D-二聚体在肺炎支原体肺炎患儿病情及预后判断中的应用

Application of D-dimer in diagnosis and prognosis of childhood Mycoplasma pneumoniae pneumonia

目的分析急性期D-二聚体水平对儿童肺炎支原体肺炎(MPP)急性期病情轻重及预后的判断价值.方法回顾性分析2009年1月至2017年7月首都医科大学附属北京儿童医院呼吸科病房收治的606例MPP急性期患儿的病历资料,根据病情分为重症组(298例)和轻症组(308例),比较2组患儿的一般资料、实验室检查、影像学表现,将有统计学意义的单因素进行多因素Logistic回归分析,得到影响儿童MPP急性期轻重症的独立相关因素,作受试者工作特征(ROC)曲线并计算ROC曲线下面积及诊断临界值,了解儿童急性期MPP轻重判断的预测指标,并根据恢复期纤维支气管镜下表现判断疾病的预后.结果急性期重症MPP组白细胞计数(WBC)[(10.25±3.76)×109/L]、中性粒细胞计数(Neu)[(7.31±3.76)×109/L]、血小板计数(PLT)[(334.66±143.80)×109/L]、C反应蛋白(CRP)[(69.00±80.50)mg/L]、红细胞沉降率(ESR)[(39.38±26.29)mm/1 h]、乳酸脱氢酶(LDH)[(436.61±248.96)IU/L]、纤维蛋白原(Fib)[(4.61±1.36)g/L]及D-二聚体水平[(2.09±1.66)mg/L]均高于MPP轻症组[(7.55±3.14)×109/L、(4.77±2.54)×109/L、(291.60±109.19)×109/L、(23.40±42.50)mg/L、(30.25±16.18)mm/1 h、(318.05±116.97)IU/L、(4.18±0.88)g、(0.58±0.72)mg/L],差异均有统计学意义(均P<0.01).Neu、PLT、CRP、LDH和D-二聚体为急性期MPP病情轻重的独立相关因素,各指标ROC曲线下面积分别为Neu 0.719、PLT 0.592、LDH0.675、CRP 0.749、D-二聚体0.848,其诊断临界值分别为6.5×109/L、265.5×109/L、417.5 IU/L、28.9 mg/L、0.73mg/L,D-二聚体对于儿童急性期MPP病情判断的灵敏度及特异性最高.根据恢复期纤维支气管镜下表现分为气管支气管内膜炎症组和亚支气管狭窄、通气不良及闭塞组,2组间D-二聚体水平差异有统计学意义[(1.11±0.26)mg/L比(2.14±1.84)mg/L,t=-5.870,P<0.05].结论D-二聚体水平可作为判断MPP病情严重程度及预后最灵敏的指标之一.

Objective To analyze the practical value of D-dimer in diseases condition judgment and prognosis evaluation of childhood Mycoplasma pneumoniae pneumonia(MPP).Methods Retrospective analysis was performed on clinical data of 606 MPP at Department of Respiratory,Beijing Children's Hospital,Capital Medical University from January 2009 to July 2017,and the subjects were divided a severe group(298 cases)and a moderate group(308 cases)according to severity.By comparing clinical characteristics,laboratory tests and imaging findings,multivariate Logistic regression analysis for significant single factors was accomplished,which was to find out the independent factors affecting the severity of childhood MPP in acute phase.Receiver operating characteristic(ROC)curves were drawn in the area under the curve(AUC)and the diagnosis threshold value was calculated,which could be used to judge the predicators affecting the severity judgment of childhood MPP in acute phase.And the prognosis was judged according to the convalescent fiberoptic bronchoscopic indicators in recovery phase.Results The levels of white blood cells(WBC)[(10.25±3.76)×109/L],neutrophil(Neu)[(7.31±3.76)×109/L],platelet(PLT)[(334.66±143.80)×109/L],C-reactive protein(CRP)[(69.00±80.50)mg/L],erythrocyte sedimentation(ESR)[(39.38±26.29)mm/1 h],lactate dehydrogenase(LDH)[(436.61±248.96)IU/L],fibrinogen(Fib)[(4.61±1.36)g/L]and D-dimer[(2.09±1.66)mg/L]in the severe group were higher than those in the moderate group[(7.55±3.14)×109/L,(4.77±2.54)×109/L,(291.60±109.19)×109/L,(23.40±42.50)mg/L,(30.25±16.18)mm/1 h,(318.05±116.97)IU/L,(4.18±0.88)g,(0.58±0.72)mg/L],and the differences were statistically significant(all P<0.01).The levels of Neu,PLT,CRP,LDH and D-dimer were independent and relevant factors for the severity of acute MPP.The area under each ROC curve was Neu 0.719,PLT 0.592,LDH 0.675,CRP 0.749,D-dimer 0.848,and each diagnostic threshold was 6.5×109/L,265.5×109/L,417.5 IU/L,28.9 mg/L,0.73 mg/L,respectively.Obviously,D-dimer had the highest sensitivity and specificity for the severe MPP.There was a significant difference in D-dimer level between the endobronchial inflammation group and the subbronchial stenosis,poor ventilation and occlusion group of fiberoptic bronchoscopy[(1.11±0.26)mg/L vs.(2.14±1.84)mg/L,t=-5.870,P<0.05].Conclusion D-dimer levels can be used as one of the most sensitive indicator for determining the severity and prognosis of MPP.