肾上腺髓质素原联合降钙素原对老年重症社区获得性肺炎患者预后的预测价值

摘要

目的 探讨肾上腺髓质素原(pro-ADM)和降钙素原(PCT)在老年重症社区获得性肺炎(SCAP)患者中的变化及其预测预后的价值.方法 回顾性分析2016年1月至2017年9月海南省儋州市人民医院急诊科收治的老年SCAP患者162例,根据患者28 d死亡或存活情况分为存活组(n=114)和死亡组(n=48),监测患者确诊SCAP第1,3,7天时的血清pro-ADM和PCT水平变化.采用SPSS 19.0统计软件对数据进行分析.根据数据类型,组间比较采用成组t检验或χ2检验,组内比较采用重复测量的方差分析;受试者工作特征(ROC)曲线分析各时间点pro-ADM、PCT以及两者联合对老年SCAP患者预后预测的价值.结果 死亡组的 CURB-65评分、肺炎严重度指数(PSI)评分及急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)分值明显高于存活组,差异具有统计学意义(P <0.05).死亡组患者确诊第1天[(4.66 ±1.83) vs (3.04 ±1.31)nmol/L]、第3天[(5.47 ±1.96) vs(2.95 ±1.34)nmol/L]、第7天时[(6.81 ±2.17) vs (1.53 ±0.82)nmol/L]血清pro-ADM水平明显高于存活组患者;死亡组患者确诊第3天[(3.28 ±1.24) vs (1.05 ±0.53) ng/ml]和第7天[(5.62 ±1.83) vs (0.26 ±0.12)ng/ml]时血清 PCT 水平高于存活组患者;死亡组患者确诊第7天时的 pro-ADM [(6.81 ±2.17) vs(5.47 ±1.96)nmol/L]和PCT[(5.62 ±1.83) vs(3.28 ±1.24)ng/ml]水平明显高于第3天水平,差异均具有统计学意义(P<0.05).第3天血清pro-ADM联合PCT预测老年SCAP患者28 d预后的ROC曲线下面积(AUC)是0.942 (0.883~0.998),明显高于pro-ADM的0.892(0.830~0.951)和PCT的0.857(0.793~0.924),灵敏度为95.2%,特异度为86.4%,预测价值较好.结论 pro-ADM 及 PCT 水平变化与老年 SCAP 患者的病情严重程度及预后相关,第3天血清pro-ADM联合PCT对患者28 d预后的预测价值较好.%Objective To investigate the changes of proadrenomedullin (pro-ADM) and procalcitonin (PCT) in the elderly patients with severe community-acquired pneumonia (SCAP), and assess their prognostic value.Methods A total of 162 elderly SCAP patients who were admitted in Emergency Department of our hospital from January 2016 to September 2017 were retrospectively enrolled in this study.According to the 28-day survival,they were divided into survival group (n=114) and death group (n=48). The serum pro-ADM and PCT levels in the patients were measured in 1,3 and 7 d after SCAP diagnosis.SPSS statistics 19.0 was used to perform the statistical analysis.Student's t test or Chi-square test was employed for comparison between the 2 groups,and repeated measures analysis of variance for intragroup comparison.Receiver operating characteristic (ROC) curve was adopted to analyze the prognostic value of pro-ADM, PCT and combination for SCAP at various time points.Results The CURB-65 score, pneumonia severity index (PSI),and the score of acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) were significantly higher in the death group than the survival group (P <0.05).When compared with the survival group, the serum pro-ADM level was significantly higher in the death group on 1st day [(4.66 ±1.83) vs (3.04 ±1.31) nmol/L], 3rd day [(5.47 ±1.96) vs (2.95 ±1.34) nmol/L] and 7th day[(6.81 ±2.17) vs(1.53 ±0.82) nmol/L,all P<0.05],but such diffe-rences of serum PCT level were only found on the 3rd day[(3.28 ±1.24) vs(1.05 ±0.53) ng/ml] and 7th day[(5.62 ±1.83) vs(0.26 ±0.12) ng/ml,both P<0.05 ].The serum pro-ADM and PCT levels on the 7th day were obviously higher than those on the 3rd day in the death group [(6.81 ±2.17) vs(5.47 ±1.96) nmol/L,(5.62 ±1.83) vs(3.28 ±1.24) ng/ml,P<0.05].The area under ROC curve of combined diagnosis was 0.942(0.883-0.998) for 28-day prognosis in elderly SCAP patients, significantly higher than that by pro-ADM alone (0.892,0.830-0.951) or by PCT alone (0.857,0.793-0.924).The sensitivity and specificity were 95.2%and 86.4%respectively,suggesting good predictive value.Conclusion The changes in pro-ADM and PCT levels are associated with the severity of the disease and prognosis in elderly patients with SCAP,and combination of serum pro-ADM and PCT levels on the 3rd day shows good predictive value for 28-day prognosis.