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急性胰腺炎初期全身炎症反应综合征持续时间与感染性胰腺坏死的关系

严永峰 蒋鑫 钟瑞 徐欢 彭燕 汤小伟

严永峰, 蒋鑫, 钟瑞, 等. 急性胰腺炎初期全身炎症反应综合征持续时间与感染性胰腺坏死的关系[J]. 临床肝胆病杂志, 2021, 37(3): 654-659. DOI: 10.3969/j.issn.1001-5256.2021.03.029
引用本文: 严永峰, 蒋鑫, 钟瑞, 等. 急性胰腺炎初期全身炎症反应综合征持续时间与感染性胰腺坏死的关系[J]. 临床肝胆病杂志, 2021, 37(3): 654-659. DOI: 10.3969/j.issn.1001-5256.2021.03.029
YAN YF, JIANG X, ZHONG R, et al. Association of the duration of systemic inflammatory response syndrome with infectious pancreatic necrosis at the initial stage of acute pancreatitis [J]. J Clin Hepatol, 2021, 37(3): 654-659. DOI: 10.3969/j.issn.1001-5256.2021.03.029
Citation: YAN YF, JIANG X, ZHONG R, et al. Association of the duration of systemic inflammatory response syndrome with infectious pancreatic necrosis at the initial stage of acute pancreatitis [J]. J Clin Hepatol, 2021, 37(3): 654-659. DOI: 10.3969/j.issn.1001-5256.2021.03.029

急性胰腺炎初期全身炎症反应综合征持续时间与感染性胰腺坏死的关系

DOI: 10.3969/j.issn.1001-5256.2021.03.029
基金项目: 

西南医科大学附属医院博士科研启动基金资助项目 16229

泸州市人民政府西南医科大学科技战略合作项目 2019LZXNYDJ24

详细信息
    作者简介:

    严永峰(1994—),男,主要从事胰腺疾病的基础和临床研究

    通讯作者:

    汤小伟,583437126@qq.com

  • 利益冲突声明:本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突,特此声明。
  • 作者贡献声明:汤小伟负责课题设计;蒋鑫、钟瑞、徐欢参与收集数据和资料分析;严永峰负责拟定写作思路及撰写论文;彭燕、汤小伟指导撰写文章并最后定稿。
  • 中图分类号: R576

Association of the duration of systemic inflammatory response syndrome with infectious pancreatic necrosis at the initial stage of acute pancreatitis

  • 摘要:   目的  探究急性胰腺炎 (AP) 患者早期炎症反应与晚期感染性胰腺坏死(IPN)的潜在关系。  方法  回顾性纳入西南医科大学附属医院2019年6月—2020年6月收治的中度重症急性胰腺炎(MSAP)患者219例,重症急性胰腺炎(SAP)患者53例,根据起病初期是否合并全身炎症反应综合征(SIRS),分为SIRS组160例,非SRIS组112例。纳入基线资料、血清学指标、并发症及病死率。计量资料两组间比较采用t检验或Mann-Whitney U检验;计数资料组间比较采用χ2检验,多组间进一步两两比较采用Bonferroni法。logistic回归分析筛选有价值的变量,受试者工作特征曲线(ROC曲线)用于比较变量的诊断价值,ROC曲线下面积(AUC)的两两比较采用Z检验。  结果  SIRS组患者的WBC、CRP、降钙素原更高(P值均<0.05),SIRS组合并急性胰周坏死物聚集(ANC)、IPN、胰腺坏死(PN)、器官功能障碍(OF)、多器官功能障碍(MODS)、重症急性胰腺炎(SAP)、危重症急性胰腺炎(CAP)、死亡、BISAP评分>2、CTSI评分>2、RANSON评分>2的比例均高于非SIRS组(P值均<0.05)。单因素分析显示,SIRS持续时间、肥胖、CRP、WBC、血尿素氮、PN、ANC、SAP、MODS、RANSON评分、BISAP评分、CTSI评分均是AP患者发生IPN的影响因素(P值均<0.05);多因素分析显示,SIRS持续时间(OR=1.307,95%CI:1.081~1.580,P=0.006)、ANC(OR=42.247,95%CI:10.829~164.818,P<0.001)是IPN的危险因素,排除ANC时,SIRS持续时间(OR=1.430,95%CI:1.207~1.694,P<0.001)、PN(OR=5.296,95%CI:1.845~15.203,P=0.002)是IPN的危险因素。预测IPN的ROC曲线显示:SIRS持续时间(AUC=0.772,约登指数:0.521)、RANSON评分(AUC=0.701,约登指数:0.319)、BISAP评分(AUC=0.741,约登指数:0.377)、CTSI评分(AUC=0.765,约登指数:0.414)的AUC两两比较差异均无统计学意义(P值均>0.05)。超长时间SIRS组(>4 d)患者发生PN、ANC、IPN、SAP、CAP的比例均显著高于无SIRS组(0)、短暂性SIRS组(1~2 d)和持续性SIRS组(3~4 d)(P值均<0.05),持续性SIRS组患者发生SAP的比例高于无SIRS组(P<0.05)。  结论  AP患者早期合并SIRS时更容易发生器官功能衰竭及局部并发症,当SIRS持续时间>4.5 d时,患者发生IPN的风险显著增加。
  • 图  1  SIRS持续时间与AP病情评分预测IPN的ROC曲线

    表  1  两组AP患者基线资料比较

    项目 SIRS组(n=160) 非SIRS组(n=112) 统计值 P
    年龄(岁) 48(42~57) 48(42~54) Z=-0.343 0.731
    男性[例(%)] 105(65.6) 67(59.8) χ2=0.954 0.329
    病因[例(%)] χ2=1.067 0.785
      胆源性 65(40.6) 51(45.5)
      高脂血症性 64(40.0) 38(33.9)
      酒精性 15(9.4) 11(9.8)
      其他 16(10.0) 12(10.7)
    肥胖[例(%)] 75(46.9) 45(40.2) χ2=1.198 0.274
    吸烟史[例(%)] 64(40.0) 42(37.5) χ2=0.173 0.677
    2型糖尿病[例(%)] 32(20.0) 21(18.8) χ2=0.066 0.798
    高血压[例(%)] 51(31.9) 25(22.3) χ2=2.987 0.084
    下载: 导出CSV

    表  2  两组AP患者临床资料比较

    项目 SIRS组(n=160) 非SIRS组(n=112) 统计值 P
    血清学指标
      WBC(109/L) 14.88(12.25~18.68) 11.65(9.66~16.37) Z=-4.315 <0.001
      CRP (mg/L) 99.68(36.02~173.00) 47.21(7.62~104.64) Z=-3.973 <0.001
      PCT (ng/L) 0.35(0.13~1.46) 0.13(0.05~0.40) Z=-4.447 <0.001
      BUN(mmol/L) 5.17(3.81~7.24) 5.16(3.88~6.49) Z=-0.570 0.569
    并发症[例(%)]
      APFC 141(88.1) 105(93.8) χ2=2.411 0.120
      ANC 48(30.0) 20(17.9) χ2=5.181 0.023
      IPN 35(21.9) 9(8.0) χ2=9.306 0.002
      PN 50(31.3) 12(10.7) χ2=18.788 <0.001
      OF 45(28.1) 8(7.1) χ2=18.488 <0.001
      MODS 39(24.4) 4(3.6) χ2=21.423 <0.001
    疾病严重程度[例(%)]
      SAP 45(28.1) 8(7.1) χ2=10.210 0.001
      CAP 19(11.9) 1(0.9) χ2=11.664 0.001
      死亡 10(6.3) 1(0.9) χ2=4.872 0.027
    AP相关评分[例(%)]
      BISAP评分>2 40(25.0) 1(0.9) χ2=29.909 <0.001
      CTSI评分>2 140(87.5) 80(71.4) χ2=11.005 0.001
      RANSON评分>2 75(46.9) 13(11.6) χ2=37.422 <0.001
    下载: 导出CSV

    表  3  IPN的单因素回归分析

    项目 B SE Wald P OR 95%CI
    SIRS持续时间 0.429 0.067 40.674 <0.001 1.535 1.346~1.751
    胆源性AP(是=1,否=0) 0.573 0.331 2.990 0.084 1.774 0.926~3.397
    肥胖(是=1,否=0) 0.950 0.341 7.759 0.005 2.587 1.325~5.409
    PCT 0.013 0.007 3.121 0.077 1.013 0.999~1.207
    CRP 0.005 0.002 4.437 0.035 1.005 1.000~1.009
    WBC 0.152 0.034 20.589 <0.001 1.164 1.090~1.244
    BUN 0.083 0.040 4.411 0.036 1.087 1.006~1.174
    SAP(是=1,否=0) 1.594 0.357 19.995 <0.001 4.924 2.448~9.904
    APFC(是=1,否=0) 1.667 1.034 2.601 0.107 5.296 0.699~40.147
    PN(是=1,否=0) 2.436 0.370 43.438 <0.001 11.424 5.537~23.572
    ANC(是=1,否=0) 4.622 0.632 53.452 <0.001 101.741 29.466~351.289
    MODS(是=1,否=0) 1.866 0.373 25.004 <0.001 6.460 3.109~13.422
    BISAP评分 0.828 0.163 25.831 <0.001 2.288 1.663~3.149
    CTSI评分 0.510 0.098 27.365 <0.001 1.665 1.376~2.016
    RANSON评分 0.402 0.087 21.418 <0.001 1.494 1.261~1.772
    下载: 导出CSV

    表  4  IPN的多因素回归分析

    项目 B SE Wald P OR 95%CI
    回归方程1
      SIRS持续时间 0.267 0.097 7.613 0.006 1.307 1.081~1.580
      ANC(是=1,否=0) 3.744 0.695 29.050 <0.001 42.247 10.829~164.818
    回归方程2
      SIRS持续时间 0.358 0.086 17.135 <0.001 1.430 1.207~1.694
      WBC 0.023 0.013 3.238 0.072 1.024 0.998~1.050
      PN(是=1,否=0) 1.667 0.538 9.600 0.002 5.296 1.845~15.203
    下载: 导出CSV

    表  5  预测IPN的ROC曲线结果

    项目 AUC P 敏感度(%) 特异度(%) 约登指数 95%CI cut-off值
    SIRS持续时间 0.772 <0.001 59.09 92.98 0.521 0.718~0.821 4.5
    BISAP评分 0.741 <0.001 75.00 62.72 0.377 0.685~0.792 1.5
    RANSON评分 0.701 <0.001 59.09 72.81 0.319 0.643~0.755 2.5
    CTSI评分 0.765 <0.001 54.55 86.84 0.414 0.710~0.810 7.0
    下载: 导出CSV

    表  6  根据SIRS持续时间分组比较

    项目 无SIRS组(n=112) 短暂性SIRS组(n=54) 持续性SIRS组(n=64) 超长时间SIRS组(n=42) χ2 P
    PN[例(%)] 12(10.7)1) 6(11.1)1) 13(20.3)1) 31(73.8) 75.811 <0.001
    ANC[例(%)] 20(17.9)1) 4(7.4)1) 11(17.2)1) 33(78.6) 78.330 <0.001
    IPN[例(%)] 9(8.0)1) 3(5.6)1) 6(9.4)1) 26(61.9) 76.919 <0.001
    SAP[例(%)] 8(7.1)1)2) 6(11.1)1) 15(23.4)1) 24(57.1) 51.890 <0.001
    CAP[例(%)] 1(0.9)1) 1(1.9)1) 2(3.1)1) 16(38.1) 69.207 <0.001
    注:与超长时间SIRS组比较,1)P<0.05;与持续性SIRS组比较,2)P<0.05。
    下载: 导出CSV
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  • 收稿日期:  2020-08-27
  • 修回日期:  2020-10-20
  • 刊出日期:  2021-03-16
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