免疫抑制合并重症肺炎患者预后评估指标的筛选

The Screening of Prognostic Indicators for Immunocompromised Patients with Severe Pneumonia

目的筛选有助于评估免疫抑制并重症肺炎患者预后的临床指标。方法回顾性分析2018年8月至2020年1月郑州大学第一附属医院呼吸重症监护病房(RICU)收治的83例免疫抑制合并重症肺炎患者的临床资料。根据28 d预后分为好转组(48例)和恶化组(35例),比较两组入ICU 24 h内急性生理与慢性健康评分Ⅱ(APACHEⅡ)、英国胸科协会改良肺炎评分(CURB-65)、中性粒细胞与淋巴细胞比值(NLR)、血小板与淋巴细胞比值(PLR)、外周血淋巴细胞亚群、降钙素原(PCT)及C反应蛋白(CRP)的差异;观察各指标在入ICU 7 d内的变化趋势;采用Spearman相关分析评估各指标间的相关性;绘制受试者工作特征曲线(ROC),评估各指标对28 d预后的预测价值。结果恶化组入ICU第1天的NLR、APACHEⅡ评分、CURB-65评分高于好转组,CD4^(+)、CD3^(+)T细胞计数低于好转组,差异有统计学意义(P<0.05);两组间PLR、PCT、CRP、CD8^(+)T细胞计数、CD4^(+)/CD8^(+)差异无统计学意义(P>0.05)。恶化组入ICU第1、3、5、7天NLR均高于好转组同期,差异有统计学意义(P<0.05)。相关性分析显示入ICU第1天的NLR与APACHEⅡ评分(r=0.261,P=0.017)、CURB-65评分(r=0.227,P=0.039)呈正相关,与CD3^(+)T细胞计数(r=-0.396,P<0.001)、CD4^(+)T细胞计数(r=-0.352,P=0.001)呈负相关。ROC曲线显示,入ICU第1、3、5、7天的NLR,入ICU 24 h内的APACHEⅡ评分、CURB-65评分、CD3^(+)T细胞及CD4^(+)T细胞计数对免疫抑制合并重症肺炎患者的28 d预后有一定的评估价值(P<0.05),其中以APACHEⅡ评分的曲线下面积最大(AUC=0.756),第3天的NLR次之(AUC=0.703),而入ICU第1天的PCT、CRP、PLR对预后的评估效能不佳(P>0.05)。结论APACHEⅡ评分、CURB-65评分、CD3^(+)T细胞计数、CD4^(+)T细胞计数及NLR对免疫抑制并重症肺炎患者28 d预后有一定的评估价值。NLR能在一定程度上反映该部分患者的免疫状态及病情严重程度,其长期维持较高水平提示患者预后不良。

Objective To screen the clinical indicators for evaluating the prognosis of immunocompromised patients with severe pneumonia.Methods The clinical data of 83 immunocompromised patients with severe pneumonia admitted to the respiratory intensive care unit(RICU)of the First Affiliated Hospital of Zhengzhou University from August 2018 to January 2020 were retrospectively analyzed.The patients were divided into improved group(48 cases)and deteriorated group(35 cases)according to 28-day prognosis.The differences of APACHEⅡscore,CURB-65 score,neutrophil to lymphocyte ratio(NLR),platelet to lymphocyte ratio(PLR),peripheral blood lymphocyte subsets,procalcitonin(PCT),C reactive protein(CRP)within 24 hours after ICU admission were compared between the two groups.The change trend of each index within 7 days after entering ICU was observed.Spearman correlation analysis was used to evaluate the correlation between NLR and other indicators.Receive operating characteristic(ROC)curve was drawn to evaluate the predictive value of each index on 28-day prognosis.Results On the first day,the NLR,APACHEⅡscores,CURB-65 scores in the deteriorated group were higher than those of the improved group,while the CD3^(+)and CD4^(+)T cell counts were less than those of the improved group,and the differences were statistically significant(P<0.05).There were no statistically significant differences in PLR,PCT,CRP,CD8^(+)T cell counts and CD4^(+)/CD8^(+)between the two groups(P>0.05).The NLR of patients in the deteriorated group was higher than that of the improved group on the first,third,fifth,seventh day after entering ICU,respectively,and the differences were all statistically significant(P<0.05).Correlation analysis results showed that the NLR on first day after entering ICU was positively correlated with APACHEⅡscores(r=0.261,P=0.017)and CURB-65 scores(r=0.227,P=0.039),while negatively correlated with CD3^(+)cell counts(r=-0.396,P<0.001)and CD4^(+)T cell counts(r=-0.352,P=0.001).According to ROC curve analysis,the NLR on first,third,fifth,seventh day after entering ICU,APACHEⅡscore,CURB-65 score,CD3^(+)T cell counts and CD4^(+)T cell counts on first day had a certain predictive value for the 28-day prognosis of immunocompromised patients with severe pneumonia(P<0.05);APACHEⅡscore had the maximum area under the ROC curve(AUC=0.756),followed by the NLR on the third day(AUC=0.703).However,PCT,CRP and PLR on the first day were not effective in evaluating the prognosis(P>0.05).Conclusion APACHEⅡscore,CURB-65 score,CD3^(+)T cell counts,CD4^(+)T cell counts and NLR have certain evaluation value for the 28-day prognosis of immunosuppressed patients with severe pneumonia.NLR can reflect the severity of the disease and the immune status to a certain extent,and long-term maintenance of a high level indicates a poor prognosis.