摘要
目的 探讨免疫功能及其变化对脓毒症患者预后的影响.方法 纳入2003年4月至2017年4月解放军南部战区总医院收治的符合脓毒症3.0诊断标准的患者共393例,收集临床数据进行回顾性分析.根据初始免疫状态,将病程≥4 d的患者分为初始免疫功能抑制组(219例)和初始免疫功能正常组(174例);根据免疫功能变化,将病程≥7 d的患者分为持续抑制组(113例)、持续正常组(96例)、先正常后抑制组(22例)、先抑制后正常组(59例);另外再根据年龄,将患者分为老年组(≥65岁)和年轻组(＜65岁).收集并比较各组患者间确诊脓毒症后24 h内的急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、降钙素原(PCT)、C-反应蛋白(CRP)、天冬氨酸转氨酶(AST)、丙氨酸转氨酶(ALT)、血肌酐(SCr),28 d内是否出现呼吸衰竭、循环衰竭,是否使用激素、免疫调节药物和高通量血液滤过(血滤)治疗,确诊后连续4 d及观察终点事件前(28 d内死亡或存活≥28 d)连续4 d的淋巴细胞计数绝对值.结果 393例脓毒症患者中,初始免疫功能正常者174例,其中年龄≥65岁85例;初始免疫功能抑制者219例,其中年龄≥65例118例.与初始免疫功能正常组比较,初始免疫功能抑制组PCT、CRP、ALT、AST、SCr水平显著升高〔PCT(μg/L):9.32(2.13, 34.01)比4.28(1.02,19.02),CRP(mg/L):89.00(26.00,142.00)比65.25(19.88,119.04),ALT(mmol/L):39.0(39.0, 99.0)比27.0(16.2,73.0),AST(mmol/L):55.0(31.0,148.0)比39.0(23.0,100.8),SCr(μmol/L):132.00(74.75, 245.00)比100.25(61.00,182.54)〕,连续4 d的淋巴细胞计数绝对值均值显著降低〔0.615(0.380,0.810)比1.442 (1.217,1.742)〕,SOFA、APACHEⅡ评分明显升高〔SOFA(分):9.25±4.19比6.87±4.66,APACHEⅡ(分):22.27±8.96比18.25±9.47〕,循环衰竭发生率(66.2%比50.0%)、呼吸衰竭发生率(87.7%比69.0%)、28 d病死率(65.3%比33.9%)显著升高,差异均有统计学意义(均P＜0.05).合并免疫抑制时,老年组与年轻组脓毒症患者28 d病死率差异无统计学意义(26.3%比15.8%,P＞0.05);当免疫功能正常时,老年组脓毒症患者28 d病死率显著高于年轻组(48.2%比20.2%,P＜0.01).持续抑制组和先正常后抑制组28 d病死率均显著高于持续正常组和先抑制后正常组〔83.2%(94/113)、81.8%(18/22)比26.0%(25/96)、40.7%(24/59),均P＜0.05〕.老年患者免疫抑制发生率〔33.3%(14/42)比10.5%(8/76)〕 和持续免疫抑制发生率〔77.0%(67/87)比54.1% (46/85)〕均比年轻患者高(均P＜0.01).结论 免疫功能状态与脓毒症患者预后密切相关,老年脓毒症患者比年轻患者更容易出现免疫抑制或持续的免疫抑制,预后更差.
Abstract
Objective To investigate the influence of immune function and its changes on the prognosis of patients with sepsis. Methods 393 patients who met the diagnostic criteria of Sepsis-3 admitted to General Hospital of Southern War Zone of PLA from April 2003 to April 2017 were enrolled. Clinical data were collected and analyzed retrospectively. According to the initial immune status, patients with more than 4 days course of disease were divided into the initial immune suppression group (219 cases) and the initial immune function normal group (174 cases). According to the changes of immune function, patients with more than 7 days course of disease were divided into persistent inhibition group (113 cases), persistent normal group (96 cases), first normal inhibition group (22 cases) and first inhibited normal group (59 cases). In addition, the patients were divided into the elderly group (≥ 65 years old) and the young group (< 65 years old). Acute physiology and chronic health evaluation Ⅱ(APACHEⅡ), sequential organ failure assessment (SOFA), procalcitonin (PCT), C-reactive protein (CRP), aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum creatinine (SCr) within 24 hours after diagnosis of sepsis, whether respiratory failure and circulatory failure occur, hormone, immunomodulatory drugs and high-volume hemofiltration treatment within 28 days, the absolute value of lymphocyte counts for 4 consecutive days after diagnosis and 4 consecutive days before the end point event (death or survival within 28 days or more than 28 days) were collected and compared between each group. Results Among 393 sepsis patients, 174 cases had normal initial immune function, of whom 85 cases were older than 65 years old;219 cases had depression of initial immune function, of whom 118 cases were older than 65 years old. Compared with the initial immune function normal group, the levels of PCT, CRP, ALT, AST and SCr in the initial immunosuppressive group were significantly increased [PCT (μg/L): 9.32 (2.13, 34.01) vs. 4.28 (1.02, 19.02), CRP (mg/L): 89.00 (26.00, 142.00) vs. 65.25 (19.88, 119.04), ALT (mmol/L): 39.0 (39.0, 99.0) vs. 27.0 (16.2, 73.0), AST (mmol/L): 55.0 (31.0, 148.0) vs. 39.0 (23.0, 100.8), SCr (μmol/L): 132.00 (74.75, 245.00) vs. 100.25 (61.00, 182.54)], the mean absolute value of lymphocyte counts for 4 consecutive days was significantly decreased [0.615 (0.380, 0.810) vs. 1.442 (1.217, 1.742)], SOFA and APACHEⅡ were significantly increased (SOFA: 9.25±4.19 vs. 6.87±4.66, APACHEⅡ:22.27±8.96 vs. 18.25±9.47), the incidence of circulatory failure (66.2% vs. 50.0%), the incidence of respiratory failure (87.7% vs. 69.0%) and 28-day mortality (65.3% vs. 33.9%) were significantly increased, with statistically significant differences (all P < 0.05). When combined with immunosuppression, there was no significant difference in 28-day mortality between the elderly group and the young group (26.3% vs. 15.8%, P > 0.05); when the immune function was normal, the 28-day mortality of the elderly group was significantly higher than that of the young group (48.2% vs. 20.2%, P < 0.01). The 28-day mortality of the persistent inhibition group and the first normal inhibition group were significantly higher than those of the persistent normal group and the first inhibition normal group [83.2% (94/113), 81.8% (18/22) vs. 26.0% (25/96), 40.7% (24/59), all P < 0.05]. The incidence of immunosuppression in elderly patients [33.3% (14/42) vs. 10.5% (8/76)] and the incidence of persistent immunosuppression [77.0% (67/87) vs. 54.1% (46/85)] were higher than those in young patients (all P < 0.01). Conclusions Immune function is closely related to the prognosis of sepsis patients. Elderly patients with sepsis are more likely to have immunosuppression or persistent immunosuppression than young patients, and the prognosis is worse.
基金项目
广东省广州市科技计划项目(201707010020)
NETL
NSTL
维普
万方数据