血清分化簇40配体水平及血管外肺水指数与重症肺炎合并呼吸衰竭患者病情程度和预后的关系

Relationships between CD40L level and EVLWI and the severity and prognosis of patients with severe pneumonia complicated with respiratory failure

目的探讨血清分化簇40配体(CD40L)水平及血管外肺水指数(EVLWI)与重症肺炎合并呼吸衰竭患者病情程度和预后的关系。方法选择重症肺炎合并呼吸衰竭患者121例,根据急性生理学和慢性健康状况评分Ⅱ(APACHEⅡ)分为低危者31例、中危者49例、高危者41例;入组后规范治疗并随访30天,根据生存状态分为死亡者37例、存活者84例。采集所有研究对象入重症监护室24 h内外周静脉血,离心留取血清,采用ELISA法检测血清CD40L;通过股动脉、肱动脉或腋动脉留置导管,连接PiCCO监测仪,通过肺热稀释法测量EVLWI。比较不同病情程度重症肺炎合并呼吸衰竭患者血清CD40L水平及EVLWI,采用Spearman相关分析法分析重症肺炎合并呼吸衰竭患者血清CD40L水平、EVLWI与APACHEⅡ评分的关系。采用多因素Logistic回归模型分析重症肺炎合并呼吸衰竭患者预后不良的危险因素。采用受试者工作特征(ROC)曲线分析血清CD40L水平、EVLWI对重症肺炎合并呼吸衰竭患者死亡的预测价值。结果重症肺炎合并呼吸衰竭患者低危者、中危者、高危者血清CD40L水平和EVLWI依次升高(P均<0.05)。Spearman相关分析显示,重症肺炎合并呼吸衰竭患者血清CD40L水平及EVLWI与APACHEⅡ评分均呈正相关关系(P均<0.01)。多因素Logistic回归分析显示,年龄增长、肺外并发症≥2个、APACHEⅡ评分增加以及血清CD40L水平和EVLWI升高为重症肺炎合并呼吸衰竭患者预后不良的独立危险因素(P均<0.05)。ROC曲线分析显示,血清CD40L水平、EVLWI单独与联合评估重症肺炎合并呼吸衰竭患者死亡的曲线下面积分别为0.773、0.779、0.880,血清CD40L水平、EVLWI联合预测重症肺炎合并呼吸衰竭患者死亡的曲线下面积大于血清CD40L水平、EVLWI单独(P均<0.05)。结论血清CD40L水平及EVLWI升高与重症肺炎合并呼吸衰竭患者病情程度增加有关,也是其预后不良的独立危险因素;血清CD40L水平、EVLWI对重症肺炎合并呼吸衰竭患者死亡均有一定预测价值,二者联合预测价值更高。

Objective To investigate the relationships between the level of cluster of differentiation 40 ligand(CD40L)and extravascular lung water index(EVLWI)and the severity and prognosis of patients with severe pneumonia complicated with respiratory failure.Methods Totally 121 patients with severe pneumonia complicated with respiratory failure were selected and were divided into the low-risk(31 cases),medium-risk(49 cases)and high-risk(41 cases)groups according to acute physiology and chronic health evaluation II(APACHE II).After enrollment,standard treatment and 30-day follow-up were performed,and 37 patients died and 84 survived according to their survival status.The internal and external venous blood of all subjects was collected after 24 h in the intensive care unit,serum was collected by centrifu⁃gation,and serum CD40L was detected by ELISA.EVLWI was measured by pulmonary thermodilution using an indignant catheter placed in the femoral artery,brachial artery or axillary artery and was connected to a PiCCO monitor.The levels of serum CD40L and EVLWI in patients with severe pneumonia complicated with respiratory failure were compared.Spear⁃man correlation analysis was used to analyze the relationships between serum CD40L level,EVLWI and APACHEⅡscore in patients with severe pneumonia complicated with respiratory failure.Multivariate Logistic regression template was used to analyze the risk factors of poor prognosis in patients with severe pneumonia complicated with respiratory failure.Receiv⁃er operating characteristic(ROC)curve was used to analyze the predictive value of serum CD40L level and EVLWI on death in patients with severe pneumonia complicated with respiratory failure.Results The levels of serum CD40L and EVLWI increased in the low-risk,medium-risk and high-risk patients with severe pneumonia complicated with respiratory failure(all P<0.01).Spearman correlation analysis showed that serum CD40L level and EVLWI were positively correlated with APACHEⅡscore in patients with severe pneumonia complicated with respiratory failure(all P<0.01).Multivariate Logistic regression analysis showed that increasing age,≥2 extrapulmonary complications,increased APACHEⅡscore,and increased serum CD40L level and EVLWI were independent risk factors for poor prognosis in patients with severe pneu⁃monia combined with respiratory failure(all P<0.05).ROC curve analysis showed that the area under the curve of serum CD40L level,EVLWI alone and combined in assessment of death in patients with severe pneumonia complicated with re⁃spiratory failure was 0.773,0.779 and 0.880,respectively.The area under the curve of serum CD40L level and EVLWI combined in predicting the death of severe pneumonia complicated with respiratory failure was greater than that of serum CD40L level or EVLWI alone(all P<0.05).Conclusions The increased serum CD40L and EVLWI levels are related to the increase of severe pneumonia complicated with respiratory failure,and are independent risk factors for poor prognosis.Serum CD40L level and EVLWI have certain predictive value for death of patients with severe pneumonia complicated with respiratory failure,but the predictive value of them combined is higher.