社区获得性肺炎凝血功能异常对预后的影响

Coagulopathy correlates with outcomes in patients with community-acquired pneumonia

目的 探讨社区获得性肺炎（CAP）凝血功能异常与预后的相关性.方法 回顾性分析厦门大学附属第一医院呼吸科2010年6月至2011年5月收治的385例成人CAP患者凝血酶原时间（PT）、活化的部分凝血活酶时间（APTT）、纤维蛋白原（Fib）、凝血酶时间（TT）、血小板计数（PLT）及D-二聚体等凝血指标,观察其在不同预后组患者间的差异.入组患者同时计算肺炎严重度指数（PSI）并评估病情.按PSI及是否合并呼吸衰竭及出院时转归将385例分为低危组、中高危组、呼吸衰竭组、无呼吸衰竭组、生存组和死亡组.结果 中高危CAP患者PT、TT、D-二聚体测定值分别为（15.1±1.4）s、（16.0±1.8）s和（7.5±8.3） mg/L,均显著高于低危患者[（14.5±0.9）s、（15.4±1.2）s及（1.6±2.0）mg/L],差异均具有统计学意义（P＜0.001）,PLT、APTT、Fib差异无统计学意义（均P ＞0.05）.中高危CAP患者和低危患者PLT、PT、D-二聚体异常率分别为30％（45/148）和20％（47/237）、18％ （26/148）和5％ （13/237）、99％（146/148）和85％ （202/237）,差异有统计学意义（χ^2值分别为5.602、14.609及23.442,均P＜0.05）,TT、APTT及Fib比较差异无统计学意义（P＞0.05）.D-二聚体与PSI存在等级相关性（r=0.798,P＜0.001）,血小板计数与PSI无关（χ^2=6.040,P ＞0.05）.合并呼吸衰竭的CAP患者D-二聚体为（10.0±9.9）mg/L,高于无呼吸衰竭者的（2.4±3.6） mg/L,差异有统计学意义（P＜0.001）,血小板计数比较差异无统计学意义（χ^2=3.457,P＞0.05）.死亡CAP患者的D-二聚体为（14.0±8.8） mg/L,高于生存患者的（2.8±4.6）mg/L,差异有统计学意义（P＜0.001）,血小板计数比较差异有统计学意义（χ^2=4.909,P＜0.05）.使用ROC曲线分析D-二聚体、PSI及血小板计数对CAP患者病死率的独立预测能力,三者曲线下面积分别为0.962、0.906和0.583,D-二聚体及PSI预测死亡的准确性高（P＜0.001）,D-二聚体的敏感性优于特异性,血小板计数预测病死率准确性欠佳（P＞0.05）.结论 CAP患者血浆D-二聚体显著升高,且与病情严重程度及病死率呈正相关,D-二聚体可作为CAP预后评估的良好指标之一.

Objective To explore and evaluate the predictive value of coagulopathy in patients with community-acquired pneumonia （CAP） Methods A retrospective study was performed by investigating the prothrombin time （PT）,activated partial thromboplastin time （APTT）,plasma fibrinogen （FIB）,thrombin time（TT）,platelets （PLT）,and D-dimer in 385 patients with CAP,who were admitted to the Respiratory Medical Department of the First Affiliated Hospital of Xiamen University from June,2010 to May,2011.The differences of the aforementioned results in patients with different prognostic risks were compared and analyzed.The Pneumonia Severity Index （PSI） was calculated to assess the severity.Results The serum levels of PT,TT and D-dimer in high-risk patients with CAP were （15.1 ± 1.4） s,（16.0 ± 1.8） s,（7.5 ± 8.3） mg/L,respectively.They were all increased compared with those in the low-risk group （14.5 ± 0.9） s,（15.4 ± 1.2） s,（1.6 ± 2.0） mg/L] ; the differences being statistically significant （P 〈 0.001）,while PLT,APTT,and FIB were not statistically different （P 〉 0.05）.The difference of the abnormal rate of PLT,PT,and D-dimer in high-risk group and the low-risk group were 30% （45/148） and 20% （47/237）,18% （26/148） and 5% （13/237）,99% （146/148） and 85% （202/237）,respectively,the differences being statistically significant （χ^2value were 5.602,14.609,23.442,respectively,P 〈 0.05）,while TT,APTT,FIB were not （P 〉 0.05）.Rank correlation existed between D-dimer and PSI （r =0.798,P 〈0.001）,while there was no correlation between PLT and PSI（χ^2 =6.040,P 〉 0.05）.D-dimer in patients with respiratory failure was （10.0 ± 9.9） mg/L,which was significantly increased compared with that in patients without respiratory failure （2.4 ± 3.6） mg/L,P 〈 0.001,and there was no significant difference in PLT （χ^2 =3.457,P 〉 0.05）.D-dimer was significantly higher in patients who died of pneumonia as compared to those who survived [（14.0 ± 8.8） mg/L,（2.8 ± 4.6） mg/L,P 〈 0.001],and there was a significant difference in PLT （χ^2 =4.909,P 〈 0.05）.The area under the receiver operator characteristic curve （ROC） of D-dimer,PSI and PLT were 0.962,0.906,0.583,respectively.Concerning the predictive value of mortality,both D-dimer and PSI showed ideal predictive accuracy （P 〈 0.001）.The sensitivity of D-dimer was superior to its specificity.PLT showed poor predictive value for mortality.Conclusions Ddimer was significantly higher in patients with CAP.D-dimer level was positively correlated with severity and mortality.D-dimer could be a good biomarker to assess the severity and mortality of patients with CAP.