263例危重患儿2周内不同血清酶学变化的总结分析

Analysis on serum different enzymes in 263 children with critical illness within 2 weeks after admission

目的对比分析危重患儿ALT、AST、LDH、CK和CKMB动态变化,总结各自变化特点、以及相互间的可能关系,为危重患儿病情及预后判断提供帮助。方法回顾分析263例危重症患儿住院14d内相关资料,应用SPSS16.0统计软件,计量资料按正态分布检查情况,或用方差分析、t检验及Pearson相关分析,或用KruskalWallis和Mann-WhitneyU检验。结果①入院0、1、2、3、5、7和9d各酶学均值均明显高于正常范围,但标准差较大,CK、CKMB最大均值在第1d,ALT、AST、LDH在第2天,第9天均有明显下降;总分析各酶学9d内升高者多在5倍以下,部分可超过50倍,其中LDH异常升高者最多(74.7%),其次是AST和CKMB,而ALT和CK半数在正常范围(50.0%～56.0%)。②各酶学动态变化趋势不尽相同,其中LDH异常出现早、回复慢;而CK早期异常率相对较少,回复则较快;CKMB相较CK早期异常率高,且回复慢;ALT比AST早期异常率为低,回复也较快。各酶学异常率和升高程度2、3d达高峰,3d后开始好转,但9d时除CK(90.0%)基本回复正常范围外,其他各酶学仍有约50.0%以上在异常范围,尤其是AST和LDH。③分析前3d各酶学不同水平患儿的死亡率,正常范围者死亡率为15.0%～28.0%,～2倍者23.0%～40.0%、～5倍35.0%～54.0%、～10倍40.0%～60.0%、～50倍40.0%～70.0%、>50倍60.0%以上;除了ALT和AST在50倍以上死亡率有所降低外,总趋势是升高倍数越高预后越差,死亡率越高(P<0.001),尤其LDH呈阶梯状上升,趋势尤为明显。④ALT、AST(>50倍)和LDH(>10倍)明显升高者总住院时间延长,同时LDH明显升高者住PICU时间增加,但各酶学结果和以上时间相关性分析均差异无显著性。结论①入院2周内危重病患儿血清ALT、AST、LDH、CK和CKMB异常率不同,且患儿个体间差异较大,其中ALT和CK半数左右在正常值范围,是否其正常值定义过高值得关注;②LDH和AST、CKMB更能反映器官组织损害情况,尤其LDH升高程度可作为判断病情预后的指标;CKMB升高程度不仅提示心肌受损,也可能是脑损伤的部分反映;③病程接近10d时除CK外,其他各酶学半数患儿仍有不同程度升高,提示组织损伤修复是一较长时间的过程。

[ Objective ] To analyze the change trends of serum enzymes including ALT, AST, LDH, CK, CKMB, and possible interrelationship between them in children with critical illness, in order to provide help for assessing severity of disease and prognosis. [Methods] The values of ALT, AST, LDH, CK, CKMB were analyzed in 263 cases with critical illness in PICU within 14 days after admission. SPSS 16.0 was used to analyze the related data, in which t-tests and pearson correlation analysis, or Kruskal Wallis and Mann-Whitney U test were applied. [Results] The mean value of enzymes were significantly higher than definite normal range from admission to 9th day, but having larger standard deviation in all of them. The largest mean of CK, CKMB occurred at 1st day, ALT, AST, LDH at 2nd day, all of which decreased significantly at 9th day. Overall, most of them were increased less than 5 times within 9 days, but some could be up to 50 times. The percent of children with abnormal LDH value was maximum （74.7%）, followed by AST and CKMB, CK, ALT. The change trend of the enzymes differed, abnormal value of LDH early appeared and slowly recovered, early abnormal percent of CK was relatively less than CKMB and recovered faster than CKMB, and early abnormal percent of ALT and AST was low and recovered rapidly. The percent of children with the abnormal enzymes and the degree of normality arrived at the peak during 2-3ds, getting better in 3 days. Nevertheless, CK （90%） basically went back to the normal range at the 9th day, other enzymes in more than 50% children were still in abnormal range, especially AST and LDH. According to the analysis of mortality with different values of enzymes in the first 3 day, the mortality with the value of normal range was 15-28%, 〉2 times than normal range 23%-40%, 5 times 35%-54%, 10 times 40%-60%, -50 times 40%-70%, 〉50 times 60% more. Although the mortality decreased in children with increased ALT and AST morn than 〉50 times, the general trend was that the higher the increasing multiple, the worse the prognosis, and the higher the mortality rate （P 〈0.001）, especially when LDH increased in the pattern of stepladder. The patients with significantly increased ALT, AST （〉50 times） and LDH （〉10 times） had prolonged hospitalization, and those with significantly increased LDH stayed longer in PICU, but the correlation analysis had no significantly statistical significance between the value of enzymes and stay period of the above. [Conclusion] The abnormal rate of serum ALT, AST, LDH, CK, CKMB were different in children with critical illness within 2 weeks after admission, and inter-individual differences in children were larger, of which about half of ALT and CK in the normal range, should be paid attention to the definition of their normal definition which whether or not is over-high. LDH and AST, CKMB better response to tissue damage, in particular, the increased level of LDH can be used as indicators to assess disease prognosis. CKMB increase degree not only prompt myocardial damage, but also may partially reflect brain damage. In course of disease near to 10th day, in addition to CK, the other enzymes in half of the children are still elevated with varying degrees, suggesting that tissue healing is a longer process.