凝血/纤溶指标与急诊社区获得性肺炎患者院内死亡风险相关性分析

The analysis of the correlation between coagulation / fibrinolysis index and risk of death in emergency patients with community-acquired pneumonia

目的研究凝血/纤溶指标与急诊社区获得性肺炎（CAP）患者院内死亡风险的相关性。方法收集中国医科大学附属第一医院急诊科2010年8月至2013年8月期间患社区获得性肺炎患者96例,排除恶性肿瘤、活动性肺结核、血液系统疾病、确诊或疑诊的肺栓塞、免疫功能抑制、长期使用抗凝药、皮质激素和抗血小板药物、孕妇以及实验室检查不全者。根据是否院内死亡,将患者分为死亡组和存活组。分析两组患者年龄、性别及急诊首次静脉血白细胞计数（WBC）、血小板计数（PLT）、凝血酶原时间（PT）、活化部分凝血活酶时间（APTT）、国际标准化比值（INR）、纤维蛋白原（FIB）、D二聚体（D-D）、血谷丙转氨酶（ALT）、白蛋白（ALB）、总胆红素（TBIL）、尿素氮（BUN）、肌酐（CR）、脑钠肽（BNP）、血糖等。将上述单因素分析得出的显著性因素（P〈0.1）进行多因素Logistic回归分析,以P〈0.05为差异有统计学意义。进一步对多因素分析得出的独立危险因素绘制受试者工作曲线（ROC）,并计算ROC曲线下面积（AUC）、截断值、灵敏度、特异度、95%可信区间,AUC进行Pairwise检验。结果与存活组比较,死亡组的Cr[73（60-120）μmol/L∶61（49-53）μmol/L,P=0.032]、PT[14.7（13.0-17.8）s∶14.1（13.5-15.0）s,P=0.055]、INR[1.18（1.05-1.50）∶1.11（1.02-1.21）,P=0.009]、D-D[5.5（2.0-20.0）μg/ml∶2（1-4）μg/ml,P=0.000]均明显升高。Logistic回归多因素分析结果显示：D-D（β=0.220,OR=1.246,P=0.000）、INR（β=3.646,OR=38.32,P=0.047）为CAP患者院内死亡的独立危险因素。将独立危险因素绘制ROC曲线,AUC由大到小分别为：D-D×INR（0.770）、INR（0.760）和D-D（0.742）。Pairwise检验结果显示：PT、INR及D-D×INR的ROC曲线AUC之间无显著性差异。当D-D×INR的截断值为3.82时,敏感度为0.750,特异度为0.691。结论凝血/纤溶指标中除了D-D之外,INR也可以用于急诊CAP患者院内死亡的风险评估。

Objective To investigate the correlation between coagulation/fibrinolysis indexes and risk of death in emergency department（ED） patients with community-acquired pneumonia（CAP）. Methods Totally 96 patients with CAP in ED of the First Hospital of China Medical University from August 2010 to August 2013 were studied retrospectively, excluding those with malignant tumour, avtive tuberculosis,hematopoietic disease, documented or suspected pulmonary embolism,immunosuppression,long-term usage of anticoagn lants, glucocorticosteroids and antiplatelet drugs,pregnant,laboratory tests deficiency. All cases were divided into survival group and non-survival group according to whether they died or not in hospital. Age, sex, white blood cell （ WBC ）, platelet count （ PLT）, prothrombin time （PT）, activated partial thromboplastin time （APTI＇）, international normalized ratio （INR）, fibrinogen （ FIB ）, D-Dimer （ D-D ）, glutamic- pyruvic transaminase enzyme （GPT）, albumin （ALB）, total bilirubin （TBil）, urea nitrogen （BUN）, creatinine （Cr）, brain natriuretic peptide（BNP） ,glucose（GLU） and arterial blood gases （ABG） were analyzed. The measurement data with Gaussian distribution was described with x ＋ s deviation and groups were compared with t-test. The measurement data with abnormal distribution was described with median（ quartile range） and groups were compared with non-parametric rank-sum test. In single-factor analysis,P 〈 0.1 was considered to be have significant difference. These significances were analized with multiple-factor analysis,and P 〈0.05 was considered to be have significant difference. Receiver operating characteristic （ROC） curves were drawn and areas under ROC curve （AUC）, cut -off value, sensitivity and specificity were calculated. Results Compared with suvivals,non-survivals Cr[73（60-120）Ixmol/L vs 61 （49-53）μmol/ L,P =0.032] ,PT[14.7（13.0-17.8） seconds vs 14. 1（13.5-15.0） seconds,P =0.0551 ,INR [1.18（1.05-1.50） vs 1.11（1.02- 1.21 ）, P = 0.009 ], D-D [ 5.5 （2.0-20.0） μg/ml vs 2 （ 1-4 ） μg/ml, P = 0. 000 ] were significantly elevated. Analyze P 〈 0. 10 factors with Logistic regression multiple-factor analysis： D-D （ 13 = 0. 220, OR = 1. 246, P = 0）, INR （ 13 = 3. 646, OR = 38.32, P = 0. 047 ） were the independent risk factors of death in hospital. Draw ROC curves and AUG is： D-D × INR（0.770）, INR （0.760）, D-D （0.742）. When cutoff value of D-D × INR was 3.82, sensitivity was 0.750, specificity was 0.691. Conclusion Not only D-D is one indicator of the coagnlation/fibrinolys indexes,but also INR can be used for assessing the risk of death in ED patients with CAP.