血清甲状腺激素水平对慢性阻塞性肺疾病急性加重患者预后评估价值研究

Prognostic value of serum thyroid hormone levels for patients with acute exacerbation of chronic obstructive pulmonary disease

目的研究无原发甲状腺疾病的慢性阻塞性肺疾病(简称慢阻肺)急性加重患者血清甲状腺激素水平与疾病预后的关系,并探讨血清甲状腺激素水平对慢阻肺急性加重患者预后评估的价值。方法回顾性分析2013年1月至2017年11月于北京积水潭医院呼吸与危重症医学科因慢阻肺急性加重住院的患者239例,男149例,女90例,年龄42~92岁,平均(77.7±8.9)岁。入院时采用电化学发光法测定血清甲状腺激素水平[总甲状腺素(TT4)、总三碘甲状腺原氨酸(TT3)、促甲状腺素(TSH)、游离甲状腺素(FT4)、游离三碘甲状腺原氨酸(FT3)]。根据预后分为治疗好转组和死亡组。进行两组间血清甲状腺激素水平的比较,以及血清甲状腺激素水平与疾病转归的相关性分析,采用受试者工作特征(ROC)曲线评估不同甲状腺激素指标对于慢阻肺急性加重患者预后的判断价值,并确定慢阻肺急性加重患者死亡发生风险的甲状腺激素最佳预测值。结果慢阻肺急性加重治疗好转组血清TT4、TT3、FT4、FT3明显高于死亡组[TT4:(89.35±21.45)nmol/L比(76.84±21.33)nmol/L;TT3:(1.05±0.34)nmol/L比(0.72±0.19)nmol/L;FT4:(16.17±2.91)pmol/L比(14.45±2.85)pmol/L;FT3:(3.06±0.81)pmol/L比(2.24±0.72)pmol/L,P<0.05]。两组间血清TSH差异无统计学意义[0.98(0.54~1.83)m IU/L比0.57(0.31~1.84)m IU/L,P>0.05]。Spearman相关分析显示,慢阻肺急性加重患者血清TT4、TT3、FT4、FT3与死亡发生呈显著相关(r值分别为0.226、0.417、0.220、0.387,均P<0.05),血清TSH与死亡发生无显著相关性(P>0.05)。拟合不同甲状腺激素指标(TT4、TT3、TSH、FT4、FT3)与慢阻肺急性加重患者发生死亡关系的ROC曲线,曲线下面积分别为0.659、0.793、0.588、0.655、0.772。对于预测慢阻肺急性加重患者死亡发生风险,TT3优于其他甲状腺激素指标。当血清TT3=0.85 nmol/L时,Youden指数最大(0.486),敏感性70.2%,特异性78.3%,为慢阻肺急性加重患者死亡发生风险的TT3最佳预测值。结论慢阻肺急性加重患者血清甲状腺激素水平与预后密切相关,对慢阻肺急性加重患者预后评估具有一定的价值。

Objective To investigate the association between serum thyroid hormone levels and prognosis for patients with acute exacerbation of chronic obstructive pulmonary disease（AECOPD） without thyroid disease, and explore the prognostic value of serum thyroid hormone levels for patients with AECOPD. Methods The clinical data of239 hospitalized cases of AECOPD [149 males, 90 females, aged 42-92（77.7±8.9） years] from January 2013 to November2017 were retrospectively analyzed. Serum thyroid hormone levels including total tetraiodothyronin（TT4）, total triiodothyronin（TT3）, thyroid stimulating hormone（TSH）, free tetraiodothyronin（FT4） and free triiodothyronin（FT3）were measured by chemiluminescence immunoassay. All patients were divided into a survival group and a death group according to the prognosis. Serum thyroid hormone levels were compared between two groups. Correlations of serum thyroid hormone levels with the occurrence of death in AECOPD patients were analyzed. The prognostic value of serum thyroid hormone levels for AECOPD patients was explored by receiver operating characteristic（ROC） curve analysis. And the best cut-off value of serum thyroid hormone level in predicting the risk of death was calculated. Results Serum TT4,TT3, FT4 and FT3 levels in the survival group were significantly higher than those in the death group [TT4：（89.35±21.45） nmol/L vs.（76.84±21.33） nmol/L; TT3：（1.05±0.34） nmol/L vs.（0.72±0.19） nmol/L; FT4：（16.17±2.91） pmol/L vs.（14.45±2.85） pmol/L; FT3：（3.06±0.81） pmol/L vs.（2.24±0.72） pmol/L; all P0.05]. The differences of serum TSH level between two groups were not statistically significant [0.98（0.54-1.83） vs. 0.57（0.31-1.84）, P0.05]. Spearman correlation analysis showed that serum TT4, TT3, FT4 and FT3 levels were significant correlated with the occurrence of death（r values were 0.226, 0.417, 0.220, 0.387, respectively, P0.05）. And there was no significant correlation between serum TSH level and the occurrence of death（P0.05）. ROC curve analysis was done between serum thyroid hormone levels（TT4, TT3, TSH, FT4 and FT3） and the occurrence of death in the AECOPD patients. The areas under ROC curve were0.659, 0.793, 0.588, 0.655 and 0.772, respectively. Serum TT3 was the best indicator for predicting the occurrence of death.When serum TT3 level was 0.85 nmol/L, the Youden index was the highest（0.486）, with a sensitivity of 70.2%, and a specificity of 78.3%. It was the best cut-offl value of serum TT3 to predict the risk of death in AECOPD patients.Conculsions Serum thyroid hormone levels are significant associated with the prognostic for AECOPD patients. There is certain value of serum thyroid hormone levels in prognostic evaluation of AECOPD patients.