廖小龍 郭偉新 王中華 梁駿 王首紅
[摘要]目的 探討降鈣素原(PCT)、C反應(yīng)蛋白(CRP)與線(xiàn)粒體DNA(mt-DNA)水平檢測(cè)在老年膿毒癥多器官功能衰竭(MODSE)病情評(píng)估中的應(yīng)用價(jià)值。方法 選取2014年1月~2016年12月我院收治的62例老年膿毒癥患者,將其中合并器官功能衰竭的29例患者設(shè)為衰竭組,未合并器官功能衰竭的33例患者設(shè)為未衰竭組;選取同期的30例正常體檢者作為對(duì)照組。比較三組受檢者的PCT、CRP、mt-DNA水平差異。結(jié)果 膿毒癥患者的PCT、CRP、mt-DNA水平均顯著高于對(duì)照組(P<0.05),衰竭組的mt-DNA、PCT水平顯著高于未衰竭組(P<0.05),但衰竭組的CRP水平與未衰竭組比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。根據(jù)器官衰竭情況進(jìn)一步分組,分為單器官衰竭組(11例)、雙器官衰竭組(9例)、三個(gè)及以上器官衰竭組(9例),隨著衰竭器官數(shù)量的增多,患者的mt-DNA、PCT水平也顯著增高,各組間比較差異均有統(tǒng)計(jì)學(xué)意義(P<0.05),但各組間CRP水平比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論 PCT、CRP及mt-DNA均能提示老年患者膿毒癥的發(fā)生,PCT、mt-DNA水平測(cè)定不但能夠用于膿毒癥的診斷,更能夠用于老年膿毒癥患者器官功能衰竭情況的評(píng)估,值得在臨床中推廣和應(yīng)用。
[關(guān)鍵詞]膿毒癥;多器官功能衰竭;老年;降鈣素原;C反應(yīng)蛋白;線(xiàn)粒體DNA
[中圖分類(lèi)號(hào)] R592 [文獻(xiàn)標(biāo)識(shí)碼] A [文章編號(hào)] 1674-4721(2017)10(c)-0123-03
Application of procalcitonin,C-reactive protein and mitochondrial DNA level test in the assessment of multiple organ dysfunction in elderly patients with sepsis
LIAO Xiao-long GUO Wei-xin WANG Zhong-hua LIANG Jun WANG Shou-hong
Institute of Geriatrics,People′s Hospital of Guangdong Province (Guangdong Academy of Medical Sciences),Guangzhou 510080,China
[Abstract]Objective To explore the application values of procalcitonin (PCT),C-reactive protein (CRP) and mitochondrial DNA (mt-DNA) level test in the assessment of multiple organ dysfunction in multiple organ dysfunction in elderly (MODSE) patients with sepsis.Methods From January 2014 to December 2016,62 elderly patients with sepsis admitted into our hospital were selected as research objects.Among them,29 patients complicated with organ failure were classified into the failure group,and the rest was categorized into the non-failure group.Meanwhile,another group of 30 healthy participants after physical examinations was classified into the control group.The differences of PCT,CRP,and mt-DNA levels were compared.Results The levels of PCT,CRP and mt-DNA levels in sepsis patients were significantly higher than those in the control group (P<0.05).The levels of mt-DNA and PCT in the failure group were significantly higher than those in the non-failure group (P<0.05).But,there was no great difference in CRP between the failure group and the non-failure group (P>0.05).According to the conditions of organ failure,the patients were further divided into the single-organ failure group (n=11),the double-organ failure group (n=9),and the three or above organ failure group (n=9).With the increased number of failure organs,the levels of mt-DNA and PCT were greatly increased,which were displayed statistical significance between inter-group comparison (P<0.05),the CRP level was not in a statistical difference after comparison (P>0.05).Conclusion Procalcitonin,CRP and mt-DNA all can indicate the occurrence of sepsis in elderly patients.Test of PCT and mt-DNA levels can not only be used in the diagnosis of sepsis,but also to evaluate the MODSE patients with sepsis,which is worthy of clinical promotion and application.endprint
[Key words]Sepsis;Multiple organ dysfunction;Elderly;Procalcitonin;C-reactive protein;Mitochondrial DNA
膿毒癥是感染引起的全身炎癥反應(yīng)綜合征,具有復(fù)雜的生理病理機(jī)制,此類(lèi)疾病發(fā)病快、進(jìn)展迅速,死亡率高,且患者易出現(xiàn)休克及多器官功能衰竭等情況,因此膿毒癥的早期病情評(píng)估對(duì)于患者的預(yù)后而言十分重要[1]。近年來(lái)生物標(biāo)志物的應(yīng)用給膿毒癥的診斷和評(píng)估提供了新的思路,目前臨床常用的膿毒癥評(píng)估指標(biāo)包括降鈣素原(PCT)、C反應(yīng)蛋白(CRP)、乳酸等,但這些指標(biāo)具有一定的局限性[2]。線(xiàn)粒體DNA(mt-DNA)是血漿中可檢測(cè)到的游離DNA片段,主要是由于細(xì)胞壞死或凋零釋放,也有部分為主動(dòng)分泌釋放,在正常人體血漿中含量較低。近年來(lái)關(guān)于mt-DNA水平檢測(cè)在多種疾病診斷上均有較好應(yīng)用[3],但國(guó)內(nèi)關(guān)于mt-DNA水平與膿毒癥相關(guān)性的研究報(bào)道尚少。本文就PCT、CRP、mt-DNA水平檢測(cè)在膿毒引起的老年膿毒癥多器官功能衰竭(multiple organ dysfunction syndrome in the elderly,MODSE)評(píng)估中的應(yīng)用效果進(jìn)行研究評(píng)價(jià),現(xiàn)報(bào)道如下。
1資料與方法
1.1一般資料
選取2014年1月~2016年12月轉(zhuǎn)入或入住我科的62例老年膿毒癥患者,將其中合并器官功能衰竭的29例患者設(shè)為衰竭組,未合并器官功能衰竭的33例患者設(shè)為未衰竭組;選取同期的30例正常體檢者作為對(duì)照組。衰竭組中,男性15例,女性14例;年齡70~92歲,平均(79.4±2.5)歲。未衰竭組中,男性17例,女性16例;年齡71~90歲,平均(79.2±2.6)歲。對(duì)照組中,男性16例,女性14例;年齡70~91歲,平均(79.5±2.9)歲。三組受檢者均知情同意參與研究,一般資料比較差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。本研究經(jīng)醫(yī)院醫(yī)學(xué)倫理委員會(huì)審批通過(guò)。
1.2方法
患者轉(zhuǎn)入或入住ICU后進(jìn)行常規(guī)檢查,包括CRP、PCT檢測(cè),收集臨床檢驗(yàn)中的這兩項(xiàng)數(shù)據(jù)。另外再取患者靜脈血2 ml置于EP管中,室溫下靜置30 min,3000 r/min下離心10 min,將上層血漿轉(zhuǎn)移至另外一個(gè)潔凈EP管中,再于10000 r/min下離心10 min,完全去除細(xì)胞成分后將上層血漿轉(zhuǎn)移至凍存管中,置于-80℃條件下保存?zhèn)溆?。采用?shí)時(shí)熒光定量檢驗(yàn)進(jìn)行mt-DNA水平測(cè)定,引物序列參照Butt等[4]的文獻(xiàn),上游引物:CACAGAAGCTGCCATCAAGTA,下游引物:CCGGAGAGTATATTGTTGAAGAG。試劑盒由Qiagen公司提供,檢測(cè)過(guò)程嚴(yán)格按照試劑說(shuō)明書(shū)進(jìn)行操作。
1.3觀(guān)察指標(biāo)
比較三組受檢者的PCT、CRP及mt-DNA水平差異。將衰竭組患者根據(jù)衰竭器官數(shù)量進(jìn)行進(jìn)一步分組,對(duì)比不同衰竭器官數(shù)量患者的PCT、CRP及mt-DNA水平差異。
1.4統(tǒng)計(jì)學(xué)方法
采用SPSS 20.0統(tǒng)計(jì)學(xué)軟件對(duì)數(shù)據(jù)進(jìn)行處理,計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(x±s)表示,組間比較采用方差分析,檢驗(yàn)水平α=0.05。
2結(jié)果
2.1三組患者PCT、CRP、mt-DNA水平的比較
膿毒癥患者(衰竭組與未衰竭組)的PCT、CRP、mt-DNA水平均顯著高于對(duì)照組(P<0.05),衰竭組的mt-DNA、PCT水平顯著高于未衰竭組(P<0.05),但衰竭組的CRP水平與未衰竭組比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)(表1)。
2.2不同衰竭器官數(shù)量患者PCT、CRP、mt-DNA水平的比較
根據(jù)器官衰竭情況進(jìn)一步分組,隨著衰竭器官數(shù)量的增多,患者的mt-DNA、PCT水平也顯著增高,各組間比較差異有統(tǒng)計(jì)學(xué)意義(P<0.05),但各組間的CRP水平比較,差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)(表2)。
3討論
膿毒癥具有發(fā)病急、進(jìn)展快、預(yù)后差的特點(diǎn),多見(jiàn)于兒童。對(duì)于老年膿毒癥患者而言,由于身體各項(xiàng)功能均出現(xiàn)衰退,發(fā)生器官衰竭的可能性也有所增加。PCT被廣泛用于感染性疾病的診斷,能夠反映全身性炎癥反應(yīng)的活躍程度,一般而言,影響PCT水平的因素主要包括感染器官的大小和類(lèi)型等,但Dwivedi等[5]的研究顯示,在胰島素抵抗患者血清中也能發(fā)現(xiàn)PCT水平的異常增高,因此認(rèn)為PCT并非針對(duì)傳統(tǒng)意義上的急性感染而發(fā)生改變,而是發(fā)生在感染性和自身免疫性炎癥水平以下的炎癥反應(yīng)中。CRP屬于一種急性時(shí)相反應(yīng)蛋白,對(duì)于各種炎癥反應(yīng)均有較高的敏感性,當(dāng)CRP水平增高時(shí)往往提示慢性免疫系統(tǒng)被激活。CRP屬于多功能蛋白,能夠激活蛋白Ⅰ/核因子K*的信號(hào)傳導(dǎo)通路,從而導(dǎo)致酪氨酸磷酸化過(guò)程異常,Gloria等[6]的研究顯示,膿毒癥患者隨著癥狀的加深,CRP水平也會(huì)表現(xiàn)出明顯的上升。目前關(guān)于PCT、CRP與膿毒癥的關(guān)系已有報(bào)道,但主要集中在診斷應(yīng)用上[7-9]。
Mt-DNA是由線(xiàn)粒體分泌的一種遺傳物質(zhì),在不同組織中的變化很大,一般而言,正常人體血漿內(nèi)的mt-DNA水平極低,而當(dāng)組織細(xì)胞出現(xiàn)大面積的壞死、凋零時(shí),mt-DNA會(huì)被釋放入血,導(dǎo)致血漿mt-DNA水平的增高[10-12]。mt-DNA由于缺乏組蛋白的保護(hù),且無(wú)對(duì)應(yīng)的修復(fù)機(jī)制,因此當(dāng)感染誘發(fā)炎癥反應(yīng)時(shí)mt-DNA會(huì)被氧自由基和其他毒性物質(zhì)損傷,同時(shí)線(xiàn)粒體遭到破壞,mt-DNA被釋放入血,導(dǎo)致循環(huán)中游離的mt-DNA及碎片增多[13-15]。從本次研究數(shù)據(jù)來(lái)看,膿毒癥患者的PCT、CRP及mt-DNA水平顯著高于正常人群,但CRP并不能反應(yīng)患者是否發(fā)生器官衰竭。從進(jìn)一步的研究來(lái)看,CRP水平與器官衰竭數(shù)量無(wú)關(guān),但PCT、mt-DNA不但能夠反映膿毒癥患者是否合并器官衰竭,同時(shí)也能夠反應(yīng)器官衰竭的數(shù)量??紤]原因可能是由于組織器官出現(xiàn)損傷時(shí)血漿mt-DNA水平增高,且受累器官越多,損傷越重則游離mt-DNA也就越多,而CRP只能反應(yīng)機(jī)體的炎癥進(jìn)展。endprint
綜上所述,PCT、CRP及mt-DNA均能提示老年患者膿毒癥的發(fā)生,mt-DNA水平測(cè)定不但能夠用于膿毒癥的診斷,更能夠用于老年膿毒癥患者器官功能衰竭情況的評(píng)估,值得在臨床中推廣和應(yīng)用。
[參考文獻(xiàn)]
[1]Sj■vall F,Morota S,Persson J,et al.Patients with sepsis exhibit increased mitochondrial respiratory capacity in peripheral blood immune cells[J].Crit Care,2013,17(4):R152.
[2]Pyle A,Burn DJ,Gordon C,et al.Fall in circulating mononuclear cell mitochondrial DNA content in human sepsis[J].Intensive Care Med,2010,36(6):956-962.
[3]Simmon JD,Yann LL,Sujata M,et al.Elevated levels of plasma mitochondrial DNA DAMPs are linked to clinical outcome in severely injured human subjects[J].Ann Surg,2013,258(4):591-598.
[4]Butt AN,Swaminathan R.Overview of circulating nucleic acids in plasma Serum[J].Ann N Y Acad Sci,2008,1137(10):236-242.
[5]Dwivedi DJ,Toltl LJ,Swystun LJ,et al.Prognostic utility and characterization of cell-free DNA in patients with severe sepsis[J].Crit Care,2012,16(4):R151.
[6]Gloria G,Constanza M,Sonia L,et al.The effects of sepsis on mitochondria[J].J Infect Dis,2012,205(1):392-400.
[7]龔平,李春盛.膿毒癥和線(xiàn)粒體功能障礙[J].中華危重病急救醫(yī)學(xué),2013,25(4):254-256.
[8]Avital A,Maya PW,Yaniv A,et al.Admission cell free DNA levels predict 28-day mortality in patients with severe sepsis in intensive care[J].PLoS One,2014,9(6):e100514.
[9]Kung CT,Hsiao SY,Tsai TC,et al.Plasma nuclear and mitochondrial DNA levels as predictors of outcome in severe sepsis patients in the emergency room[J].J Transl Med,2012,21(10):1-8.
[10]Jon D,Simmon MD,Yann LL,et al.Elevated levels of plasma mitochondrial DNA DAMPs are linked to clinical outcome in severely injured human subjects[J].Ann Surg,2013,258(4):591-598.
[11]Bouchon A,F(xiàn)acchetti F,Weigand MA,et al.TREM-1 amplifies inflammation and is a crucial mediator of septic shock[J].Nature,2011,420(6):1103-1107.
[12]Gibot S,Kolopp-Sarda MN,Be′ne′ MC,et al.Plasma level of a triggering receptor expressed on myeloid cells-1:its diagnostic accuracy in patients with suspected sepsis[J].Ann Intern Med,2014,151(2):9-15.
[13]Dimopoulou I,Orfanos S,Pelekanou A,et al.Serum of patients with septic shock stimulates the expression of TREM-1 on U937 monocytes[J].Inflamm Res,2015,64(3):127-132.
[14]Gibot S,Buonsanti C,Massin F,et al.Modulation of the triggering receptor expressed on the myeloid cell type 1 pathway in murine septic shock infection and immunity[J].Infect Immun,2012,80(5):2823-2830.
[15]Wiersinga WJ,Veer CT,Wieland CW,et al.Expression profile and function of triggering receptor expressed on myeloid cells-1 during melioidosis[J].Infect Dis,2014,203(11):1707-1716.
(收稿日期:2017-06-25 本文編輯:祁海文)endprint