降钙素原对尿路感染儿童膀胱输尿管反流的诊断价值及其关联性

Diagnostic value and association of procalcitonin with urinary tract infections and vesicoureteral reflux in children

目的探讨降钙素原（PCT）对儿童尿路感染伴膀胱输尿管反流（VUR）的诊断价值及其关联。方法纳入2012年1月1日至2015年12月31日湖南省儿童医院首次诊断为尿路感染且住院期间进行了PCT、CRP检测、排尿期膀胱尿道造影（VCUG）检查和尿液细菌定量培养的患儿,排除医院获得性尿路感染者和进行过尿道外科手术者。以VCUG作为金标准,以PCT和CRP为待测标准,将诊断为VUR的患儿分为无反流组和反流组（轻度反流亚组和重度反流亚组）。采集性别、月龄和VCUG信息,仅截取入院后24 h内行PCT和CRP检测的结果。比较PCT和CRP对VUR的诊断参数。结果进入本文分析的尿路感染患儿156例,经VCUG确诊的VUR（反流组）58例,其中轻度反流亚组38例,重度反流亚组20例;无反流组98例。无反流组与反流组患儿月龄、男女比例差异无统计学意义（Z=-1.667,P=0.096;χ^2=0.291,P=0.590）。PCT（ng·m L^-1）和CRP（mg·L^-1）反流组高于无反流组[1.01（0.78,1.28）vs 0.40（0.10,0.60）和14.2（8.9,31.1）vs11.0（6.6,19.5）],差异有统计学意义（Z=-7.863,P=0.000;Z=-2.327,P=0.02）。PCT无反流组与轻度反流亚组[0.99（0.68,1.16）]和重度反流亚组[1.57（0.93,1.96）]、CRP无反流组与重度反流亚组[28.9（12.7,45.2）]、PCT与CRP轻度反流亚组及重度反流亚组,差异均有统计学意义。CRP无反流组与轻度反流亚组[12.6（8.5,19.5）],差异无统计学意义。PCT区分有无反流的最佳截值为0.77 ng·m L^-1,敏感度为77.6%,特异度90.8%,ROC曲线下面积0.877（95%CI：0.811-0.943）。在控制了性别和CRP等因素的情况下,PCT≥0.77 ng·m L^-1的尿路感染患儿VUR的风险是PCT〈0.77 ng·m L^-1的3.604倍。结论 PCT对于判断尿路感染患儿是否存在VUR具有一定的临床价值,可作为预测VUR的独立指标。

Objective To explore the diagnositc value and association with procalcitonin（PCT） in children with urinary tract infection and vesicoureteral reflux（VUR）.Methods From Jan 1st2012 to Dec 31 st.2015,children admitted with the first urinary tract infection from in-patient of one hospital were recruited in the study,all the patients performed the detection of PCT,CRP,VCUG and urine bacterial culture.Children with hospital acquired urinary tract infection,or experienced with urinary tract operation were excluded.All patients were divided into non-VUR group and VUR group（including mild VUR subgroup and severe VUR subgroup）,as well as sequential grades according the results of VCUG（gold standard）.Data of PCT,CRP（detected within 24 h of admission）,urine bacterial culture,ultrasonography of the urinary system,voiding cystourethrography（VCUG） were collected for analyzing.Diagnositic performances of PCT and CRP in VUR were compared.Results Among 156 children included,58 had VUR（including 38 cases of mild VUR and 20 cases of severe VUR）,98 had no VUR,there was no difference in age and sex between VUR and non-VUR groups（Z =-1.667,P = 0.096;χ^2= 0.291,P = 0.590）.Levels of PCT（ng·m L^-1） and CRP（mg·L^-1） in the VUR group[1.01（0.78,1.28） vs 0.40（0.10,0.60）;14.2（8.9,31.1） vs 11.0（6.6,19.5） ] were significantly higher than the nonVUR group（Z =-7.863,P = 0.000;Z =-2.327,P = 0.02）.There were statisitical differences in PCT level among groups of nonVUR,mild VUR subgroup[0.99（0.68,1.16） ],and severe VUR subgroup[1.57（0.93,1.96） ].There were statisitical differences in CRP level between groups of non-VUR and severe VUR subgroup[28.9（12.7,45.2） ].There were statisitical differences in PCT and CRP level between mild VUR subgroup and severe VUR subgroup.But there was no statisitical difference in CRP level between non-VUR and mild VUR subgroups[12.6（8.5,19.5） ].The best cutoff of PCT to discriminate VUR and non-VUR was 0.77 ng·mL^-1,with the sensitivity of 77.6%,specificity of 90.8%,AUC ROC of 0.877（0.811-0.943）.After adjusting for sex,CRP and other confounding factors,the risk of children with PCT≥0.77 ng·mL^-1was 3.604 times higher than children with PCT0.77 ng·mL^-1.Conclusion Procalcitonin may play a role in determining the presence of vesicoureteral reflux in children with urinary tract infections,and may be independently used to predict the VUR.