艾滋病重症肺炎患者并发急性呼吸窘迫综合征的危险因素分析

Rrisk factors of acute respiratory distress syndrome in AIDS patients with severe pneumonia

目的探讨获得性免疫缺陷综合征(简称艾滋病)重症肺炎患者并发急性呼吸窘迫综合征(acute respiratory distress syndrome,ARDS)的早期危险因素,力求对ARDS进行早期识别及干预,以期改善患者预后。方法回顾性分析成都市公共卫生临床医疗中心重症医学科自2017年1月1日—2020年12月30日期间收治的232例艾滋病重症肺炎患者的临床资料,包括一般资料、生命体征、实验室检查指标、基础疾病等。先采用单因素Logistic回归分析筛选对并发ARDS有影响的指标,然后将筛选出的指标进行多重共线性评估,再将有统计学意义且不存在多重共线性的指标纳入多因素Logistic逐步回归分析,最后绘制受试者操作特征(receiver operating characteristic,ROC)曲线,并评估各项指标的预测价值。结果232例艾滋病重症肺炎患者中有33例并发ARDS。ARDS组患者组内病死率81.8%;非ARDS组的组内病死率33.7%。单因素Logistic回归分析显示pH、白细胞计数、乳酸脱氢酶、α-羟丁酸脱氢酶(α-hydroxybutyrate dehydrogenase,α-HBDH)、丙氨酸氨基转移酶、天门冬氨酸氨基转移酶、钙、纤维蛋白原降解产物(fibrinogen degradation product,FDP)、钙、D-二聚体、序贯器官衰竭评分、急性生理学和慢性健康状况评价Ⅱ等11项指标与ARDS的发生相关。这11项指标构建模型进行多重共线性分析显示:除丙氨酸氨基转移酶、天门冬氨酸氨基转移酶的方差膨胀因子大于10以外,其余9项指标之间不存在多重共线性问题。多因素Logistic逐步回归分析:α-HBDH[比值比(odds ratio,OR)=1.001,95%置信区间(confidence interval,CI)1.000~1.002,P=0.045]、D-二聚体(OR=1.044,95%CI 1.006~1.083,P=0.024)。绘制ROC曲线:α-HBDH(ROC曲线下面积为0.667,P=0.002,最佳临界值为391 U/L,对应敏感性为78.8%,特异性为61.8%),D-二聚体(ROC曲线下面积为0.602,P=0.062,最佳临界值为4.855μg/mL,对应敏感性为42.4%,特异性为82.9%)。结论艾滋病重症肺炎并发ARDS与多种因素相关,其中入院时α-HBDH(≥391 U/L)、D-二聚体(≥4.855μg/mL)为其独立危险因素,具有较大的早期预测价值,可为临床早期识别ARDS高危患者提供参考。

Objective To investigated the early risk factors of AIDS severe pneumonia complicated with acute respiratory distress syndrome in order to carry out early recognition and intervention of ARDS and improve the prognosis of patients.Methods The clinical data of 232 patients with severe AIDS pneumonia admitted to Chengdu Public Health Clinical Medical Center from January 2017 to December 2020 were retrospectively analyzed,including general data,vital signs,laboratory examination indexes,basic diseases,etc.Firstly influential indexes for complicated with ARDS were screened by single factor logistic regression analysis,then the multicollinearity assessment indicators were filtered out in multi-factor logistic stepwise regression analysis,finally the receiver operating characteristic(ROC)curves were drawn and the predictive value of the indicators were assessed.Results Thirty-three of 232 AIDS patients with severe pneumonia were complicated with ARDS.The mortality rate in ARDS group was 81.8%.The intra-group mortality of non-ARDS group was 33.7%.Single factor logistic regression analysis showed that pH,acute physiology and chronic health evaluationⅡgrade,sequential organ failure assessment grade,white blood cell count,lactate dehydrogenase,α-hydroxybutyric acid dehydrogenase(α-HBDH),alanine aminotransferase(ALT),aspartic acid aminotransferase(AST),calcium,fibrinogen degradation produc(FDP)and D-dimer,total 11 indicators were associated with the incidence of ARDS.The multicollinearity analysis of the 11 indicators showed that there was no multicollinearity problem among the other 9 indicators except the variance inflation factor of ALT and AST which was greater than 10.Multivariate logistic stepwise regression analysis showedα-HBDH(OR=1.001,95%confidence interval 1.000-1.002,P=0.045)and D-dimer(OR=1.044,95%confidence interval 1.006-1.083,P=0.024)were independent factors.ROC curve indicated the following:alpha hydroxy butyric acid dehydrogenase(the area under ROC curve=0.667,P=0.002,the optimal threshold was 391 U/L,the corresponding sensitivity and specificity was 78.8%and 61.8%,respectively),D-dimer(the area under ROC curve=0.602,P=0.062,the optimal threshold was 4.855μg/mL,the corresponding sensitivity and specificity was 42.4%and 82.9%,respectively).Conclusion AIDS severe pneumonia complicated with ARDS is associated with many factors,among whichα-HBDH(≥391 U/L)and D-dimer(≥4.855μg/mL)on admission are independent risk factors,which have great early predictive value and can provide reference for early clinical identification of ARDS high-risk patients.