脓毒症患者HVHF治疗后血清可溶性CD14水平对并发急性呼吸窘迫综合征的预测价值

Predictive value of serum soluble CD14 levels in patients with sepsis after HVHF treatment for acute respiratory distress syndrome

目的探讨脓毒症患者高容量血液过滤(high volume hemo filtration,HVHF)后血清可溶性CD14(soluble CD14,sCD14)水平对并发急性呼吸窘迫综合征(acute respiratry distress syndrme,ARDS)的预测价值。方法选择2019年6月至2020年5月在甘肃省中医院住院进行HVHF治疗的200例脓毒症患者,根据患者治疗后是否发生ARDS将其分为ARDS组(64例)和非ARDS组(136例)。收集患者临床资料及相关实验室指标。通过曲线拟合和阈值效应分析确定sCD14与脓毒症患者HVHF治疗后发生ARDS的关系。通过多因素Logistic回归分析脓毒患者HVHF治疗后并发ARDS的独立危险因素。根据多因素结果,构建贝叶斯网络模型,使用Netica软件进行贝叶斯网络推理,并对模型效能进行评价。结果ARDS组和非ARDS组在年龄、性别、饮酒史、身体质量指数(body mass index,BMI)、序贯器官衰竭(sepsis-related organ failure assessment,SOFA)评分、格拉斯哥昏迷(glasgow coma scale,GCS)评分、高血压病史、三酰甘油(triacylglycerol,TG)、总胆固醇(total cholesterol,TC)、总胆红素、白细胞总数等方面的差异均无统计学意义(P>0.05)。两组患者在体温、慢性健康状况评分系统Ⅱ(acute physiology and chronic health evaluationⅡ,APACHEⅡ)评分、吸烟史、糖尿病史、氧和指数(PaO_(2)/FiO_(2))、sCD14、C反应蛋白(c reactive protein,CRP)以及脂多糖结合蛋白(lipopolysaccharide binding protein,LBP)间的差异具有统计学意义(t/χ^(2)=3.30、18.15、15.24、5.30、8.54、28.54、25.12,10.36,P值均<0.05)。多因素Logistic回归分析结果显示,APACHE II、吸烟史、sCD14及LBP水平为脓毒患者HVHF治疗后并发ARDS的独立危险因素(OR=3.83、4.14、5.14、5.26,P值均<0.05)。拟合曲线及阈值效应分析发现,当sCD14>36.76μg/L时,随着sCD14的升高,ARDS发生率呈上升趋势(OR=0.84,95%CI:0.78~0.91,P<0.001)。贝叶斯网络模型显示,有吸烟史和sCD14>36.76μg/L的患者发生ARDS的概率最高(75.70%),上述指标均正常者ARDS发生概率最低(8.65%)。ARDS预测模型内部验证结果显示,内部验证前后曲线下面积(area under curve,AUC)分别为0.88(95%CI:0.81~0.92)和0.87(95%CI:0.80~0.92),灵敏度分别为89.53%和89.72%,特异度分别为90.58%和90.67%。结论血清sCD14水平为脓毒患者HVHF治疗后并发ARDS的独立危险因素,具有良好的预价值,可作为预判脓毒患者HVHF治疗后并发ARDS的早期指标。

Objective To explore the predictive value of serum soluble CD14(sCD14)levels in patients with sepsis after high volume hemo filtration(HVHF)treatment for acute respiratory distress syndrome(ARDS).Methods Total of 200 sepsis patients who were hospitalized in Gansu Hospital of Traditional Chinese Medicine from June 2019 to May 2020 for HVHF treatment were selected as the study subjects.According to the occurrence of ARDS after treatment,the patients were divided into ARDS group(64 cases)and non ARDS group(136 cases).The general clinical data and laboratory indexes of the two groups were collected.The relationship between sCD14 and the occurrence of ARDS after HVHF treatment in sepsis patients was determined by curve fitting and threshold effect analysis.Multivariate Logistic regression was used to analyze the independent risk factors of ARDS in sepsis patients after HVHF treatment.According to the results of multiple factors,a Bayesian network model was constructed,and Netica software was used for Bayesian network reasoning,and the model efficacy was evaluated.Results No statistically significant differences had been found in age,gender,history of alcohol consumption,body mass index(BMI),sequential organ failure assessment(SOFA)score,Glasgow coma scale(GCS)score,history of hypertension,triglycerides(TG),total cholesterol(TC)and total bilirubin between the ARDS group and non ARDS group(P>0.05).There were statistically significant differences in the body temperature,chronic health evaluation II(APACHE II)score,smoking history,diabetes history,oxygen index(PaO_(2)/FiO_(2)),sCD14,C-reactive protein(CRP)and lipopolysaccharide binding protein(LBP)between the two groups(t/χ^(2)=3.30,18.15,15.24,5.30,8.54,28.54,25.12,10.36,all P values<0.05).The results of multivariate logistic regression analysis showed that APACHE II,smoking history,sCD14 and LBP levels were independent risk factors for ARDS in sepsis patients after HVHF treatment(OR=3.83,4.14,5.14,5.26,all P values<0.05).Analysis of fitting curves and threshold effects found that when sCD14>36.76μg/L,with the increase of sCD14,the incidence of ARDS showed an upward trend(OR=0.84,95%CI:0.78~0.91,P<0.001).The Bayesian network model shows that patients with a history of smoking and sCD14>36.76μg/L have the highest probability of developing ARDS(75.70%),while those with normal indicators have the lowest incidence of ARDS(8.65%).The internal validation results of the ARDS prediction model showed that the area under curve(AUC)before and after internal validation were 0.88(95%CI:0.81~0.92)and 0.87(95%CI:0.80~0.92),with sensitivity of 89.53%and 89.72%,and specificity of 90.58%and 90.67%,respectively.Conclusion Serum sCD14 level is an independent risk factor for ARDS in patients with sepsis after HVHF treatment.It has good prognostic value and can be used as an early indicator for predicting ARDS in patients with sepsis after HVHF treatment.