瓜氨酸在儿科危重症急性胃肠损伤中的作用

The function of citrulline in pediatric acute gastrointestinal injury

目的观察不同程度危重患儿急性胃肠损伤发生情况，评估血清瓜氨酸浓度变化与急性胃肠损伤之间的关系，并分析血清瓜氨酸与C反应蛋白（CRP）、降钙素原（PCT）、血肌酐、尿素氮、胆红素、乳酸、清蛋白之间的相关性。评估血清瓜氨酸在危重患儿病情、预后及转归中的作用。方法本研究纳入兰州大学第二医院儿童重症监护病房患儿96例，排除原发性胃肠疾病、慢性肾病，记录临床特征，并检测CRP、PCT、血肌酐、尿素氮、胆红素、乳酸、清蛋白等指标，采用高效液相色谱法检测血清瓜氨酸水平。其中胃肠损伤患儿65例测定血清瓜氨酸浓度，计算敏感度、特异度及受试者工作特征曲线（ROC）曲线下面积。结果非危重组、危重组、极危重组急性胃肠损伤发生率分别为47.06%（16/34例）、75.00%（36/48例）、92.86%（13/14例），差异有统计学意义（χ2＝11.848，P＝0.003）；胃肠损伤组及非胃肠损伤组血清瓜氨酸水平分别为（14.655±8.231） μmol/L、（23.522±11.079） μmol/L，差异有统计学意义（t＝4.398，P〈0.05）；血清瓜氨酸ROC曲线下面积为0.079 8；极危重组胃肠损伤患儿治疗3 d后血清瓜氨酸水平较入院时显著升高[（26.40±16.10） μmol/L比（14.40±6.82） μmol/L]，差异有统计学意义（t＝5.524，P＝0.029）；血清瓜氨酸水平越低，病死率越高；血清瓜氨酸水平与CRP、PCT、住院时间均呈显著负相关（r＝－0.319、－0.299、－0.364，P＝0.003、0.006、0.001），与血肌酐、尿素氮、乳酸、清蛋白、胆红素水平无显著相关性。结论危重症患儿病情越危重，急性胃肠损伤发生率越高，预后越差，血清瓜氨酸水平可以很好地反映急性胃肠损伤的程度、转归，有望成为评估危重患儿胃肠道功能的可靠指标之一。

ObjectiveTo study the occurrence of acute gastrointestinal injury under different critical status in Pediatric Intensive Care Unit, and to assess the connection between citrulline and acute gastrointestinal injury.To analyze the correlation among serum citrulline and C-reaction protein（CRP）, procalcitonin （PCT）, creatinine, urea nitrogen, bilirubin, lactate, albumin.To study the role of citrulline in evaluating the children condition, prognosis and changes in critically ill children.MethodsNinety-six pediatric patients who were critically ill at the Pediatric Intensive Care Unit of the Second Hospital of Lanzhou University were selected, excluding those with primary gastrointestinal diseases and chronic kidney disease.Clinical features were recorded and CRP, PCT, creatinine, urea nitrogen, bilirubin, lactate, and albumin were measured.Serum citrulline concentrations were measured by high performance liquid chromatography in 65 patients with gastrointestinal injury, and sensitivity, specificity and area under the receiver operating characteristic（ROC） curve were calculated.ResultsThe incidence of acute gastrointestinal injuries in non-critical group, critical group, reorganization critical group were 47.06%（16/34 cases）, 75.00%（36/48 cases）, 92.86%（13/14 cases） （χ2=11.848, P=0.003）. The serum citrulline concentrations of gastrointestinal injury group and non- gastrointestinal injury group were （14.655±8.231） μmol/L, （23.522±11.079） μmol/L （t=4.398, P〈0.05）. The area under ROC of citrulline was 0.079 8.Serum citrulline concentrations increased significantly in infants with very severe gastrointestinal injury after 3 days of treatment compared with admission [（26.40±16.10） μmol/L vs.（14.40±6.82） μmol/L, t=5.524, P=0.029]. The lower serum citrulline levels the children had, the higher mortality was.There were negative correlations among serum citrullin and CRP, PCT and length of hospital stay（r=-0.319, -0.299, -0.364, P=0.003, 0.006, 0.001）. There were no correlations among serum citrullin and blood urea nitrogen, lactic acid, albumin, and bilirubin levels.ConclusionThe more critically ill children have a higher incidence of acute gastrointestinal injury and the worse the prognosis.Serum citrulline levels may well reflect the extent of acute gastrointestinal injury and the outcome.Perhaps it can be one of the reliable markers to evaluate the function of gastrointestinal and participate in assessing critical condition and prognosis in critical ill children ness.