/L；重症组和轻症组患儿以上3个指标水平均高于对照组（sFas：重症组 vs.对照组：t = 27.605、P < 0.001；轻症组vs.对照组：t = 17.322、P < 0.001；sFasL：重症组 vs.对照组：t = 29.908、P < 0.001，轻症组vs.对照组：t = 9.744、P < 0.001；MPO：重症组 vs.对照组：t = 71.920、P < 0.001；轻症组vs.对照组：t = 38.647、P < 0.001），重症组患儿以上3个指标水平均显著高于轻症组（t = 13.885、22.488、41.973，P均< 0.001）。重症组患儿预后不良发生率为15.93%（29/182）。预后不良组患儿双重/多重感染占比（χ² = 12.081、P = 0.001）、多肺叶感染占比（χ² = 32.378、P < 0.001）和外周血白细胞计数（WBC）（t = 6.432、P < 0.001）、中性粒细胞百分比（N%）（t = 3.658、P = 0.001）、C-反应蛋白（CRP）（t = 19.415、P < 0.001）、降钙素原（PCT）（t = 26.101、P < 0.001）、sFas（t = 13.717、P < 0.001）、sFasL（t = 5.357、P < 0.001）和MPO（t = 5.435，P < 0.001）水平均显著高于预后良好组患儿；多因素Logistic回归分析显示以上指标均为重症组患儿预后不良的危险因素，差异均有统计学意义（OR = 5.969、95%CI：4.857~6.304、P = 0.029，OR = 7.485、95%CI：6.785~8.126、P = 0.014，OR = 5.332、95%CI：4.593~5.567、P = 0.010，OR = 4.959、95%CI：4.246~5.337、P = 0.015，OR = 5.143、95%CI：4.879~5.695、P = 0.003，OR = 6.126、95%CI：5.630~6.558、P = 0.008，OR = 8.325、95%CI：6.452~9.902、P = 0.005，OR = 8.469、95%CI：7.879~8.653、P = 0.001，OR = 9.132、95%CI：8.882~9.594，P = 0.003）。外周血sFas、sFasL和MPO水平预测重症组预后不良的Cut-off值分别为125.07 ng/L、1 171.21 ng/L和1 053.04 U/L；sFas、sFasL和MPO以及3个指标联合预测的曲线下面积（AUC）分别为0.875、0.890、0.897和0.955，3个指标联合预测AUC均显著高于sFas、sFasL、MPO水平单独预测，差异均有统计学意义（Z = 5.693、P = 0.005，Z = 5.192、P = 0.007，Z = 4.982、P = 0.009）。 结论重症肺炎患儿外周血sFas、sFasL和MPO水平均偏高，且在预后不良重症患儿中水平均更高，其联合应用可预测患儿不良预后。

Predictive value of peripheral blood levels of soluble Fas protein,soluble Fas protein ligand and myeloperoxidase on poor prognosis in children with severe pneumonia

ObjectiveTo investigate the changes of soluble Fas protein (sFas), soluble Fas protein ligand (sFasL) and myeloperoxidase (MPO) in peripheral blood of children with severe pneumonia, and to explore the predictive value on poor prognosis. MethodsTotal of 182 cases of severe pneumonia, 196 cases of mild pneumonia and 178 healthy children in Mianyang Fulin hospital, Sichuan College of traditional Chinese Medicine were enrolled as severe group, mild group and control group, respectively; Children in severe group were then divided into poor prognosis group (29 cases) and good prognosis group (153 cases). The levels of sFas, sFasL and MPO in peripheral blood were compared among cases of severe group and mild group before treatment with those of control group by one way ANOVA. The risk factors for poor prognosis in severe group were determined by univariate and multivariate Logistic regression analysis, and the value of peripheral blood sFasL, sFasL, MPO levels and the combination of the three indexes on predicting poor prognosis in severe group were explored by receiver operating characteristic curve (ROC). ResultsThere was no significant difference in gender, age and weight among cases in the three groups; distribution of pathogenic microorganisms and stages of pneumonia between cases in severe group and mild group were also without significant difference (all P > 0.05). The levels of sFas, sFasL and MPO in peripheral blood of cases in severe group were (104.63 ± 19.75) ng/L, (1 062.36 ± 179.85) ng/L, (1 020.26 ± 59.71) U/L, which were (80.52 ± 13.66) ng/L, (703.57 ± 127.66) ng/L and (796.75 ± 43.02) U/L in cases of mild group, while (58.78 ± 10.16) ng/L, (577.83 ± 121.22) ng/L and (632.59 ± 38.71) U/L in cases of control group, respectively; and the levels of the above indexes of cases in severe group and mild group before treatment were significantly higher than those of the control group (sFas: severe group vs. control group: t = 27.605, P < 0.001; mild group vs. control group: t = 17.322, P < 0.001. sFasL: severe group vs. control group: t = 29.908、P < 0.001; mild group vs. control group: t = 9.744, P < 0.001. MPO: severe group vs. control group: t = 71.920, P < 0.001; mild group vs. control group: t = 38.647, P < 0.001), which were significantly higher in severe group than those of the mild group (t = 13.885, 22.488, 41.973, all P < 0.001). The incidence of poor prognosis in severe group was 15.93% (29/182). The proportions of double/multiple infection (χ² = 12.081, P = 0.001), multiple lobe infection (χ² = 32.378, P < 0.001) and white blood cell (WBC) (t = 6.432, P < 0.001), percentage of neutrophils (N%) (t = 3.658, P = 0.001), C-reactive protein (CRP) (t = 19.415, P < 0.001), procalcitonin (PCT) (t = 26.101, P < 0.001), sFas (t = 13.717, P < 0.001), sFasL (t = 5.357, P < 0.001) and MPO (t = 5.435, P < 0.001) levels in peripheral blood of cases with poor prognosis were significantly higher than those with good prognosis; which were all independent risk factors of poor prognosis in severe group by multivariate Logistic regression analysis (OR = 5.969, 95%CI: 4.857-6.304, P = 0.029; OR = 7.485, 95%CI: 6.785-8.126, P = 0.014; OR = 5.332, 95%CI: 4.593-5.567, P = 0.010; OR = 4.959, 95%CI: 4.246-5.337, P = 0.015; OR = 5.143, 95%CI: 4.879-5.695, P = 0.003; OR = 6.126, 95%CI: 5.630-6.558, P = 0.008; OR = 8.325, 95%CI: 6.452-9.902, P = 0.005; OR = 8.469, 95%CI: 7.879-8.653, P = 0.001; OR = 9.132, 95%CI: 8.882-9.594, P = 0.003). The Cut-off values of peripheral blood sFas, sFasL and MPO levels predicting poor prognosis in severe group were 125.07 ng/L, 171.21 ng/L and 1 053.04 U/L, respectively. The area under ROC curve (AUC) predicted by peripheral blood sFas, sFasL and MPO and the three indicators combination were 0.875, 0.890, 0.897 and 0.955, respectively, and the AUC of combination prediction was significantly higher than that of sFas, sFasL and MPO alone (Z = 5.693, P = 0.005; Z = 5.192, Z = 0.007; Z = 4.982, P = 0.009). ConclusionsThe levels of sFas, sFasL and MPO in peripheral blood of children with severe pneumonia are high, especially higher in children with severe pneumonia with poor prognosis, which can be used to predict poor prognosis.