CT评价系统联合血浆D-二聚体对重症急性胰腺炎预后的预测价值

Effect of CT evaluation system combined with plasma D-dimer on predicting the prognosis of severe acute pancreatitis

目的探讨改良CT严重指数(modified CT severity index, MCTSI)及Balthazar CT分级联合血浆D-二聚体(D-dimer, DD)在重症急性胰腺炎(severe acute pancreatitis, SAP)患者预后评估中的作用。方法 276例SAP患者,依据ICU转归分为存活组198例和死亡组78例。2组入院时,记录急性生理和慢性健康状况(Acute Physiology and Chronic Health EvaluationⅡ,APACHEⅡ)评分等资料,采用免疫乳胶比浊法检测血浆DD水平,行腹部CT检查,记录Balthazar CT分级、MCTSI评分;比较2组Balthazar CT分级、MCTSI评分、DD水平。采用多因素logistic回归分析SAP患者ICU死亡的危险因素;绘制ROC曲线,评估MCTSI、Balthazar CT分级、APACHEⅡ评分联合血浆DD预测SAP患者ICU死亡的价值。结果死亡组入院时APACHEⅡ[(28.70±5.52)分]、Balthazar CT分级[(3.78±0.33)分]、MCTSI评分[(6.12±0.62)分]及血浆DD水平[(3.87±0.98)mg/L]均高于存活组[(23.35±5.26)分、(3.27±0.36)分、(5.35±0.78)分、(1.92±0.86)mg/L],且高Balthazar CT分级(C级以上)、高MCTSI评分(>5分)、高DD水平(DD>2.56 mg/L)患者ICU病死率(40.00%、39.46%、34.96%)高于低Balthazar CT分级(C级及以下)、低MCTSI评分(≤5分)、低DD水平(DD≤2.56 mg/L)患者(12.07%、15.50%、22.87%)(P<0.05);APACHEⅡ评分>26.00分(OR=1.76,95%CI:1.22~2.63,P=0.002)、Balthazar CT分级>2分(OR=1.93,95%CI:1.35~4.29,P<0.001)、MCTSI评分>5分(OR=1.69,95%CI:1.17~2.58,P=0.006)、血浆DD>2.56 mg/L(OR=2.07,95%CI:1.56~5.37,P<0.001)是SAP患者ICU死亡的独立危险因素;MCTSI联合DD、Balthazar CT联合DD预测SAP患者ICU死亡的AUC[0.897(95%CI:0.841~0.932)、0.885(95%CI:0.837~0.925)]高于APACHEⅡ联合DD[0.826(95%CI:0.766~0.859)]。结论 SAP患者ICU病死率较高,Balthazar CT分级>2分、MCTSI评分>5分、血浆DD>2.56 mg/L可增加其ICU死亡风险,入院时MCTSI评分联合DD、Balthazar CT评分联合DD预测SAP患者ICU死亡的价值高于APACHEⅡ评分联合DD。

Objective To investigate the roles of modified CT severity index(MCTSI) plus plasma D-dimer(DD) and Balthazar CT grade plus DD in predicting the prognosis of patients with severe acute pancreatitis(SAP). Methods Totally 276 SAP patients were divided into survival group(n=198) and death group(n=78) according to ICU outcomes. The Acute Physiology and Chronic Health Evaluation Ⅱ(APACHEⅡ) score and other data were recorded at admission, the plasma DD level was detected by immunolatex turbidimetry, and the Balthazar CT grade and MCTSI score were recorded by abdominal CT examination. Balthazar CT grade, MCTSI score and DD level were compared between two groups. Multivariate logistic regression analysis was used to analyze the risk factors for ICU death in SAP patients. ROC was drawn to analyze the clinical values of MCTSI plus DD, Balthazar CT grade plus DD and APACHEⅡ score plus DD to the prediction of ICU death. Results The APACHEⅡ score, Balthazar CT grade, MCTSI score and plasma DD level were higher in death group(28.70±5.52, 3.78±0.33, 6.12±0.62,(3.87±0.98) mg/L) than those in survival group(23.35±5.26, 3.27±0.36, 5.35±0.78,(1.92±0.86) mg/L)(P<0.05). The ICU mortalities were higher in patients with high Balthazar CT grade(>C grade), high MCTSI score(>5) and high DD level(>2.56 mg/L)(40.00%, 39.46%, 34.96%) than those in patients with low Balthazar CT grade(≤C grade), low MCTSI(≤5) and low DD level (≤2.56 mg/L)(12.07%,15.50%,22.87%)(P<0.05).APACHEⅡ score >26.00(OR=1.76,95%CI:1.22-2.63,P=0.002),Balthazar CT grade>2(OR=1.93,95%CI:1.35-4.29,P<0.001),MCTSI score>5(OR=1.69,95%CI:1.17-2.58,P=0.006),and plasma DD level>2.56 mg/L(OR=2.07,95%CI:1.56-5.37,P<0.001)were the risk factors for ICU death in SAP patients.The AUCs of MCTSI plus DD,and Balthazar CT plus DD for predicting ICU death in patients with SAP(0.897(95%CI:0.841-0.932),0.885(95%CI:0.837-0.925))were higher than that of APACHEⅡ plus DD(0.826(95%CI:0.766-0.859)).Conclusion SAP patients have a high ICU mortality.Balthazar CT grade>2,MCTSI score>5,and DD level>2.56 mg/L would increase the risk for ICU death,and MCTSI score plus DD and Balthazar CT grade plus DD at admission are superior to APACHEⅡplus DD in predicting ICU death in SAP patients.