血管生成素2与炎症因子在脓毒症患儿中的表达

Expression of angiopoietin-2 and inflammatory factors in children with sepsis

目的探讨血清血管生成素(Ang)2、白细胞介素(IL)-6和肿瘤坏死因子(TNF)-α水平与儿童脓毒症严重程度的相关性,为儿童脓毒症临床诊断及治疗提供依据。方法选择2017年7月至2018年7月,在浙江大学金华医院儿科及浙江大学医学院附属儿童医院诊治的64例发热患儿为研究对象,其年龄为1个月至12岁。根据患儿是否罹患脓毒症及脓毒症分级标准,将其分为3组:A组(n=22,脓毒症患儿),B组(n=24,感染不伴SIRS的的非脓毒症患儿)、C组(n=18,严重脓毒症患儿)。选择同期于浙江大学金华医院儿童保健科进行体检的21例健康受试儿作为对照,纳入对照组,其年龄为3个月至12岁。采用酶联免疫吸附测定(ELISA)法检测4组受试儿血清Ang-2、IL-6、TNF-α水平。绘制4组受试儿血清Ang-2水平诊断严重脓毒症患儿的受试者工作特征(ROC)曲线,计算ROC曲线下面积(ROC-AUC),根据约登指数最大原则,确定血清Ang-2水平诊断严重脓毒症患儿的最佳临界值,同时计算其敏感度和特异度。采用直线相关分析,对4组受试儿血清Ang-2水平分别与其血清IL-6、TNF-α水平进行相关性分析。本研究遵循的程序符合2013年修订的《世界医学协会赫尔辛基宣言》要求,并与所有受试儿监护人签署临床研究知情同意书。结果①4组受试儿年龄、性别构成比等一般临床资料比较,差异均无统计学意义(P>0.05)。②4组受试儿血清Ang-2、TNF-α和IL-6水平分别总体比较,差异均有统计学意义(F=261.24、33.82、28.00,P均<0.001)。进一步进行两两比较的结果显示,C组受试儿血清Ang-2、TNF-α水平,均显著高于A组、B组和对照组,并且差异均有统计学意义(血清Ang-2水平:LSD-t=-5.35、-15.98、25.31,P均<0.001;血清TNF-α水平:LSD-t=-2.24、P=0.030,LSD-t=-4.91、P<0.001,LSD-t=8.59、P均<0.001);C组受试儿血清IL-6水平分别显著高于B组和对照组,并且差异有统计学意义(LSD-t=-4.93、8.50,P均<0.001)。③ROC曲线分析结果显示,4组受试儿血清Ang-2水平诊断严重脓毒症患儿的ROC-AUC为0.998(95%CI:0.946~1.000,P<0.001)。根据约登指数最大原则,血清Ang-2水平诊断严重脓毒症患儿的最佳临界值为163.4ng/L,此时其诊断严重脓毒症患儿的敏感度为100.0%,特异度为98.5%。④4组受试儿中,其血清Ang-2水平分别与血清IL-6、TNF-α水平呈正相关关系(r=0.606、0.556,P均<0.001)。结论血清Ang-2水平随着脓毒症患儿病情严重程度增加而增高,可用于辅助判断脓毒症患儿病情严重程度。血清IL-6、TNF-α水平与血清Ang-2水平具有相关性,可以协助临床诊断脓毒症患儿。

Objective To evaluate the relationship between levels of serum angiopoietin (Ang)-2, interleukin (IL)-6 and tumor necrosis factor (TNF)-α, and the severity of sepsis in children, and to provide evidence for clinical diagnosis and treatment of children with sepsis. Methods A total of 64 cases of children with fever who were treated in Department of Pediatrics, Jinhua Hospital of Zhejiang University and The Children′s Hospital, Zhejiang University School of Medicine were selected as research subjects. Their age ranged from 1 month after birth to 12 years old. They were divided into three groups according to whether they suffered from sepsis or not and the grading standards of sepsis: group A ( n =22, children with sepsis), group B [( n =24, children with infection and without systemic inflammatory response syndrome (SIRS)], and group C ( n =18, children with severe sepsis). In the same period, another 21 children underwent health examination in Department of Child Healthcare, Jinhua Hospital of Zhejiang University were included into control group. Their age ranged from 3 months after birth to 12 years old. Enzyme-linked immunosorbent assay (ELISA) was used to detect the levels of serum Ang-2, IL-6 and TNF-α. The receiver operating characteristic (ROC) curve of level of serum Ang-2 for diagnosing children with severe sepsis among 4 groups were drawn, and the area under the ROC curve (ROC-AUC) was calculated. The optimal critical value of serum Ang-2 level for diagnosing children with severe sepsis was determined according to the principle of maximum Youden index, and its sensitivity and specificity were calculated. Linear correlation analysis was used to analyze the correlation between levels of serum Ang-2 level and serum IL-6 and TNF-α. This study was in line with the requirements of World Medical Association Declaration of Helsinki revised in 2013. The guardians of all children signed the clinical research informed consents. Results ① There were no significant differences in age, gender composition ratio and other general clinical data among 4 groups ( P >0.05).②There were significant differences among 4 groups in the levels of serum Ang-2, TNF-α and IL-6 ( F =261.24, 33.82, 28.00;P all<0.001). Further comparison results showed that the levels of serum Ang-2 and TNF-α in group C were significantly higher than those in group A, group B and control group, and all the differences were statistically significant (level of serum Ang-2: LSD- t =-5.35,-15.98, 25.31, P all<0.001;level of serum TNF-α: LSD- t =-2.24, P =0.030, LSD- t =-4.91, P <0.001, LSD- t =8.59, P <0.001). The level of serum IL-6 in group C was higher than that in group B and control group, respectively, and both the differences were statistically significant (LSD- t =-4.93, 8.50;P all<0.001).③The results of ROC curve analysis showed that ROC-AUC of serum Ang-2 level in diagnosis of children with severe sepsis was 0.998 (95% CI : 0.946-1.000, P <0.001). According to the principle of maximum Youden index, the optimal critical value of serum Ang-2 level to predict children with severe sepsis was 163.4 ng/L, and its sensitivity and specificity for diagnosis of children with severe sepsis were 100.0% and 98.5%, respectively.④Among the children in 4 groups, serum Ang-2 level was positively correlated with serum IL-6 and TNF-α levels, respectively ( r =0.606, 0.556;P all<0.001). Conclusions The level of serum Ang-2 is significantly elevated with the severity of children with sepsis, which can be used to evaluate the severity of children with sepsis. The levels of serum IL-6 and TNF-α are correlated with serum Ang-2 level, which can assist in the diagnosis of children with sepsis.