CAJ | 학술논문

目的探讨D-二聚体浓度能否预测急诊脓毒症患者28 d病死率,以及D-二聚体浓度对于脓毒症患者预后的意义.方法采用前瞻性研究方法,选取2009年10月至2010年7月首都医科大学附属北京朝阳医院急诊科766例脓毒症患者,检测患者入院时的血中D-二聚体浓度(固相免疫层析法),并记录各项实验室检测指标和临床生理指标.以28 d为终点比较存活组与死亡组患者的D-二聚体水平、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分和简化急性生理学评分系统Ⅱ(SAPSⅡ)评分；分析D-二聚体水平与28 d病死率的关系.结果 766例脓毒症患者28 d内共有233例死亡,死亡组血中D-二聚体浓度(μg/L)明显高于存活组[1220.0(789.0,1835.0)比323.0(158.0,642.0),P＜0.01].D-二聚体水平与APACHEⅡ评分和SAPSⅡ评分均呈显著正相关(r1=0.643,r2=0.632,均P＜0.01).D-二聚体水平预测28 d病死率的受试者工作特征曲线(ROC曲线)下面积为0.880,95％可信区间(95％CI)为0.855～0.904,P＜0.001,预测28 d病死率的最佳界值为663.5 μg/L.血中D-二聚体＞663.5μg/L、APACHEⅡ评分＞19.5分和SAPSⅡ评分＞39.5分是预测患者28 d病死率的独立危险因素[优势比(OR值)分别为17.5、15.7、19.6,均P＜0.001].D-二聚体＜ 250.0、250.0～663.5、＞663.5 μg/L 3组间28 d病死率(1.4％、12.3％、64.2％)、APACHEⅡ评分[分:11(9,13)、13(11,16)、19(15,22)]、SAPSⅡ评分[分:24(18,29)、31(24,36)、40(33,49)]比较差异均有统计学意义(均P＜0.01).结论 D-二聚体水平是预测急诊脓毒症患者28 d病死率的独立指标.其预测能力与APACHEⅡ评分和SAPSⅡ评分十分相近；检测D-二聚体水平有助于脓毒症患者的危险分层.
목적 탐토D-이취체농도능부예측급진농독증환자28 d병사솔,이급D-이취체농도대우농독증환자예후적의의.방법 채용전첨성연구방법,선취2009년10월지2010년7월수도의과대학부속북경조양의원급진과766례농독증환자,검측환자입원시적혈중D-이취체농도(고상면역층석법),병기록각항실험실검측지표화림상생리지표.이28 d위종점비교존활조여사망조환자적D-이취체수평、급성생이학여만성건강상황평분계통Ⅱ(APACHEⅡ)평분화간화급성생이학평분계통Ⅱ(SAPSⅡ)평분；분석D-이취체수평여28 d병사솔적관계.결과 766례농독증환자28 d내공유233례사망,사망조혈중D-이취체농도(μg/L)명현고우존활조[1220.0(789.0,1835.0)비323.0(158.0,642.0),P＜0.01].D-이취체수평여APACHEⅡ평분화SAPSⅡ평분균정현저정상관(r1=0.643,r2=0.632,균P＜0.01).D-이취체수평예측28 d병사솔적수시자공작특정곡선(ROC곡선)하면적위0.880,95％가신구간(95％CI)위0.855～0.904,P＜0.001,예측28 d병사솔적최가계치위663.5 μg/L.혈중D-이취체＞663.5μg/L、APACHEⅡ평분＞19.5분화SAPSⅡ평분＞39.5분시예측환자28 d병사솔적독립위험인소[우세비(OR치)분별위17.5、15.7、19.6,균P＜0.001].D-이취체＜ 250.0、250.0～663.5、＞663.5 μg/L 3조간28 d병사솔(1.4％、12.3％、64.2％)、APACHEⅡ평분[분:11(9,13)、13(11,16)、19(15,22)]、SAPSⅡ평분[분:24(18,29)、31(24,36)、40(33,49)]비교차이균유통계학의의(균P＜0.01).결론 D-이취체수평시예측급진농독증환자28 d병사솔적독립지표.기예측능력여APACHEⅡ평분화SAPSⅡ평분십분상근；검측D-이취체수평유조우농독증환자적위험분층.
Objective To investigate the value of the concentration of D-dimer in predicting 28-day mortality of sepsis patients in emergency department in order to determine its prognostic values.Methods A prospective study was conducted.A total of 766 sepsis patients treated in the emergency department of Beijing Chaoyang Hospital of the Capital Medical University from October 2009 to July 2010 were enrolled,and admission blood samples were obtained for D-dimer measurement(solid phase immune chromatography).A variety of clinical and laboratory variables were recorded.With 28 days as end point,the D-dimer levels,acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ)score,and simplify acute physiology score Ⅱ(SAPS Ⅱ)were compared respectively between survivors and non-survivors.The status of each patient was ascertained,and the association between the concentration of D-dimer and 28-day mortality was assessed.Results Two hundred and thirty-three patients died during the 28-day observation period among 766 patients.D-dimer concentration(μg/L)among deceased were significantly higher than those of survivors[1220.0(789.0,1835.0)vs.323.0(158.0,642.0),P＜0.01].The level of D-dimer showed positive correlation with APACHE Ⅱ score and SAPS Ⅱ(r1=0.643,r2=0.632,both P＜0.01).D-dimer concentration had an area under the receiver operating characteristic(ROC)curve(AUC)of 0.880 for predicting 28-day mortality,with 95％ confidence interval(95％ CI)0.855-0.904,P＜0.001; the optimal D-dimer cut point for predicting 28-day mortality was 663.5 μg/L.D-dimer concentration higher than 663.5 μg/L,APACHE Ⅱ score higher than 19.5 and SAPS Ⅱ higher than 39.5 were the independent predictors of 28-day mortality[odds ratio(OR):17.5,15.7,19.6,all P＜0.001].The 28-day mortality(1.4％,12.3％,64.2％),APACHEⅡ score[11(9,13),13(11,16),19(15,22)]and SAPS Ⅱ[24(18,29),31(24,36),40(33,49)]showed statistically significant among D-dimer ＜250.0,250.0-663.5,＞663.5 μg/L three groups(all P ＜0.01).Conclusions D-dimer concentration is an independent predictor of 28-day mortality in patients with sepsis.D-dimer level shows a high predictive value in patients with sepsis,similar to APACHE Ⅱ score and SAPS Ⅱ.It can be helpful in risk stratification in septic patients.