动态联合监测血清淀粉样蛋白A、血清可溶性髓系细胞触发受体-1、D-二聚体对Sepsis患者预后的评估价值:前瞻性巢式病例对照研究

  目的  探讨血清淀粉样蛋白A(serum amyloid A protein, SAA)、血清可溶性髓系细胞触发受体-1(soluble triggering receptor expressed on myeloid cell-1, sTREM-1)、D-二聚体在Sepsis患者预后评估中的价值。  方法  2018年1月至2019年2月, 前瞻性纳入海南省人民医院ICU收治的Sepsis患者, 检测患者诊断Sepsis后第1、3、7天的SAA、sTREM-1、D-二聚体、C-反应蛋白(C-reactive protein, CRP)、降钙素原(procalcitonin, PCT)水平、并记录患者急性生理和慢性健康状况评估(acute physiology and chronic health evaluation Ⅱ, APACHE Ⅱ)结果, 将诊断Sepsis后28 d内死亡患者作为研究组(死亡组), 存活患者作为对照组(生存组), 采用多因素Logistic回归分析和受试者工作特征(receiver operator characteristic, ROC)曲线分析各指标与患者预后的相关性及对预后的评估价值。  结果  共82例符合纳入和排除标准的Sepsis患者入选本研究, 其中男性51例, 女性31例, 平均年龄(68.17±9.94)岁。死亡组30例, 生存组52例, 两组年龄、性别、体质量指数差异无统计学意义(P均>0. 05)。死亡组与生存组在诊断Sepsis后第1、3、7天SAA、sTREM-1、D-二聚体、CRP和PCT水平及APACHEⅡ评分差异均具有统计学意义(P均 < 0.05)。诊断Sepsis后第1天, SAA(P=0.004)、sTREM-1(P=0.025)、CRP(P=0.005)、PCT(P=0.016)均为预测Sepsis预后的独立相关因素, 且SAA、sTREM-1水平在第1、3、7天与APACHEⅡ评分呈正相关(P均 < 0.05), 而D-二聚体仅在第3天和第7天与APACHEⅡ评分呈正相关(P均 < 0.05)。ROC曲线发现, SAA第1、3、7天的曲线下面积均最大(分别为0.878、0.916、0.954), sTREM-1第3天和第7天(0.907、0.929)的ROC曲线下面积均大于CRP(0.897、0.927)和PCT(0.892、0.890), SAA+sTREM-1+D二聚体联合检测在第1、3、7天的ROC曲线下面积分别为0.918、0.974、0.984。  结论  SAA、sTREM-1和D-二聚体的动态联合监测结果可作为Sepsis的预后指标, 且优于CRP、PCT等传统预测指标。

Value of Dynamic Combined Monitoring of Serum Amyloid A Protein,Soluble Triggering Receptor Expressed on Myeloid Cell-1, and D-Dimer in Evaluating the Prognosis of Patients with Sepsis:A Prospective Nested Case-control Study

  Objective  The aim of this study was to investigate the clinical significance of serum amyloid A protein (SAA), soluble triggering receptor expressed on myeloid cell-1(sTREM-1), and D-Dimer in the evaluation of prognosis of sepsis.  Methods  From January 2018 to February 2019, patients with sepsis who were prospectively included in the ICU of Hainan Provincial People's Hospital were tested for the levels of SAA, sTREM-1, D-Dimer, C-reactive protein (CRP), and procalcitonin (PCT).Patients' acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) scores were recorded. The patients who died within 28 days after the diagnosis of sepsis were included in the study group (death group), otherwise the septic patients were included in the control group (survival group). The multivariate Logistic regression analysis and the receiver operator characteristic (ROC) curve were used to analyze the correlation of each index with the prognosis of patients and the evaluation value.  Results  A total of 82 patients with sepsis who met the inclusion and exclusion criteria were selected for this study, 51 males and 31 females, with an average age of (68.17±9.94) years. There were 30 cases in the death group and 52 cases in the survival group. There was no significant difference in age, sex, and body mass index between the two groups (all P>0.05). There were significant differences in APACHE Ⅱ scores, SAA, sTREM-1, D-Dimer, CRP, and PCT level between the survival group and the death group on the 1st, 3rd and 7th day after the diagnosis (all P < 0.05). Multivariate Logistic regression analysis showed that SAA (P=0.004), sTREM-1 (P=0.025), CRP (P=0.005), and PCT (P=0.016) were independent predictors for the prognosis of sepsis. It was also found that there was a positive correlation of SAA and sTREM-1 levels with APACHE Ⅱ scores on the 1st, 3rd and 7th day (all P < 0.05), and there was a positive correlation between D-Dimer and APACHE Ⅱ scores on the 3rd and 7th day (all P < 0.05). It was found that the areas under ROC curve of SAA on the 1st, 3rd and 7th day were the largest (0.878, 0.916, 0.954, respectively). On the 3rd and 7th day, the areas under the ROC curve of sTREM-1 were (0.907, 0.929) larger than those of CRP (0.897, 0.927) and PCT (0.892, 0.890). The areas under the ROC curve (0.918, 0.974, 0.984, respectively) of the combined detection of SAA, sTREM-1, and D-Dimer on the 1st, 3rd and 7th day were larger than those of the individual indexes.  Conclusions  The dynamic joint monitoring results of SAA, sTREM-1, and D-Dimer can be used as the prognostic indicators for sepsis, and have a higher predictive value than traditional indicators such as CRP and PCT.