髓样细胞可溶性触发受体-1在呼吸机相关肺炎预后评估中的价值研究

Effect of sTREM-1 on prognosis of patients with ventilator-associated pneumonia

目的 探讨髓样细胞可溶性触发受体-1 （sTREM-1） 对呼吸机相关性肺炎（VAP） 患 者预后的评估价值。方法 前瞻性选取2013 年6 月至2015 年5 月南京医科大学附属无锡人民 医院重症医学科（ICU）诊断为VAP 患者103 例。收集患者基本资料及确诊VAP 后24 h 内的血 清sTREM-1、降钙素原（PCT）、全血C 反应蛋白（CRP）、临床肺部感染评分（CPIS）、急性生理 与慢性健康评分Ⅱ（APACHE Ⅱ）等指标。依据确诊后28 d 存活情况分为存活组和病死组，比 较两组患者相关指标的差异，采用受试者工作特征（ROC） 曲线评价相关指标对患者预后的判断 价值，Kaplan-Meier 法绘制患者的28 d 生存曲线，多因素Logistic 回归分析影响患者预后的相 关因素。结果 存活组76 例，病死组27 例。两组患者基本资料差异无统计学意义（ 均P〉0.05）。 病死组确诊VAP 后24 h 内的sTREM-1、PCT、CPIS 评分及APACHE Ⅱ 评分[（89.50±18.45） pg/ mL、（823.86±182.74） pg/mL、（7.20±1.74） 及（19.58±3.43）] 较存活组[（54.09±12.71） pg/mL、 （579.81±193.45）pg/mL、（4.79±1.93） 及（17.23±3.12）] 显著增高（ 均P〈0.05）。sTREM-1、PCT、CPIS 评分及APACHE Ⅱ评分预测患者28 d 死亡的ROC 曲线下面积分别为0.84±0.04（95%CI：0.75~0.92， P〈0.01）、0.65±0.05（95%CI：0.55~0.74，P=0.49）、0.67±0.06（95%CI：0.55~0.79，P〈0.01） 及 0.79±0.04（95%CI：0.70~0.87，P=0.03）。以sTREM-1 水平为75.00 pg/mL 为最佳界值分组， 低 sTREM-1 组患者28 d 累计生存率优于高sTREM-1 组患者（82.5% vs. 63.4%，χ2=3.96，P 〈0.05）。多 因素Logistic 回归分析显示sTREM-1（OR=1.08，95%CI：1.04~1.13，P 〈0.01） 及APACHE Ⅱ 评分 （OR=1.39，95%CI：1.15~1.67，P〈0.01） 是VAP 患者28 d 死亡的独立危险因素。结论 sTREM-1 是 一种可早期预测VAP 患者预后的可靠指标。

Objective To explore the prognostic value of soluble triggering receptor expressed on myeloid cells-1（sTREM-1） in patients with ventilator-associated pneumonia （VAP）. Methods A total of 103 VAP patients were enrolled from June 2013 to May 2015 in the ICU of Wuxi People＇s Hospital Affiliated to Nanjing Medical University. The demographics and clinical data were collected, while serum sTREM-1, procalcitonin （PCT）, C-reactive protein（CRP）, clinical pulmonary infection score（CPIS） and acute physiology and chronic health evaluation II （APACHE II ） were measured. Patients were dividedinto the death group and the survival group according to 28 d survival. The differences in demographics and clinical data were compared between groups.The values of sTREM-1, PCT, CPIS and APACHE II for predicting 28 d death were evaluated by receiver operating curves（ROC）. The surviving curve was drawn by Kaplan-Meier method. The possible prognostic factors were analyzed by univariate and logistic multivariate analysis. Results There were 76 patients in the survival group and 27 patients in the death group, and there was no difference in demographics between two groups（P〉0.05）. The serum sTREM-1, PCT, CPIS and APACHE II were higher in the death group[（89.50±18.45） pg/mL, （823.86±182.74） pg/ mL, （7.20±1.74） and （19.58±3.43）] than those in the survival group[（54.09±12.71） pg/mL, （579.81±193.45） pg/mL, （4.79±1.93） and （17.23±3.12）, all P〈0.05]. The areas under the ROC of sTREM-1, PCT, CPIS and APACHE 11 for predicting 28 d death were 0.84±0.04（95%CI：0.75-0.92, P〈0.01）, 0.65~0.05（95%CI：0.55- 0.74, P=0.49）, 0.67±0.06（95%CI：0.55-0.79, P〈0.01）, 0.79±0.04（95%CI：0.70-0.87, P=-0.03）, respectively. Patients were assigned into two groups by the best cutoff point of sTREM-1=75.00 pg/mL, and Kaplan-Meier survival analysis showed that 28 d survival rate in the low sTREM-1 group was significantly higher than that in the high sTREM-1 group （82.5% vs. 63.4%, x2=3.96, P〈0.05）. Multivariate logistic regression analysis showed that both sTREM-1 （OR=1.08,95%CI：1.04-1.13,P〈0.01） andAPACHE Ⅱ （OR=1.39,95%C1：1.15-1.6%P〈0.01） were risk factors associated with 28 d death. Conclusions Early serum sTREM-1 can be used as a reliable predictor for the outcome of patients with VAP.