目的: 探讨生物标志物联合检测对脓毒症相关急性肝损伤患者的早期诊断和预后评估的价值。方法: 收集内蒙古科技大学包头医学院第一附属医院重症医学科(ICU)2019年11月-2022年1月收治的104例脓毒症患者临床资料,按照入ICU时是否发生急性肝损伤分为脓毒症相关急性肝损伤组(n=42)和非肝损伤组(n=62),将脓毒症相关急性肝损伤患者按28 d是否存活分为存活组(n=16)和死亡组(n=26),记录104例患者入ICU 6 h内血清正五聚蛋白3(PTX-3)、C-反应蛋白(CRP)、降钙素原(PCT)、总胆红素(TBIL)、谷草转氨酶(AST)、谷丙转氨酶(ALT)、凝血酶原时间国际标准化比值(INR值)、凝血酶原时间(PT)、凝血酶原活动度(PTA)、血小板(PLT)、入ICU 24 h内急性生理与慢性健康状况评估量表II(APACHEII)评分最差值及序贯器官衰竭评估(SOFA)评分;同时记录脓毒症相关急性肝损伤患者28 d预后。PTX-3的相关性采用Spearman 相关分析;绘制受试者工作特征曲线(ROC曲线),计算ROC曲线下面积(AUC),分析各指标单独检测以及联合检测对脓毒症相关急性肝损伤患者的诊断价值以及对其不良预后的预测效果。结果: 脓毒症相关急性肝损伤组血清PTX-3、CRP、PCT、TBIL、AST、ALT、INR值、PT、APACHEII评分、SOFA评分高于非肝损伤组,PTA、PLT低于非肝损伤组,差异具有统计学意义(均P＜0.05);Spearman 相关分析显示,PTX-3与APACHEII评分及SOFA评分均呈显著正相关。ROC曲线分析显示,TBIL、INR值、PTX-3对脓毒症相关急性肝损伤的诊断效能相近,优于其他指标;三者联合检测诊断的效能更高(AUC=0.945),敏感度为85.7 %,特异度为95 %。死亡组患者血清PTX-3、CRP、PCT、TBIL、AST、ALT、INR值、PT、APACHEII评分、SOFA评分均高于存活组,PTA、PLT低于存活组,差异具有统计学意义(均P＜0.05)。ROC曲线分析显示,PTX-3对脓毒症相关急性肝损伤患者28 d死亡的评估效能优于其他指标;PTX-3联合TBIL及INR值的AUC可达0.913,敏感度为96 %,特异度为75 %。结论: PTX-3同TBIL、INR值一样是早期诊断脓毒症相关急性肝损伤良好的生物标志物,3个指标单独检测效果相近,三者联合检测可明显提高对脓毒症相关急性肝损伤患者的早期诊断价值;PTX-3与病情危重程度相关,PTX-3对脓毒症相关急性肝损伤患者28 d死亡的预测效能最高,且PTX-3联合TBIL、INR可以提高脓毒症相关急性肝损伤患者28 d预后的预测能力。另外发现PLT的减少可能是脓毒症相关急性肝损伤的独立因素。
Objective: To investigate the early diagnosis and prognosis value of biomarker combination test in patients with sepsis-associated acute liver injury. Methods: The clinical data of 104 sepsis patients admitted to the Intensive Care Unit (ICU) of Baotou First Affiliated Hospital of Inner Mongolia University of Science and Technology from November 2019 to January 2022 were collected. Selected cases were divided into sepsis-associated acute liver injury group (n=42) and non-liver injury group (n=62) based on acute liver injury occurring or not when entering ICU. Patients with septic acute liver injury were divided into survival groups (n=16) and death groups (n=26) after 28 days of survival. The sera pentraxin-3 (PTX-3), c-reactive protein (CRP), procalcitonin (PCT), total bilirubin (TBIL), glutamic-oxal(o)acetic transaminase (AST), glutamate pyruvate transaminase (ALT), international normalized ratio (INR value), prothrombin time (PT), prothrombin activity (PTA), platelet (PLT) of the 104 patients were recorded within 6h after entering ICU, the worst score of acute physiology and chronic health assessment scale Ⅱ(APACHE Ⅱ) score and sequential organ failure assessment (SOFA) grade within 24 hours was recorded after entering the ICU. The 28 d prognosis of patients with sepsis-related acute liver injury was also recorded. The correlation of PTX-3 was analyzed using Spearman correlation coefficient. The receiver operating characteristic curve (ROC curve) was also drawn, and the area under the roc curve (AUC) was calculated. The diagnosis and prognosis value of individual detection and combined testing on sepsis-related acute liver injury were analyzed and evaluated. Results: The levels of serum PTX-3, CRP, PCT, TBIL, AST and ALT, INR value, PT, APACHE Ⅱ score and SOFA score were significantly higher in the sepsis-associated acute liver injury group than those in the non-liver injury group, PTA and PLT level were lower than that in the non-liver injury group (P＜0.05). The Spearman correlation analysis result showed that a significant positive correlation between PTX-3 level and APACHE Ⅱ score and SOFA score. The ROC curve analysis results showed that the diagnostic efficacy of TBIL level, INR value and PTX-3 level were similar for sepsis-associated acute liver injury, which were outperformed the other indicators. The combination testing of the three indicators was more effective (AUC=0.945), with the sensitivity of 85.7 % and the specificity of 95 %. The levels of serum PTX-3, CRP , PCT, TBIL, AST and ALT, INR value, PT, APACHE Ⅱ score and SOFA score in the death group were significantly higher than those in the survival group, but PTA and PLT level were lower than that in the survival group (P＜0.05). The ROC curve analysis results showed that the diagnostic efficacy of PTX-3 level was better for 28 d death of sepsis-associated acute liver injury than other indicators. AUC of combination of PTX-3 level and TBIL and INR value reached 0.913, with the sensitivity of 96 % and the specificity of 75 %. Conclusion: The PTX-3 level, TBIL level and INR value are helpful biomarkers for early diagnosis of sepsis-associated acute liver injury, which could obviously improve the early diagnostic value in patients with sepsis-associated acute liver injury. The diagnostic efficacy of PTX-3 level, TBIL level and INR value were similar for sepsis-associated acute liver injury. PTX-3 level is related to severity, and the highest prognostic value on 28 d death of sepsis-associated acute liver injury, and combination testing on PTX-3 level, TBIL level and INR value could improve the 28-day prognosis of patients with acute liver injury. Meanwhile, the reduction of PLT level may be independently correlated with sepsis-associated acute liver injury.
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