严重脓毒症胰岛素目标血糖管理下Wnt5a的变化及其临床意义

Study of the changes and clinical significance of WntSa in target glucose control therapy for serious septic patients

目的探讨严重脓毒症目标血糖管理过程中Wnt5a浓度的动态变化及其临床意义。方法采用随机对照双盲的临床试验设计方案，将61例脓毒症患者随机分为：A组20例（目标血糖控制在4．4—6．1mmol／L），B组21例（目标血糖控制在6．2～8．3mmol／L），C组20例（目标血糖控制在8．4～10．0mmol／L）。在入住ICU时就给予目标血糖控制，分别在入住ICU时（0d）及入住ICU后1、3、5、7d采集静脉血，分别用ELISA法、酶联荧光分析（ELFA）法、比浊法检测Wnt5a、降钙素原（PCT）、C-反应蛋白（CRP）浓度的变化；相同时间点观察急性生理学和慢性健康状况Ⅱ（APACHEII）评分，并计算28d死亡率。根据28d存活情况将患者分为死亡组和存活组，并进行对比分析。结果随着治疗时间的延长，A、B、C3组Wnt5a浓度及APACHEⅡ评分均降低，治疗第3、5、7天与人院时比较差异有统计学意义（P均〈0．05）；治疗第7天Wnt5a浓度及APACHEII评分A组较B、C组明显降低（P均〈0．05），B组低于C组，但差异无统计学意义（P〉0．05）。28d死亡率：A组30％（6／20）与B组33．3％（7／21）、C组35％（7／20）比较降低，但差异无统计学意义（P〉0．05）。死亡组Wnt5a浓度及APACHEII评分较存活组明显提高（P〈0．05）。脓毒症患者入院时Wnt5a浓度与APACHEⅡ评分呈正相关（r=0．737，P=0．001）。结论严重脓毒症患者在严格目标血糖管理下，能明显抑制炎症反应程度，降低Wnt5a浓度及病死率，并改善预后，WntSa有望成为判断脓毒症患者病情严重程度和预后的良好指标。

Objective To explore the dynamic changes and clinical significance of the Wnt5a in target glucose control therapy for serious septic patients. Methods 61 serious septic patients were randomly divided into three groups： target glucose control A group 20 cases（ glucose control in 4.4 -6. 1 mmol/L ）, target glucose control B group 21 cases （glucose control in 6.2 - 8.3 mmol/L） and target glucose control C group 20 cases（ glucose control in 8.4 - 10.0 mmol/L）. In admitted cases given target glucose control, enzyme linked immunosorbent assay（ELISA） was used in the detection of Wnt5a in 0, 1,3,5 and 7 d in all serious septic patients. ELFA, immunonephelometry were used in the detection of PCT and CRP, and the scores of acute physiology and chronic health evaluation II （ APACHE 1I ） were observed and 28 - day mortality was recorded. According to 28 - day survival, the patients were divided into death group （20 cases） and survival group（41 cases）. Results Both APACHE II and Wnt5a levels in A, B and C group decreased with passage of time, there were significant differences between the results in 3,5,7 d and those on admission（P 〈 0.05, respectively）. Compared with group B and C, both APACHE II and Wnt5 a levels were decreased in group A in 7 d （P 〈 0.05, respectively）. Compared with group B and C, the mortality rate in 28 d were also lower in group A, but the difference was not significant（P 〉0.05）. APACHE H and Wnt5a levels were significantly higher in death group than in survival group, there was statistically significance difference （ P 〈 0.05 ）. In the patients with sepsis after admission to hospital, Wnt5a correlated with APACHE 1I positively （ r = 0. 737, P = 0. 001 ）. Conclusion Target glucose control management can suppress inflammation and the expression of WntSa, lower fatality rate, Wnt5 a is expected to become a good indicator to determine sepsis severity and prognosis.