蛋白C、蛋白S和抗凝血酶Ⅲ与Rex手术预后的关系研究

Relationship between protein C, protein S and antithrombin Ⅲ and prognosis in children undergoing Rex shunt

目的探讨蛋白C（PC）、蛋白S（PS）和抗凝血酶Ⅲ（ATⅢ）与小儿肝外门静脉高压Rex手术预后的相关关系。方法2013年12月至2016年4月53例肝外门静脉高压患儿于首都儿科研究所接受Rex手术治疗和术后定期随访复查，男32例，女21例。收集手术前后的血液样本，17例复发组血液样本来自于13例Rex术后复发患儿出血收集的血液，40例未复发组血液样本来自于40例Rex术后无消化道出血者。正常儿童血液样本18例作为对照组。采用PC、PS和ATⅢ试剂盒检测血液中PC、PS和ATⅢ浓度和活性水平。术后随访患儿预后，包括B型超声监测分流血管直径和流速、腹部增强CT、血常规、生化和凝血功能及有无出血情况。根据患儿术后有无出血，将患儿分为复发组和未复发组，比较Rex术后PC、PS和ATⅢ与正常对照组的差别，比较Rex术后复发组与未复发组的差别。根据术后超声及腹部增强CT监测分流血管直径，将Rex术后未复发患儿分为分流血管直径大于（等于）5 mm组和直径小于5 mm组。比较直径大于5 mm组、直径小于5 mm组、复发组和对照组的差别。结果通过比较Rex术后患儿与正常对照组的差别发现，复发组的ATⅢ活性和PS较正常对照组明显降低，分别为（55.6±4.8） U/ml和（61.7±5.1） U/ml（P＝0.003），（1.9±0.2） μg/ml比（2.4±0.2） μg/ml（P＝0.000），两组之间PC和ATⅢ浓度差异无统计学意义（P＝0.109和0.085）。复发组的ATⅢ活性明显低于未复发组，分别为（55.6±4.8） U/ml和（59.8±6.4） U/ml（P＝0.015），两组之间的PC、PS和ATⅢ浓度差异无统计学意义（P＝0.253、1.000、0.677）。复发组的ATⅢ活性明显低于直径大于5 mm组，分别为（55.6±4.8） U/ml和（60.4±6.2） U/ml（P＝0.010），而与直径小于5 mm组相比，分别为（55.6±4.8） U/ml和（58.7±6.8） U/ml，差异无统计学意义（P＝0.140）。Rex术后复发与食管静脉曲张程度明显相关（P＝0.013）。食管静脉曲张者的ATⅢ活性明显低于无食管静脉曲张者（P＝0.015）。结论血清ATⅢ活性降低与小儿肝外门静脉高压Rex术后复发及食管静脉曲张有明显相关关系，是监测Rex术后预后不良的重要指标，可能与入肝血流减少有关。

ObjectiveTo explore the relationship between protein C, protein S and antithrombin Ⅲ and prognosis in children undergoing Rex shunting.MethodsFrom December 2013 to April 2016, 53 children （32 boys and 21 girls） with portal cavernous underwent Rex shunting. Both pre- and post-operative blood samples were collected. The blood samples of 18 normal children were used as control group. The concentration of protein C （PC）, protein S （PS） and antithrombin Ⅲ （ATⅢ） and activity of antithrombin Ⅲ were detected by enzyme-linked immunosorbent assay （ELISA） Kit. Based on post-shunting prognosis, they were grouped into re-bleeding and non-bleeding groups. The values of PC, PS and ATⅢ between re-bleeding and non-bleeding groups and control group were compared. Based on the diameter of bypass vein as measured by postoperative sonography and computed tomography （CT）, they were grouped into no less than 5 mm and 〈5 mm groups. PC, PS and AT Ⅲ were compared between no less than 5 mm and less than 5 mm groups and re-bleeding group.ResultsThe activity of ATⅢ and concentration of PS were significantly lower in re-bleeding group than those in control group （55.6±4.8 vs 61.7±5.1 U/ml, P=0.003; 1.9±0.2 vs 2.4±0.2 μg/ml, P=0.000）. No difference existed in the concentration of PC and ATⅢ between re-bleeding and control groups （P=0.109 ＆ 0.085）. The activity of ATⅢ was significantly lower in re-bleeding group than that in non-bleeding group （55.6±4.8 vs 59.8±6.4 U/ml, P=0.015）. No difference existed in concentrations of PC, PS and ATⅢ between re-bleeding and non-bleeding groups （P=0.253, P=1.000 and P=0.677）. The activity of ATⅢ was significantly lower in re-bleeding group than that in no less than 5 mm group （55.6±4.8 vs 60.4±6.2 U/ml, P=0.010）. No difference existed in the activity of ATⅢ between re-bleeding and 〈5 mm groups （55.6±4.8 vs 58.7±6.8 U/ml, P=0.140）.ConclusionsReduced activity of ATⅢ is significant in re-bleeding children after Rex shunting. As an important prognostic indicator of Rex shunting, it may be a result of decreased hepatopetal blood flow.