脓毒症患者血浆可溶性尿激酶型纤溶酶原激活物受体与血清降钙素原水平变化的预后价值

Dynamic Changes of Plasma Soluble Urokinase Plasminogen Activator Receptor and Serum Procalcitonin in Assessment of Prognosis in Septic Patients

【目的】观察脓毒症患者血浆可溶性尿激酶型纤溶酶原激活物受体(suPAR)、血清降钙素原(PCT)水平的变化,探讨suPAR、PCT在脓毒症预后中的价值。【方法】测定82例脓毒症患者、29例全身炎症反应综合征(SIRS)患者入组当天血浆suPAR、血清PCT水平,记录APACHEⅡ和SOFA评分。观察脓毒症存活组(n=51)和死亡组(n=31)入ICU第1、3、5、7天、出科或死亡当天血浆suPAR、血清PCT变化趋势,分析suPAR、PCT、APACHEⅡ和SOFA评分在预测死亡中的价值及相关性。【结果】脓毒症患者入组第1天血浆suPAR水平(13.89±0.65ng/mL)高于SIRS组(8.22±0.61 ng/mL)和健康对照组(4.65±0.30 ng/mL)(P<0.001)。脓毒症组血清PCT水平(19.18±4.83 ng/mL)高于SIRS组(1.10±0.77 ng/mL)(P<0.001)。存活组随时间延长血浆suPAR、血清PCT水平呈下降趋势(P<0.05),而死亡组血浆suPAR和血清PCT值随时间延长在一个较高的水平上波动,各时间点血浆suPAR水平均高于存活组(P<0.05),在第1、3、5天,死亡组与存活组的血清PCT无明显差异(P均>0.05),在第7天和出科/死亡当天,死亡组较存活组血清PCT升高(P均<0.05)。脓毒症患者第1天血浆suPAR的工作曲线(ROC)下面积为0.765,以血浆suPAR值12.01 ng/mL作为区分存活与死亡截点的灵敏度是87.1%,特异度为72.5%。suPAR联合APACHEⅡ评分区分脓毒症死亡和存活的曲线下面积(AUC)是0.857,高于单个指标suPAR(AUC0.765)和APACHEⅡ评分(AUC0.83)。血浆suPAR分别与血清PCT(r=0.326,P<0.001)、APACHE II评分(r=0.492,P<0.001)、SOFA评分(r=0.386,P<0.001)呈正相关。【结论】动态监测血浆suPAR有助于早期对脓毒症患者进行预后的评估和严重程度的判断,而血清PCT在早期不能用于脓毒症患者预后的评估和严重程度的判断,suPAR联合APACHE II评分可提高预测脓毒症死亡的效能。

[Objective] To evaluate the dynamic changes of plasma soluble urokinase plasminogen activator receptor （suPAR） and serum procalcitonin （PCT） and to investigate the prognostic significance of plasma suPAR and serum PCT in patients with sepsis.[Methods] The levels of plasma suPAR and serum PCT were monitored in 82 patients with sepsis and 29 patients with systemic inflammatory response syndrome （SIRS）.The acute physiology and chronic health evaluation Ⅱ] （APACHE Ⅱ[） and sequential organ failure assessment （SOFA） score were recorded.Dynamic changes in the levels of plasma suPAR and serum PCT were compared between the survivor group （n =51） and non-survivor group （n =31） on the 1st,3rd,5th,7th day after admission to ICU and at the day of discharge or death.The value of plasma suPAR,serum PCT,APACHE Ⅱ and SOFA score on predict the prognosis of septic patients were compared.Correlation analysis were carried out on plasma suPAR,serum PCT,APACHE Ⅱ and SOFA score.[Results] The levels of plasma suPAR in septic patients （13.89 ± 0.65 ng/mL） were higher than that in SIRS patients （8.22 ± 0.61 ng/mL） and healthy control patients （4.65 ± 0.30 ng/mL） （P all ＜ 0.001）.The levels of serum PCT in septic patients （19.18 ± 4.83 ng/mL） were higher than that in SIRS patients （1.10 ± 0.77 ng/mL） （P ＜ 0.001）.The levels of plasma suPAR and serum PCT in survivors were in a decreasing trend （P ＜ 0.05）.While the levels of plasma suPAR and serum PCT in non-survivors fluctuated at a high level.At each time point,the levels of plasma suPAR in non-survivors were higher than that in survivors （P all ＜ 0.001）.There was no significant difference in the levels of serum PCT on the 1st,3rd and 5th day between survivor group and non-survivor group （P all＞ 0.05）,but the levels of serum PCT on 7th day and the day of discharge or death in non-survivor group were significantly higher than that in survivor group （P ＜ 0.05）.Receiver operator characteristic curve （ROC curve） of the level of plasma suPAR on the 1st day could distinguish survivors from non-survivors in septic patients,maximal area under curve （AUC） of plasma suPAR was 0.765.The best cut-off value of plasma suPAR to distinguish survivors from non-survivors was 12.01 ng/mL,the sensitivity was 87.1％ and the specificity was 72.5％.The AUC was 0.857 when combine suPAR with APACHE Ⅱ score in distinguishing survivors from nonsurvivors,which was higher than each single index （suPAR：AUC0.765,APACHE Ⅱ score：AUC0.83）.Positive correlations were found between plasma suPAR and serum PCT（r =0.326,P ＜ 0.001）,plasma suPAR and APACHE Ⅱ score （r =0.492,P ＜ 0.001）,plasma suPAR and SOFA score （r =0.386,P ＜ 0.001）.[Conclusion] Dynamic monitoring of the levels of plasma suPAR can help to assess the severity and the prognosis of sepsis in the early stage,while serum PCT can＇t.To combine plasma suPAR with APACHE Ⅱ score may improve the predict accuracy of prognosis in sepsis.