降钙素原对免疫功能异常的脓毒症患者病情评估和预后判断

Diagnostic and predict vaIue of procalcitonin in ICU patients diagnosis of sepsis with immune system defect

目的探讨降钙素原（PCT）对脓毒症患者病情评估和预后判断的价值。方法回顾性分析2011年10月至2012年9月武汉大学人民医院急诊监护室、重症监护室、呼吸监护室收治的脓毒症患者278例，其中免疫功能正常患者122例，免疫功能异常患者156例。根据APACHEⅡ评分将患者分为低、中、高危3组。分析PCT质量浓度与APACHEⅡ评分，首次PCT质量浓度与入院7d病死率之间的相关性。并比较首次PCT质量浓度与动态监测PCT对患者预后的预测价值。结果Pearson相关分析结果显示，患者PCT质量浓度与即时APACHEⅡ评分存在显著正相关性（r=0．979，P〈0．05）。患者首次PCT质量浓度与入院7d病死率也存在显著正相关性（r=0．826，P〈0．05）。多因素logistic回归分析显示入院首次PCT质量浓度和APACHEⅡ评分与脓毒症患者7d预后差异具有统计学意义（首次PCT值浓度OR=1．77，95％CI=1．28，3．83，P=0．0023）。与动态监测PCT比较，分别以免疫功能正常患者PCT≥7．18ng／ml，免疫功能异常患者PCT≥3．52ng／ml为脓毒症患者入院7d死亡的最佳预警界值，敏感性差异无统计学意义，特异性低于动态监测PCT。结论PCT质量浓度并且不受糖皮质激素或免疫抑制剂的影响可以鉴别免疫功能异常的患者是否合并细菌感染。入院首次PCT值浓度是预测脓毒症患者7d死亡的独立危险因素。与免疫功能正常的患者比较，免疫功能异常患者提示短期恶性预后的PCT预警界值更低。

Objective To evaluate the diagnostic and predict value of procalcitonin （PCT） levels in patients diagnosis of sepsis with immune system defect in the intensive care unit （ICU）. Methods This is a retrospective analysis. We enrolled 278 patients diagnosis of sepsis in Emergency ICU, general ICU and Respiratory ICU in Renmin Hospital of Wuhan University from October 2011 to September 2012. Among them, 122 patients have normal immune function and 156 patients have auto-immune system diseases or/and requiring corticosteroids or chemotherapy. According to the APACHE Ⅱ score, patients were divided into low-risk group, middle-risk group and high-risk group, and their PCT levels were compared. Logistic regression analysis of the multiple factors was used to screen independent risk factors for predicting 7 days＇ mortality. The predictive ability was also evaluated and compared between the first time of PCT concentration after admission and dynamic change of PCT within the first week with area under receiver operator＇s characteristic curve （ROC curve, AUC）. Result The results of Spearman correlation analysis showed that there was a significant positive correlation between the patients＇ PCT concentration and APACHE Ⅱ score （r = 0. 979, P 〈 0. 05 ）. And there was a positive correlation between the first PCT concentration after admission and 7 days＇ mortality in-hospital （ r = 0. 826, P 〈 0. 05 ）. Muhiple factors logistic regression analysis indicated that both the first time PCT concentration after admission and APACHE Ⅱ score of patients were independent risk factors for predicting 7 days＇ mortality （PCT OR = 1.77, 95% CI = 1.28- 3.83, P = 0. 0023）. The warning value of 7 days＇ mortality for patients with normal immune function was PCT≥7.18 ng/ml and for those with abnormal immune function was PCT ≥ 3.52 ng/ml. Compared to dynamic monitoring of PCT, there was no significant difference in sensitivity but specificity is less than the dynamic monitoring of PCT. Conclusions The diagnostic and predict value of procalcitonin （PCT） levels were not affected by the immuno- suppressive therapy. The first time PCT concentration ＇after admission was an independent risk factor for predict of 7 days＇ mortality in ICU patients with sepsis. The PCT warning value of the sepsis patients with abnormal immnne function was much lower compared to those with normal immune function.