目的 通过研究血清淀粉样蛋白A(serum amyloid A protein,SAA)和载脂蛋白A-Ⅰ(apolipoproteinA-Ⅰ,ApoA-Ⅰ)的水平与脓毒症患者病情严重程度及预后的相关性,为脓毒症寻找新的临床预后标志物.方法 研究前瞻性纳入2021年9月至2022年2月收入江苏省苏北人民医院重症医学科的患者,需符合Sepsis-3确诊为脓毒症且18岁≤年龄≤80岁.纳入研究后于0 h、24 h、72 h抽取外周静脉血,检测ApoA-Ⅰ和SAA水平,计算72 h ΔSAA和72 h ΔApoA-Ⅰ.记录患者一般情况、实验室指标、急性生理学与慢性健康状况评分Ⅱ(acute physiology and chronic health evaluation Ⅱ,APACHE Ⅱ)、序贯器官衰竭评分等.患者根据生存结局分为存活组和死亡组,根据是否合并休克分为休克组和非休克组.用Logistic回归方法将ApoA-Ⅰ和SAA结合建立联测指标.使用受试者工作特征曲线分析SAA、ApoA-Ⅰ、72h ΔApoA-Ⅰ、72 h ΔSAA以及SAA联合ApoA-Ⅰ预测脓毒症患者预后的价值.结果 108例患者纳入分析,非休克组48例,休克组60例;存活组77例,死亡组31例.休克组和非休克组、死亡组和存活组间各时间点SAA和ApoA-Ⅰ水平差异有统计学意义(均P＜0.05).各时间点SAA水平与APACHE Ⅱ评分呈正相关(均P＜0.001),ApoA-Ⅰ水平与APACHE Ⅱ评分呈负相关(均P＜0.01).SAA可以预测脓毒症死亡风险,其中 24 h SAA 的曲线下面积(area under curve,AUC)最大(AUC=0.713,P=0.001),敏感度为65.3％,特异度为72.7％o ApoA-Ⅰ可以预测脓毒症死亡风险,其中72 h ApoA-Ⅰ的AUC最大(AUC=0.743,P＜0.001),敏感度为 69.4％,特异度为 77.1％.24 h SAA 和 72 h ApoA-Ⅰ 联合检测的AUC绝对值较单一指标增大(AUC=0.758,P＜0.05),Z检验提示其对脓毒症患者死亡风险预测较单一指标无显著提升(P＞0.05).结论 血清SAA、APOA-Ⅰ水平能反映脓毒症患者病情的严重程度,可作为脓毒症患者判断预后的独立指标.SAA和APOA-Ⅰ联合后的总体诊断效能较单一指标无明显改变.
The value of apolipoprotein A-Ⅰ combined with serum amyloid A in judging the severity and prognosis of patients with sepsis and septic shock
Objective This study aimed to investigate the correlation between the levels of serum amyloid A protein(SAA)and apolipoprotein A-Ⅰ(ApoA-Ⅰ)with the severity and prognosis of septic patients,in order to find new clinical prognostic markers for sepsis patients.Methods This study prospectively included patients admitted to the intensive care unit of Northern Jiangsu People's Hospital from September 2021 to February 2022.Patients were diagnosed with sepsis according to the Sepsis-3 criteria and aged between 18 and 80 years old.Peripheral venous blood samples were collected at 0 h,24 h,and 72 h after inclusion in the study,measured the levels of ApoA-Ⅰ and SAA,and the 72 h ΔSAA and 72 h ΔApoA-Ⅰ were calculated..Patient demographics,laboratory parameters,acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ)scores,sequential organ failure assessment scores,etc.,were recorded.Patients were divided into survival and death groups based on outcomes,and were divided into shock and non-shock groups based on the presence of shock.Logistic regression was used to combine ApoA-Ⅰ and SAA to establish a new combined index.Receiver Operating Characteristic curve analysis was performed to evaluate the predictive value of SAA,ApoA-Ⅰ,72 h ΔApoA-Ⅰ,72 h ΔSAA and the combined SAA and ApoA-Ⅰ for the prognosis of sepsis patients.Results A total of 108 patients were included in the analysis,with 48 cases in the non-septic shock group and 60 cases in the septic shock group;77 cases in the survival group and 31 cases in the death group.There were statistically significant differences in SAA and ApoA-Ⅰ levels at each time point between the shock and non-shock groups(all P＜0.05),as well as between the death and survival groups(all P＜0.05).SAA levels at each time point were positively correlated with APACHE Ⅱ scores(all P＜0.001),while ApoA-Ⅰ levels at each time point were negatively correlated with APACHE Ⅱ scores(all P＜0.01).SAA levels could predict the risk of death in sepsis patients,with the highest area under curve(AUC)value at 24 h SAA(AUC=0.713,P=0.001),sensitivity was 65.3％,and specificity was 72.7％for predicting 28-day mortality in sepsis.ApoA-Ⅰ levels at each time point could also predict the risk of death in sepsis patients,with the highest AUC value at 72 h ApoA-Ⅰ(AUC=0.743,P＜0.001),sensitivity was 69.4％,and specificity was 77.1％for predicting 28-day survival in sepsis.The combined detection of 24 h SAA and 72 h ApoA-Ⅰ increased the AUC value(AUC=0.758,P＜0.05),but the Z test showed that the prediction of death risk in patients with sepsis was not significantly higher than that of a single index(P＞0.05).Conclusions Serum levels of SAA and ApoA-Ⅰ could reflect the severity of sepsis in patients and serve as independent indicators for predicting the prognosis of sepsis patients.The overall diagnostic efficacy of the combined SAA and ApoA-Ⅰ was not significantly different from that of a single index.
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