2017年版中国DIC诊断积分系统在急性早幼粒细胞白血病中的应用

Clinical evaluation of Chinese disseminated intravascular coagulation scoring system （version 2017） in patients with acute promyelocytic leukemia

目的探索2017年版中国DIC诊断积分系统（CDSS）在急性早幼粒细胞白血病（APL）DIG诊断中的适用性。方法回顾性分析2004年1月至2018年2月就诊于中国医学科学院血液病医院并行诱导治疗的220例APL患者病历资料，采用CDSS、国际血栓与止血协会（ISTH）DIc积分系统和日本卫生福利部（JMHW）DIC积分系统分别进行评价及比较分析。结果220例APL患者中，男114例，女106例，中位年龄38．5（12～70）岁，其中低／中危组173例，高危组47例。11例患者诱导治疗期死亡。CDSS、ISTH、JMHW三种标准诊断DIC阳性率分别为62．27％、54．09％、69．09％。CDSS和ISTH诊断DIC的一致率为78．10％，CDSS和JMHW诊断DIC的一致率为88．32％。ROC曲线比较三者互为参照的敏感度及特异度，敏感度JMHW〉CDSS〉ISTH，特异度ISTH〉CDSS〉JMHW。CDSSDIC（＋）和DIC（-）组患者PT、APTT、纤维蛋白原（FIB）、D-二聚体及纤维蛋白原／纤维蛋白降解产物（FDP）之间差异均有统计学意义（P值均〈0．05）；但采用ISTH诊断积分系统时DIC（-）组的D-二聚体水平高于DIC（＋）组[26．3（0．6-488．7）mg／L对21．9（1．2～477．1）mg／L，χ2=1．871，P=0．002]；采用JMHW诊断积分系统时DIc（＋）与DIC（-）组的APTT差异无统计学意义[27．05（18．0-181．0）s对26．15（18．2-35．5）S，χ2=1．162，P=0．134]。CDSSDIC（＋）和DIC（-）组患者的年龄及性别差异无统计学意义（P〉0．05）；单因素Logistic回归显示患者起病时WBC、骨髓中异常早幼粒细胞比例对DIC的发生存在影响（P〈0．05），而多因素分析显示在CDSS中起病时WBC〉3×109／L是DIC发生的独立危险因素（OR=3．525，95％CI1．875-6．629，P〈0．001）。结论2017年版CDSS诊断DIC的敏感度高于ISTHDIC积分系统，特异度优于JMHWDIC积分系统。CDSS较ISTH、JMHW对于DIC相关指标具有较好区分度，适用于中国APL患者的DIC诊断。

Objective To evaluate the applicability of Chinese disseminated intravascular coagulation scoring system （CDSS） in the diagnose of DIC in patients with acute promyelocytic leukemia （APL） patients. Methods Medical records of 220 APL patients diagnosed and receiving induction therapy in Blood Disease Hospital, CAMS ＆ PUMC from January 2004 to February 2018 were retrospectively analyzed. Each patient was evaluated by CDSS, the International Society of Thrombosis and Haemostais （ISTH） scoring system for overt DIC and Japanese Ministry of Health and Welfare （JMHW） scoring system for overt DIC, respectively. Results A total of 220 APL patients were enrolled in the study, with a median age of 38.5 （12-70） years, 114 male and 106 female. Among them, 173 were in the low-medium risk group, 47 high- risk group; 11 patients died during induction treatment. The positive rates of DIC diagnosed by CDSS criteria, ISHT criteria, JMHW criteria was 62.27%, 54.09%, 69.09%, respectively. The consistency rate of CDSS and ISTH in diagnosing DIC was 78.10%; the consistency rate of CDSS and JMHW was 88.32%. There was significant difference in PT, APTT, FIB, D-Dimer and FDP in DIC（＋） and DIC（-）group by CDSS （all P 〈 0.05）, but patients in the DIC（＋） group had lower level of D-Dimer than in the DIC （-） group [21.9（1.2-477.1） mg/L vs 26.3（0.6-488.7） mg/L, χ2= 1.871, P = 0.002] by ISTH, and there was not significant difference in APTT by JMHW [27.05（18.0-181.0） s vs 26.15（18.2-35.5） s, χ2 = 1.162, P = 0.134]. In this study, both of the gender and age had no difference in the DIC （＋） and DIC （-） group by CDSS. Univariate analysis showed that the level of WBC and the percent of abnormal promyelocytic cells in bone marrow when diagnosed were different in DIC （＋） and DIC （-） group by CDSS （P 〈 0.05）. Multiple analysis showed the level of WBC （OR= 3.525, 95%CI 1.875-6.629, P〈 0.001） was the only independent predictor in DIC diagnosis by CDSS. Conclusion The sensitivity of diagnosing DIC by CDSS was higher than the ISTH; and the specificity was superior to JMHW. Using CDSS can help to make the DIC diagnosis and treatment in time for APL patients who with the coagulation abnormalities.