应用血栓弹力图评估儿童系统性红斑狼疮的出凝血紊乱状态的研究

发布时间：2018-04-03 11:01

本文选题：系统性红斑狼疮　切入点：血栓弹力图　出处：《北京协和医学院》2013年硕士论文

【摘要】：目的应用血栓弹力图(Thrombelastography, TEG)检测系统性红斑狼疮(Systemic lupus erythematosus, SLE)患儿的总体出凝血紊乱状态,探讨SLE患儿不同的疾病状态与出凝血的关系,评价糖皮质激素对SLE患儿出凝血状态的影响,以期利用简便高效的TEG监测SLE患儿临床出血或血栓事件,并指导临床针对性用药。方法选取明确诊断的SLE患儿51例,正常对照10例,结合SLE患儿临床表现和各项实验室指标,按照SLEDAI评分进行病情状态分组。采用对照分析的方法,分别对糖皮质激素治疗前、后,以及疾病活动期、缓解期的患儿进行TEG检测。分析SLE患儿与正常人,不同疾病活动状态下SLE患儿TEG结果的差异。糖皮质激素应用不同时间、剂量等对SLE患儿TEG结果的影响。结果 1.56例入选患儿中,1例发生出血,2例发生血栓事件,其TEG的图形显著地不同。 2. SLE患儿TEG结果分析：与正常对照组相比,SLE患儿TEG中R、K缩短,α角增大(即凝血因子激活增强,血凝块形成速率增快),LY30减小(即纤维蛋白溶解减弱),CI增大,凝血功能整体呈高凝状态(P0.05)。 3.疾病活动状态与TEG相关分析：重度活动SLE患儿与基本无活动患儿相比,R、K明显地缩短,α角、CI显著地增大(P0.01)；重度活动SLE患儿与轻度活动患儿相比,R、K明显地缩短,α角、CI显著地增大(P0.01),显示凝血状态比活动度较轻的患儿呈高凝状态。SLEDAI评分与TEG中R、K呈负相关(r=-0.532,-0.457,P均0.01),与α角、CI呈正相关(r=0.535,0.520,P均0.01)。 4.血小板计数与TEG中MA的关系：血小板增多组较血小板正常组MA明显增大(P0.01)。血小板减少组与血小板正常组相比,MA值差异无明显统计学意义(P0.05)。 5.糖皮质激素治疗对SLE患儿凝血状态的影响的研究：应用激素时间不同SLE患儿的TEG结果差异无统计学意义(P0.05)。足量激素组比小剂量组R缩短(P0.01),MA增大(P0.01)。TEG其他参数上差异无统计学意义(P0.05)。行甲基强的松龙冲击治疗的SLE患儿冲击治疗前后TEG结果差异无统计学意义(P0.05),但有2例患儿冲击治疗后发生血栓事件。结论 1.SLE患儿体内出凝血呈紊乱状态,既可表现为高凝和血栓,也可表现为出血,通过TEG可以清晰地检测出来。 2.SLE患儿与正常人比,总体凝血状态呈高凝,由凝血因子激活增强(R缩短)、血凝块形成速率增快(K缩短,α角增大)以及纤维蛋白溶解减弱(LY30减小)所造成。 3.SLE患儿凝血状态与疾病活动度程度相关,活动度高者高凝状态更明显,随着SLEDAI评分的增加,凝血因子激活增强(R缩短)、血凝块形成速率增快(K缩短,α角增大),总体凝血功能更偏向高凝状态。 4.血小板增多的SLE患儿与血小板计数正常者相比,血凝块强度增强(MA增大)；血小板减少的SLE患儿与血小板计数正常者相比,血凝块强度并无减低。提示血小板减少的SLE患儿无明显的出血倾向。 5.激素应用剂量对SLE患儿凝血状态有影响,足量激素组比小剂量组凝血因子激活增强,血凝块强度增大。大剂量甲基强的松龙冲击前后,SLE患儿的TEG虽无统计学差异,但冲击治疗后有血栓事件的发生,需要动态监测出凝血状态的变化。 6.推荐TEG作为评价SLE出凝血紊乱状态的方便易行的总体指标。
[Abstract]:objective
Application of Thrombelastogram (Thrombelastography, TEG) in patients with systemic lupus erythematosus (Systemic lupus, erythematosus, SLE) in the whole blood coagulation disorder, to investigate the disease status of children with SLE and the relationship between different blood coagulation, evaluation of glucocorticoid on SLE patients influence the coagulation state, in order to make use of convenient and efficient TEG monitoring SLE children with clinical bleeding or thrombotic events, and to guide clinical targeted drugs.
Method
A total of 51 cases of SLE were diagnosed, 10 cases of normal controls, combined with SLE patients clinical and laboratory indicators, according to the SLEDAI score of the disease state. The control packet analysis method respectively before glucocorticoid therapy, and disease activity, after remission were detected by TEG SLE analysis. Children and normal people, the difference of SLE in children with TEG disease activity results in different conditions. Application of glucocorticoid for different periods of time and dose effect on SLE in children with TEG results.
Result
Of the 1.56 children, 1 had bleeding and 2 had thrombus events, and the figures of TEG were significantly different.
The results of TEG analysis of 2. SLE children: compared with the normal control group, R and K in TEG of SLE patients were shortened, and the alpha angle increased (i.e. coagulation factor activation increased, blood clotting rate increased), LY30 decreased (fibrinolysis decreased), CI increased, and coagulation function showed hypercoagulable state (P0.05).
3. disease activity status and TEG correlation analysis: severe active SLE patients and no active children compared to R, K decreased, CI alpha angle, significantly increased (P0.01); severe active SLE patients compared with mild activity in children with R, K significantly shortened, alpha angle, CI significantly increased (P0.01), showed coagulation activity less than patients with hypercoagulable state and.SLEDAI score in TEG R, K was negatively correlated (r=-0.532, -0.457, P 0.01), and the alpha angle, CI was positively correlated (r=0.535,0.520, P 0.01).
4., the relationship between platelet count and MA in TEG: MA in thrombocytosis group was significantly higher than that in platelet normal group (P0.01). There was no significant difference in MA between thrombocytopenia group and normal platelet group (P0.05).
5. study on the effects of glucocorticoid therapy on blood coagulation in children with SLE: no significant use of hormone in children with SLE TEG results in different time difference (P0.05). The adequate amount of hormone group than in low dose group (P0.01), R shortened MA increases (P0.01).TEG on the other parameters had no significant difference (P0.05). Statistical significance before and after SLE treatment in children with shock stosstherapy for methyl strong differences in outcome of TEG (P0.05), thrombotic events but with shock treatment in 2 cases.
conclusion
The blood clotting of 1.SLE children is in disorder state, which can be manifested as hypercoagulability and thrombus, and may also be manifested as bleeding. It can be clearly detected by TEG.
Compared with normal controls, the overall coagulation state of 2.SLE children is hypercoagulable, increased by coagulation factor activation (R shortening), and the rate of blood clots growth is increased (K shortening, alpha angle increasing) and fibrinolysis (LY30 decrease).
The coagulation status of children with 3.SLE is related to the degree of disease activity. The hypercoagulability state is more obvious in those with high activity. With the increase of SLEDAI score, coagulation factor activation is enhanced (R shortening), the rate of blood clots growth is increased (K shortens, alpha Jiao Zengda), and the overall coagulation function is more highly hypercoagulable.
4., compared with those with normal platelet count, the blood clot intensity increased (MA increased) in SLE children with thrombocytopenia. The blood clot intensity of SLE children with thrombocytopenia was not decreased compared with those with normal platelet count. There was no obvious bleeding tendency in SLE children with thrombocytopenia.
5. application of hormone dose effect on SLE blood coagulation state, enough hormone group than in low dose group of blood coagulation factor activation, increased blood clot strength. Before and after high dose methylprednisolone, TEG have no statistical difference with SLE, but the occurrence of thrombotic events after the treatment of shock, need a dynamic monitoring of changes of blood coagulation.
6. TEG is recommended as a convenient and easy general indicator for evaluating the state of coagulation disorders in SLE.

【学位授予单位】：北京协和医学院
【学位级别】：硕士
【学位授予年份】：2013
【分类号】：R725.5

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