辅助性和调节性T淋巴细胞亚群与过敏性紫癜患儿疾病严重程度的关系

Association of helper and regulatory T lymphocyte subsets with disease severity in children with Henoch-Schonlein purpura

目的 探讨辅助性(Th)(CD3^(+)CD4^(+))和调节性(Treg)(CD4^(+)CD25^(+))T淋巴细胞亚群与过敏性紫癜(HSP)患儿疾病严重程度的关系。方法 选择2018年1月至2021年1月苏州大学附属儿童医院收治的HSP患儿(150例)为研究对象,根据HSP症状积分将其分为轻度组(<33分,50例)、中度组(33~67分,56例)、重度组(>67分,44例);另选择同期于门诊进行体检的健康儿童(150例)为对照组。对比分析各组儿童的一般资料、临床症状及实验室指标。通过曲线拟合及阈值效应分析CD3^(+)CD4^(+)和CD4^(+)CD25^(+)与HSP症状积分的关系。通过LASSO模型和多因素Logistic回归分析探讨HSP患儿病情加重的影响因素,建立反向传播(BP)神经网络模型,并对模型进行评价。结果 轻度组、中度组、重度组患儿皮肤紫癜持续时间>28d的比例比较差异有统计学意义(χ^(2)=6.340,P<0.05)。轻度组、中度组、重度组、对照组儿童的白细胞计数(WBC)、C-反应蛋白(CRP)、D-二聚体(D-D)、免疫球蛋白A(IgA)、CD3^(+)CD4^(+)、CD4^(+)CD25^(+)、白细胞介素-21(IL-21)、转化生长因子β1(TGF-β1)及肿瘤坏死因子α(TNF-α)水平比较差异均有统计学意义(F值分别为6.559、9.707、29.202、12.719、7.671、5.290、10.226、19.119、13.329,P<0.05),随着HSP病情加重,WBC、CRP、D-D、IgA、TGF-β1及TNF-α水平均有所升高,而CD3^(+)CD4^(+)、CD4^(+)CD25^(+)及IL-21水平均有所降低。随着HSP患儿病情的进展,CD3^(+)CD4^(+)和CD4^(+)CD25^(+)的水平均有所下降,当CD3^(+)CD4^(+)<37.3%时,随着CD3^(+)CD4^(+)水平升高,HSP症状积分呈下降趋势(OR=0.962,95%CI:0.947~0.977,P<0.001);当CD4^(+)CD25^(+)<10.2%时,随着CD4^(+)CD25^(+)水平升高,HSP症状积分呈下降趋势(OR=0.976,95%CI:0.953~0.998,P<0.001)。多因素Logistic回归分析显示,CRP>12.4mg/L(OR=5.017,95%CI:4.609~5.811)、D-D>3.4mg/L(OR=4.391,95%CI:4.051~5.132)、IgA>2.3g/L(OR=3.148,95%CI:2.742~3.524)、TGF-β1≥6.5pg/mL(OR=4.137,95%CI:3.372~4.512)及TNF-α≥14.5pg/mL(OR=3.811,95%CI:3.028~4.226)均为发生重度HSP的独立危险因素(P<0.05);CD3^(+)CD4^(+)≥32%(OR=0.694,95%CI:0.443~0.956)、CD4^(+)CD25^(+)≥7%(OR=0.644,95%CI:0.399~0.910)及IL-21≥23.1pg/mL(OR=0.442,95%CI:0.185~0.807)均为独立保护因素(P<0.05)。BP神经网络模型的隐含层节点数为4时,交叉验证的均方根误差最小,其中CRP(0.160分)、D-D(0.154分)、CD3^(+)CD4^(+)(0.135分)、CD4^(+)CD25^(+)(0.130分)对模型分类的贡献度较高。受试者工作特征(ROC)曲线、校准曲线和临床决策曲线(DCA)显示,该预测模型的区分度、准确性和有效性均较高。结论 CD3^(+)CD4^(+)、CD4^(+)CD25^(+)水平异常变化与HSP症状积分密切相关,随着患儿HSP病情进展,CD3^(+)CD4^(+)、CD4^(+)CD25^(+)水平明显降低;患儿HSP病情进展还与CRP、D-D、IgA、TGF-β1、TNF-α及IL-21水平密切相关。临床医护人员应密切关注相关指标,以期改善预后。

Objective To explore the relationship between helper(Th)(CD3^(+)CD4^(+)) and regulatory(Treg)(CD4^(+)CD25^(+)) T lymphocyte subsets and disease severity in children with henoch-schonlein purpura(HSP).Methods A total of 150 children with HSP who admitted to Children's Hospital of Soochow University from January 2018 to January 2021 were selected as the research subjects,and according to the HSP symptom score,they were divided into mild group(33 points,50 cases),moderate group(33-67 points,56 cases,),and severe group(67 points,44 cases).Healthy children(150 cases) who underwent physical examination in the outpatient department of the hospital during the same period were selected as the control group.The general data,clinical symptoms and laboratory indexes of children in each groups were compared and analyzed.The relationship between CD3^(+)CD4^(+) and CD4^(+)CD25^(+) and HSP symptom score was analyzed by curve fitting and threshold effect analysis.LASSO model and multivariate Logistic regression analysis was used to explore the factors affecting the exacerbation of HSP children,and back propagation(BP) neural network model was established,and the model was evaluated.Results There was significant difference between the mild group,the moderate group and the severe group in the duration of purpura28 days(χ^(2)=6.340,P<0.05).The levels of white blood cell(WBC),C-reactive protein(CRP),D-dimer(D-D),immunoglobulin A(IGA),CD3^(+)CD4^(+),CD4^(+)CD25^(+),interleukin-21(IL-21),transforming growth factor β1(TGF-β1) and tumor necrosis factor α(TNF-α) were significantly different in children in mild group,moderate group,severe group and control group(F=6.559,9.707,29.202,12.719,7.671,5.290,10.226,19.119 and 13.329,respectively,P<0.05).With the exacerbations of HSP,the levels of WBC,CRP,D-D,IGA,TGF-β1 and TNF-α were increased,while the levels of CD3^(+)CD4^(+),CD4^(+)CD25~(+ )and IL-21 were decreased.With the progression of HSP,the levels of CD3^(+)CD4^(+) and CD4^(+)CD25^(+) decreased,when CD3^(+)CD4^(+)37.3%,with the increase of CD3^(+)CD4^(+) level,the HSP symptom score showed a downward trend(OR=0.962,95%CI:0.947-0.977,P<0.001).When CD4^(+)CD25^(+)10.2%,with the increase of CD4^(+)CD25^(+) level,the HSP symptom score showed a downward trend(OR=0.976,95%CI:0.953-0.998,P<0.001).Multivariate Logistic regression analysis showed that CRP12.4mg/L(OR=5.017,95%CI:4.609-5.811) and D-D3.4mg/L(OR=4.391,95%CI:4.051-5.132),IgA2.3g/L(OR=3.148,95%CI:2.742-3.524),TGF-β1≥6.5pg/mL(OR=4.137,95%CI:3.372-4.512) and TNF-α≥14.5pg/mL(OR=3.811,95%CI:3.028-4.226) were independent risk factors for severe HSP(P<0.05).CD3^(+)CD4^(+)≥32%(OR=0.694,95%CI:0.443-0.956),CD4^(+)CD25^(+)≥7%(OR=0.644,95%CI:0.399~0.910) and interleukin-21(IL-21) ≥23.1pg/mL(OR=0.442,95%CI:0.185-0.807) were independent protective factors(P<0.05).When the number of hidden layer nodes of BP neural network model was 4,the root mean square error of cross-validation was the smallest,and CRP(0.160 points),D-D(0.154 points),CD3^(+)CD4^(+)(0.135 points),CD4^(+)CD25^(+)(0.130 points) had a higher contribution to the model classification.Receiver operating characteristic(ROC) curve,calibration curve and decision curve analysis(DCA) showed that the predictive model was highly discriminative,accurate and valid.Conclusion Abnormal changes in the levels of CD3^(+)CD4^(+) and CD4^(+)CD25^(+) are closely related to the score of HSP symptoms,and the levels of CD3^(+)CD4^(+) and CD4^(+)CD25^(+) significantly decrease with the progression of patient's HSP.The progression of HSP in children with HSP is also closely related to the levels of CRP,D-D,IgA,TGF-β1,TNF-α and IL-21.Clinical medical personnel should pay close attention to relevant indicators in order to improve the prognosis.