急诊重症系统性红斑狼疮的风险分析

Risk factors of severe systemic lupus erythematosus in emergency department

目的加强对急诊危重病患者的分类与分级管理,并对如系统性红斑狼疮(SLE)这类并非常见病但逐年增加的危重病进行风险的分析。方法回顾性研究2007年1月至2010年8月就上海仁济医院急诊,且由急诊收治入院或于急诊死亡的SLE病例。记录患者的人口学资料;急诊表现,SLEDAI,SLICC积分,并通过COX回归和Kaplan-Meier生存曲线分析影响预后的因素。结果累计获得131个SLE急诊事件,其急诊相关的近期死亡率达16.8%(22/131)。年龄≥45岁,病程长,存在肺动脉高压,肾功能不全,侵袭性感染是最为显著的预后不良危险因素。存在高脏器功能损害[SLICC,(3.86±2.14)VS(0.93±1.14)]而相对低的疾病活动度[SLEDAI,(11.5±7.7)VS(16.5±9.0)]是死亡病例的特征。而患者来源(本市或外地,城市或农村,医保与否),受教育程度,急诊留滞时间,存在神经精神狼疮,狼疮性肾炎,胃肠道血管炎,血液系统累及等均与预后无相关。急诊事件中有32.1%(42/131)为初发SLE(病程≤3个月)SLE(其中半数为在急诊事件中获得SLE诊断),该类患者具有特征的疾病模式,即更为年轻,更多为外地转诊患者,神经精神狼疮和血液系统累及更为常见,疾病高活动度而脏器功能损害较低,较少合并感染。对大剂量激素等免疫治疗反应良好,短期存活率达95.2%。结论时间累积效应和重要脏器功能损害是决定就急诊的重症SLE短期预后的两条主线,需要进一步的前瞻性研究来验证这些结果。对就急诊的SLE疾病特征和危险因子的识别,可能为SLE急重症的更有效的救治提供有用的信息。

Objective The aim of this study is to describe the characteristics of severe systemic lupus erythematosus（SLE） patients who attend emergency department and to identify the causes,outcome,and prognostic factors.Methods SLE patients who visited emergency department,Shanghai Renji Hospital,during Jan 2007 to Aug 2010,and subsequently hospitalized or died in emergency department were included in this retrospective study.The demographic data,emergency presentations,and clinical course were collected.The predictors for survival were analyzed by COX regression and Kaplan-Meier survival curve.Results Of the total 131 SLE emergency events,the overall mortality was 16.8%.Older age（≥45 years）,longer disease duration,the presence of pulmonary artery hypertension,renal insufficiency,and invasive infections are risk factors.Higher organ damage index [SLICC,（3.86 ± 2.14） VS（0.93 ± 1.14）,P0.001）] but relatively lower disease activity [SLEDAI,（11.5 ± 7.7） VS（16.5 ± 9.0）,P=0.015）] were the characteristics of the deceased events compared to the survived events.Newly onset（disease duration ≤ 3month） SLE account for 32.1% of the emergency events,that shared a distinctive pattern with younger age,higher frequencies of neuropsychiatric and hematologic manifestations.A good short-term outcome with a 95.2% survival rate can be observed in such patients.Conclusion Time effect and vital organ damage are two themes that determine the short-term outcome of severe SLE in emergency department.To recognize disease patterns and objective prognostic parameters could help physicians to provide better care based on a risk-fitted approach for SLE patients in emergencies.