肾综合征出血热危重度评分的设立及其对患者预后的评价

发布时间：2018-05-17 23:07

本文选题：肾综合征出血热 + 危重度评分　；参考：《山东大学》2013年硕士论文

【摘要】：背景和目的肾综合征出血热(hemorrhagic fever with renal syndrome,HFRS)是以鼠类为主要传染源的人畜共患传染病,主要临床表现为发热、充血出血、低血压休克、肾功能损害,病原体为汉坦病毒属,其病理基础是由病毒直接作用以及免疫损伤导致的全身广泛小血管和毛细血管的损害。HFRS起病急,病情变化快,病死率高,因此早期预测疾病的转归,及早采取相应的治疗措施对提高救治率具有重要意义。目前临床上主要的评分系统有简化急性生理学评分(simplified acute physiology score,SAPS Ⅱ)、感染相关器官衰竭评估(sepsis-related organ failure assessment,SOFA)、多器官功能障碍评分(]multiple organ dysfunction syndrome,MODS)等多种,这些评分系统从不同角度,以定量赋分的形式对一些重症疾病的发展、预后及转归进行分析,具有积极的临床指导意义。但由于HFRS的病理生理及临床过程有其本身的特殊性,现有的评分系统很难准确地对患者的病情作出评估。参照临床分型的指标并根据HFRS本身的的临床特点,本研究设计了HFRS的危重度评分,选取了全身炎症反应综合征(SIRS)状态、外渗程度、血浆胶体渗透压、血小板计数和尿蛋白浓度等5个参数,以期能更简捷、更有针对性地对患者的病情发展、转归和预后作出判断。方法研究对象为2000年1月至2011年4月住院治疗并确诊为HFRS的患者,共120例,其中男89例,女31例,年龄16-75岁,平均为(46.0±14.7)岁,按预后情况分为存活组(90例)和死亡组(30例)。HFRS的诊断均符合1987年全国流行性出血热会议制定的诊断与分型标准,血清汉坦病毒抗体(IgM)阳性。确诊为HFRS后,选择发热期第3-5天为观察点,收集患者相关临床资料,并根据患者3个月后的预后情况进行分组。 HFRS危重度评分的设立：由SIRS状态、外渗程度、血浆胶体渗透压、血小板计数和尿蛋白浓度5个参数构成。每一参数按严重程度不同分为5个等级,从低到高依次记为0、1、2、3和4分,合计总分最高为20分。SIRS诊断标准至少具备以下4条中的2条：(1)体温38℃或36℃；(2)心率90次／分；(3)呼吸20次／分或过度通气,PaCO232mmHg;(4)血白细胞计数12x109个/L或4×109个/L(12000个/μL或4000个/μL或未成熟粒细胞10%)。血浆胶体渗透压(mmHg)[6]=血浆白蛋白(g/dl)×5.54+因浆球蛋白(g/d1)×1.43。外渗程度分轻度、中度、重度和极重度,轻度：仅有球结膜水肿；中度：球结膜水肿+颜面水肿；重度：球结膜水肿+全身皮肤水肿(或三腔积液)；极重度：球结膜水肿+全身皮肤水肿+三腔积液。三腔积液是指经彩超检查明确有腹腔、胸腔和／或心包腔积液者。用Paswstat18.0统计软件分析,资料以x±S表示,组间差异采用t检验。采用受试者工作特征(receive operating characteristic, ROC)曲线下面积(area under curve, AUC)比较各评分方法对HFRS死亡风险的预测能力。根据其ROC曲线确定最佳诊断截断值,并确定截断值的敏感性(sensitivity,SN)和特异性(specificity,SP),计算Youden指数。结果 1、在HFRS危重度评分5个参数的单项评分中,死亡组的记分均高于存活组。死亡组的SIRS状态、血浆胶体渗透压和尿蛋白浓度的评分,均高于存活组(P0.05)。死亡组的外渗程度和血小板计数评分明显高于生存组存活组(P0.01)。 2、在SOFA评分、SAPSⅡ评分和HFRS危重度评分中,死亡组患者的分值均显著高于存活组(P0.01)。 3、SOFA评分、SAPSⅡ评分和HFRS危重度评分的AUC均0.7,分别为0.704,0.731和0.804。Youden指数以HFRS危重病评分为最高,SAPS Ⅱ评分次之,SOFA评分最低,分别为0.535、0.421、0.352。当取HFRS危重度评分的截断值为10分时,其预测患者存在死亡风险的敏感性为78.8%,特异性为77.4%。应用正态性z检验分别比较HFRS危重度评分与SAPS Ⅱ评分和SOFA评分的AUC,差异均有统计学意义(z=13.16,P0.05；z=29.68,P0.01)。结论 1、HFRS危重度评分参数的设定符合HFRS临床的病理生理变化特点,与传统的评分相比,更具有针对性和可操作性,方法简单、快捷。 2、HFRS危重度评分在发热期即能对HFRS疾病的严重程度和预后做出判断,能更好地提示临床医师及早采取防范措施。 3、当取HFRS危重度评分的最佳截断值10时,预测患者住院期间死亡风险的敏感性为78.8%,特异性为77.4%。 4、SOFA评分和SAPS Ⅱ评分对HFRS患者预后的评价具有一定的临床价值,但其敏感度和特异度明显低于血浆渗透压综合评分,差异具有统计学意义。
[Abstract]:Background and purpose
Hemorrhagic fever with renal syndrome (HFRS) is a zoonotic infectious disease with rodent as the main source of infection. The main clinical manifestations are fever, hyperemia, hypotension, and renal function damage, and the pathogen is hantavirus. The pathological basis is the direct effect of the virus and the wide range of the whole body caused by the immune injury. The damage of small blood vessels and capillaries is urgent, the condition changes quickly and the mortality rate is high. Therefore, it is of great significance to predict the prognosis of the disease and take the corresponding treatment measures early to improve the treatment rate. The main clinical scoring system is to simplify the acute physiological score (Simplified Acute physiology score, SAPS II) and infection. Related organ failure assessment (sepsis-related organ failure assessment, SOFA), multiple organ dysfunction score (]multiple organ dysfunction syndrome, MODS) and so on. These scoring systems have a positive clinical guidance for the analysis of the development, prognosis and prognosis of some severe diseases from different angles. However, because of the special nature of HFRS's pathophysiology and clinical process, it is difficult for the existing scoring system to accurately assess the patient's condition.
According to the clinical classification index and according to the clinical characteristics of HFRS itself, this study designed the critical score of HFRS, selected 5 parameters, such as systemic inflammatory response syndrome (SIRS), exosmosis, plasma colloid osmotic pressure, platelet count and urine protein concentration, in order to be more concise and more targeted to the development of the patient's condition. The outcome and prognosis are judged.
Method
The subjects were 120 patients who were hospitalized from January 2000 to April 2011 and diagnosed as HFRS, including 89 males and 31 females, 16-75 years old, and the average age was (46 + 14.7) years old. The prognosis was divided into the survival group (90 cases) and the death group (30 cases) in accordance with the diagnostic and classification criteria established by the national epidemic hemorrhagic fever conference in 1987. The serum hantavirus antibody (IgM) was positive. After the diagnosis of HFRS, the 3-5 day fever period was selected as the observation point. The related clinical data were collected and the patients were grouped according to the prognosis of the patients after 3 months.
The establishment of HFRS severity score was composed of 5 parameters: SIRS status, osmotic degree, plasma colloid osmotic pressure, platelet count and urine protein concentration. Each parameter was divided into 5 grades according to the severity, from low to high to 0,1,2,3 and 4, and the total score of the total score was 20.SIRS, with at least 2 of the following 4 items: 1 ) temperature 38 or 36; (2) heart rate 90 / fraction; (3) respiration 20 / sub or hyperventilation, PaCO232mmHg; (4) blood leukocyte count 12x109 /L or 4 x 109 /L (12000 / mu L or 4000 / L or immature granulocyte 10%). Plasma colloid osmotic pressure (mmHg) [6]= blood albumin (g/dl) x 5.54+ (g/d1) * 1.43. extravasation degree is light Degree, moderate, severe and extremely severe, mild: nodular conjunctiva edema; moderate conjunctival edema + facial edema; severe conjunctiva edema + total body edema (or three cavity effusion); extremely severe: conjunctiva edema + total body edema + three cavity effusion. Three cavity effusion was defined by color Doppler examination of abdominal cavity, thoracic cavity and / or pericardial cavity. Effusions.
Using the Paswstat18.0 statistical software, the data were expressed in X + S, and the difference between groups was tested by t test. The prediction ability of the death risk was compared with the area under the receive operating characteristic (ROC) curve (area under curve, AUC). The best diagnostic truncation value was determined according to the curve and the cut was determined. The sensitivity (sensitivity, SN) and specificity (specificity, SP) of the broken values were calculated, and the Youden index was calculated.
Result
1, the score of the death group was higher than the survival group in the single score of the 5 parameters of the HFRS severity score. The SIRS status of the death group, the plasma colloid osmotic pressure and the urinary protein concentration were all higher than those in the survival group (P0.05). The degree of exosmosis and platelet count in the death group were significantly higher than those in the survival group (P0.01).
2, in the SOFA score, SAPS II score and HFRS severity score, the scores in the death group were significantly higher than those in the survival group (P0.01).
3, SOFA score, SAPS II score and HFRS critical severity score were 0.7, respectively, 0.704,0.731 and 0.804.Youden index were the highest in HFRS critical disease score, SAPS II score was the second, and SOFA score was the lowest, respectively, when 0.535,0.421,0.352. when the truncated value of HFRS critical score was 10, the sensitivity of the patient to predict the risk of death was 78.. 8%, the specificity was 77.4%. application normal Z test to compare the HFRS critical severity score and the SAPS II score and the SOFA score AUC respectively. The difference was statistically significant (z=13.16, P0.05; z=29.68, P0.01).
conclusion
1, the setting of HFRS severity scoring parameters conforms to the characteristics of the pathophysiological changes in the clinical HFRS. Compared with the traditional score, it is more pertinent and operable, and the method is simple and quick.
2, HFRS severity score can predict the severity and prognosis of HFRS disease in the febrile period. It can better prompt clinicians to take preventive measures as early as possible.
3, when the optimal cut-off value of HFRS was 10, the sensitivity of predicting the risk of death during hospitalization was 78.8%, and the specificity was 77.4%.
4, SOFA score and SAPS II score have a certain clinical value in evaluating the prognosis of HFRS patients, but their sensitivity and specificity are significantly lower than that of plasma osmotic pressure, and the difference is statistically significant.
【学位授予单位】：山东大学
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R512.8

【参考文献】