神经重症康复患者住院期间低磷血症与长期预后的关系

Relationship between hypophosphatemia and long-term prognosis of patients in neurological intensive rehabilitation unit during hospitalization

目的分析神经重症康复患者住院期间最低血磷水平与长期预后的关系。方法收集2020年12月至2022年6月首都医科大学附属北京康复医院神经重症康复病房收治患者的临床资料,包括性别、年龄、主要诊断、格拉斯哥昏迷评分(GCS)、生化磷离子水平(入院时、最低、最高)、白细胞计数(WBC)、中性粒细胞/淋巴细胞计数比值(NLR)、C-反应蛋白(CRP)、降钙素原(PCT)、重症监护病房(ICU)住院时间、总住院时间、6个月和1年所在场所,以及6个月和1年病死率。根据住院期间最低血磷水平将患者分为低磷血症组(血磷<0.80 mmol/L)和非低磷血症组(血磷≥0.80 mmol/L),比较不同血磷水平组患者上述指标的差异。采用多因素Logistic回归分析影响神经重症康复患者预后的独立危险因素,并绘制受试者工作特征曲线(ROC曲线),计算ROC曲线下面积(AUC)和95%可信区间(95%CI),评价住院期间最低血磷水平对神经重症康复患者6个月及1年预后的预测价值。结果共纳入276例患者,低磷血症组168例,非低磷血症组108例。与非低磷血症组比较,低磷血症组PCT、CRP均更高〔PCT(μg/L):0.08(0.04,0.16)比0.05(0.03,0.14),CRP(mg/L):12.05(3.00,27.63)比5.35(1.53,18.88),均P<0.05〕,前白蛋白水平降低〔g/L:0.19(0.14,0.22)比0.21(0.17,0.26),P<0.01〕,ICU住院时间和总住院时间延长〔ICU住院时间(d):36.0(25.0,78.8)比28.0(21.3,46.8),总住院时间(d):116.5(60.0,180.0)比78.0(40.2,129.0),均P<0.01〕,6个月内和1年病死率增加〔6个月内病死率:13.10%(22/168)比3.70%(4/108),1年病死率:26.19%(44/168)比11.11%(12/108),均P<0.05〕。两组6个月内和1年时不同生活场所患者比较差异有统计学意义(P<0.05)。Logistic回归分析显示,最低血磷水平是影响神经重症康复患者预后的独立危险因素〔6个月内:优势比(OR)和95%CI为0.160(0.032~0.798),P=0.024;1年:OR和95%CI为0.286(0.091~0.895),P=0.032〕;ROC曲线分析显示,最低血磷水平对神经重症康复患者预后有一定价值预测(6个月内:AUC=0.66,95%CI为0.58~0.75;1年:AUC=0.62,95%CI为0.54~0.70,均P<0.01)。结论低磷血症组较非低磷血症组患者有更长的ICU住院时间和总住院时间,更高的6个月内及1年病死率。住院期间的最低血磷可以预测经重症康复患者6个月内及1年预后。

Objective To explore the relationship between minimum blood phosphorus and the long-term prognosis of patients in the neurological intensive rehabilitation unit.Methods The clinical data of patients in the neurological intensive rehabilitation ward of Beijing Rehabilitation Hospital Affiliated to Capital Medical University from December 2020 to June 2022 were analyzed.The data included gender,age,primary diagnosis,Glasgow coma scale(GCS),biochemical phosphorus ion levels(at admission,lowest,highest),white blood cell count(WBC),neutrophil/lymphocyte count ratio(NLR),C-reactive protein(CRP),and procalcitonin(PCT),length of stay in intensive care unit(ICU),total length of stay,6-month and 1-year location,and 6-month and 1-year case mortality.Patients were divided into hypophosphatemia group(serum phosphorus<0.80 mmol/L)and non-hypophosphatemia group(serum phosphorus≥0.80 mmol/L)according to the minimum blood phosphorus during hospitalization,the differences of the above indexes in different blood phosphorus level groups were compared.Multivariate Logistic regression analysis was used to evaluate the relationship between univariate variables and 6-month and 1-year prognosis.The receiver operator characteristic curve(ROC curve)was obtained,area under the curve(AUC)and its 95%confidence interval(95%CI)were calculated to evaluate the value of blood phosphorus level in predicting prognosis of patients in neurological intensive rehabilitation ward in 6 months and 1 year.Results A total of 276 patients were included,including 168 patients in the hypophosphatemia group and 108 patients in the non-hypophosphatemia group.Patients in the hypophosphatemia group had higher PCT and CRP[PCT(μg/L):0.08(0.04,0.16)vs.0.05(0.03,0.14),CRP(mg/L):12.05(3.00,27.63)vs.5.35(1.53,18.88),both P<0.05],lower prealbumin[g/L:0.19(0.14,0.22)vs.0.21(0.17,0.26),P<0.01],longer length of stay in ICU and total length of stay[length of stay in ICU(days):36.0(25.0,78.8)vs.28.0(21.3,46.8),total length of stay(days):116.5(60.0,180.0)vs.78.0(40.2,129.0),both P<0.01],higher 6-month and 1-year mortality[6-month mortality:13.10%(22/168)vs.3.70%(4/108),1-year mortality:26.19%(44/168)vs.11.11%(12/108),both P<0.05]than those in the non-hypophosphatemia group.At 6-month and 1-year follow-up,there was statistical significance between the two groups in different living places(P<0.05).Logistic regression analysis showed that the lowest blood phosphorus level was an independent risk factor for the prognosis of patients in neurological intensive rehabilitation ward[6-month:odds ratio(OR)and 95%CI were 0.160(0.032-0.798),P=0.024;1-year:OR and 95%CI were 0.286(0.091-0.895),P=0.032,respectively].ROC curve analysis showed that the minimum blood phosphorus level had a certain value in predicting the prognosis of patients with severe neurological rehabilitation(6-month:AUC=0.66,95%CI was 0.58-0.75;1-year:AUC=0.62,95%CI was 0.54-0.70,both P<0.01).Conclusions Patients with hypophosphatemia had a longer length of stay in ICU,total length of stay,and higher mortality at 6-month and 1-year compared to those in the non-hypophosphatemia group.The lowest blood phosphorus during hospitalization can predict prognosis at both 6-month and 1-year marks.