异基因造血干细胞移植后晚发重症肺炎患者预后危险因素分析

Analysis of risk factors related to the prognosis in patients with late-onset severe pneumonia after allogeneic hematopoietic stem cell transplantation

目的 探讨接受异基因造血干细胞移植后晚发重症肺炎（LOSP）的预后影响因素.方法 回顾性分析2009年1月—2015年12月北京大学人民医院血液病研究所68例LOSP患者的临床资料,通过单因素及多因素分析研究影响预后的危险因素.结果 LOSP中位发生时间为移植后213（90-2330）d,总生存率为42.6%（29/68）;LOSP患者中位死亡时间为发病后21 d（研究中定义〈21 d为早期死亡,≥21 d为晚期死亡）.LOSP发病时的中位氧合指数为199.15（92.21-290.48）mmHg（1 mmHg=0.133 kPa）.LOSP有病原学证据者32例（36.8%）,病原体包括病毒、细菌、真菌或混合型.LOSP发病时,中位CRP水平为75.65（0.94-451.00）mg/L;中位降钙素原（PCT）水平为0.66（0.00-249.00）μg/L.ROC曲线分析显示,高PCT水平（≥0.94μg/L）预示LOSP患者早期高病死率.多因素分析进一步显示,PCT水平高的LOSP患者早期死亡风险增加（OR=5.77,95%CI 1.66-20.11,P=0.006）,LOSP发生时间≥移植后213 d也是早期死亡危险因素（OR=4.74,95%CI 1.33-16.89,P=0.017）;而既往未发生过慢性移植物抗宿主病（OR=4.50,95%CI 1.58-12.83,P=0.005）及LOSP发生时间≥移植后213 d（OR=4.40,95%CI 1.61-11.99,P=0.004）是晚期死亡的危险因素.结论 PCT≥0.94μg/L及LOSP发生时间≥移植后213 d是异基因造血干细胞移植后发生LOSP患者的早期死亡的危险因素,既往未发生过慢性移植物抗宿主病及LOSP发生时间≥移植后213 d是晚期死亡的危险因素.

Objective To investigate the prognostic factors of late-onset severe pneumonia （ LOSP） in patients who underwent allogeneic hematopoietic stem cell transplantation （allo-HSCT）.Methods From January 2009 to December 2015, 68 patients with LOSP after allo-HSCT at Peking University Institute of Hematology were enrolled.In this retrospective study , univariate and multivariate analysis were used to evaluate the prognostic factors for LOSP after allo-HSCT.Results The median time from allo-HSCT to the development of LOSP was 213 （ 90-2330 ） days.The overall survival rate was 42.6% （ 29/68 ） .The median survival time from LOSP to death was 21 days.Early mortality was defined as death within 21 days after LOSP, as late death more than or equal to 21 days.The median oxygenation index was 199.15 （92.21-290.48） mmHg.LOSPs in thirty-two patients （36.8%） were caused by virus, bacteria, fungi or mixed pathogens.The median C-reactive protein （CRP） was 75.65 （0.94-451.00） mg/L.The median procalcitonin （ PCT） was 0.66 （ 0.00 -249.00 ） μg/L.The higher PCT value indicated an early higher mortality rate by the ROC curve （PCT：cut-off≥0.94μg/L）.Furthermore, multivariate analysis suggested that PCT more than or equal to 0.94 μg/L was a risk factor for early death of LOSP （ OR=5.77, 95%CI 1.66-20.11, P=0.006）.LOSP occurred later or equal to 213 days after allo-HSCT was also a risk factor of early death in LOSP （ OR=4.74, 95%CI 1.33 -16.89, P=0.017 ） .No previous history of chronic graft versus host disease （GVHD） （OR=4.50, 95%CI 1.58 -12.83, P=0.005） and LOSP later or equal to 213 days （ OR=4.40, 95%CI 1.61 -11.99,P=0.004） were the risk factors of late death in LOSP.Conclusions PCT more than or equal to 0.94 μg/L and LOSP later or equal to 213 days are the risk factors of early death in LOSP .No previous chronic GVHD and LOSP later or equal to 213 days are the risk factors of late death in LOSP .