脓毒症患者血中淋巴细胞水平的变化

Changes in blood lymphocytes in sepsis patients

目的 探讨外周血淋巴细胞计数、淋巴细胞比例在非感染性全身炎症反应综合征（SIRS）、脓毒症及严重脓毒症患者中的变化及意义.方法 回顾分析201 1年1月至2013年9月入住北京大学第三医院急诊科重症监护病房（ICU）423例患者的临床资料,其中非感染性SIRS患者54例,脓毒症患者177例,严重脓毒症患者192例；死亡150例,存活273例.入院时检测外周血白细胞计数（WBC）、中性粒细胞比例（N）、淋巴细胞计数、淋巴细胞比例、乳酸、血清超敏C-反应蛋白（hs-CRP）和降钙素原（PCT）水平,并计算急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分.根据患者诊断和预后分组,比较各指标,并采用Spearman相关分析评价淋巴细胞与各指标的相关性.结果 年龄越大,病情越重.在SIRS组、脓毒症组及严重脓毒症组,随病情加重,APACHEⅡ评分（分：7.78±3.72、13.85±7.22、24.00±9.79）、住院时间[d：6.0（1.0,9.0）、12.0（8.0,22.0）、19.5（7.0,29.0）]、病死率（0、10.2％、52.6％）、WBC（×109/L：7.59±3.27、8.94±3.95、10.32±5.50）、N（0.685±0.132、0.778±0.135、0.831±0.086）、hs-CRP[mg/L：4.60（2.80,7.52）、23.58（13.49,49.22）、59.77（19.36,110.62）和PCT[μg/L：0.05（0.05,0.05）、0.09（0.05,0.61）、0.63（0.10,5.25）]呈升高趋势（均P=0.000）,淋巴细胞计数[×109/L：1.53 （0.89,1.88）、0.90 （0.65,1.42）、0.80 （0.50,1.12）]、淋巴细胞比例（0.225±0.122、0.138±0.097、0.106±0.070）呈降低趋势（P＜0.05和P＜0.01）；3组乳酸水平比较差异有统计学意义[分别为2.40（1.30,5.10）、1.10（0.80,2.00）、1.40（1.00,2.50）mmol/L,P=0.000].与存活组比较,死亡组年龄（岁：76.71±12.21比73.21±14.49）、APACHEⅡ评分（分：24.69±9.58比13.91±8.41）、住院时间[d：12.0（4.0,28.0）比11.0（8.0,22.0）]、WBC（×109/L：10.29±5.82比8.89±3.98）、N（0.809±0.130比0.776±0.120）、乳酸[mmol/L：1.80（1.10,2.90）比1.30（0.90,2.49）]、hs-CRP[mg/L：50.94（19.21,97.13）比21.71 （6.39,54.40）和PCT[μg/L：0.74 （0.13,5.83）比0.08（0.05,0.59）]明显升高（P＜0.05或P＜0.01）,淋巴细胞计数[×109/L：0.90（0.50,1.29）比1.05 （0.70,1.54）]、淋巴细胞比例（0.123±0.098比0.143±0.097）明显降低（（P＜0.01和P＜0.05）.淋巴细胞计数与N（r=-0.597,P=0.000）、hs-CRP（r=-0.298,P=0.000）、PCT（r=-0.304,P=0.000）和APACHEⅡ评分（r=-0.214,P=0.000）呈明显负相关,与淋巴细胞比例呈明显正相关（r=0.691,P=0.000）,与WBC（r=0.082,P=0.0910）,乳酸（r=0.073,P=0.132）无相关性.结论 淋巴细胞水平与脓毒症的严重程度相关,监测其水平变化可作为脓毒症患者病情评估及治疗效果的辅助指标之一.

Objective To investigate the change in blood lymphocyte levels and lymphocyte percentage in critical patients, including those with non-infectious systemic inflammatory response syndrome （SIRS）, sepsis and severe sepsis. Methods Clinical data of 423 patients admitted to intensive care unit （ICU） of Department of Emergency of Peking University Third Hospital from January 2011 to September 2013 were retrospectively analyzed. Among these patients, there were 54 with non-infectious SIRS, 177 with sepsis and 192 with severe sepsis. 150 of them died, and 273 survived. The white blood count （WBC）, neutrophil （N）, lymphocyte count, lymphocyte percentage, lactic acid, serum high-sensitivity C-reactive protein （hs-CRP） and proealcitonin （PCT） were determined at admission, and acute physiology and chronic health evaluation II （APACHE II ） was estimated. The patients were divided into different groups according to diagnosis and prognosis to compare the value of the indexes, and the correlation between lymphocyte count and other markers were analyzed by Spearman relative analysis. Results The older the patients, the more severe the disease. In the non-infective SIRS, sepsis and severe sepsis groups, APACHE II scores （7.78 ± 3.72, 13.85 ± 7.22, 24.00 ± 9.79）, time of stay in hospital [ days ： 6.0 （ 1.0, 9.0）, 12.0 （ 8.0, 22.0）, 19.5 （7.0, 29.0） 3, the mortality rate （0, 10.2%, 52.6%）, WBC （ × 10^9/L： 7.59±3.27, 8.94±3.95, 10.32±5.50）, N （0.685 ±0.132, 0.778 ±0.135, 0.831 ±0.086）, hs-CRP [mg/L： 4.60 （2.80, 7.52）, 23.58 （13.49, 49.22）, 59.77 （19.36, 110.62）1 and PCT [ug/L： 0.05 （0.05, 0.05）, 0.09 （0.05, 0.61）, 0.63 （0.10, 5.25）3 showed gradually increasing tendency （all P= 0.000）. Serum lymphocyte count levels [ × 10^9/L： 1.53 （0.89, 1.88）, 0.90 （0.65, 1.42） and 0.80 （0.50, 1.12）3,lymphocyte percentage （0.225 ± 0.122, 0.138 ± 0.097, 0.106 ± 0.070） showed gradually decreasing tendency （P〈0.05 or P〈0.01 ）. There was significant difference in blood lactic acid among three groups [ blood lactic acid were 2.40 （ 1.30, 5.10）, 1.10 （0.80, 2.00） and 1.40 （ 1.00, 2.50） mmol/L in the non-infective SIRS, sepsis and severe sepsis groups respectively, P=0.0003. Age （years old： 76.71 ± 12.21 vs. 73.21 ± 14.49）, APACHE II score （24.69 ±9.58 vs. 13.91 ± 8.41）, time of stay in hospital [days： 12.0 （4.0, 28.01）vs. 11.0 （8.0, 22.0）1, WBC （ × 10^9/L： 10.29 ± 5.82 vs. 8.89 ± 3.98）, N （0.809 ± 0.130 vs. 0.776 ±0.120）, lactic acid [mmol/L： 1.80 （1.10, 2.90） vs. 1.30 （0.90, 2.49）3, hs-CRP [mg/L： 50.94 （19.21, 97.13） vs. 21.71 （6.39, 54.40）3 and PCT [ug/L： 0.74 （0.13, 5.83） vs. 0.08 （0.05, 0.59）3 levels in the death group were higher than those in the survival group （P〈0.05 or P〈0.01 ）, serum lymphocyte count levels × 10^9/L： 0.90 （0.50, 1.29） vs. 1.05 （0.70, 1.54）1, lymphocyte percentage （0.123 ± 0.098 vs. 0.143 ± 0.097） level in the death group were obviously lower than those in the survival group （P〈0.01 and P〈0.05 ）. Serum lymphocyte count levels were negative correlated with N （r=-0.597, P=0.000）, hs-CRP （r=-0.298, P=0.000）, PCT （r= -0.304, P=0.000）, APACHE II （r=-0.124, P=0.000）, and positively correlated with lymphocyte percentage （r=0.691, P=0.000）, and non correlations was found with WBC （r=0.082, P=0.091 ） and lactic acid （r=0.073, P= 0.132 ）. Conclusion The serum lymphocyte levels in the critically ill patients are related with the severity of sepsis, and monitoring the change in lymphocyte may he an indicator for evaluating the illness and effect of treatment.