肺炎合并全身炎性反應(yīng)綜合征患者CRP、NT-proBNP水平變化研究

宋根紅，賀曉龍(延安大學(xué)附屬醫(yī)院：.重癥醫(yī)學(xué)科;.呼吸內(nèi)科，陜西延安 76000)

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·論 著·

肺炎合并全身炎性反應(yīng)綜合征患者CRP、NT-proBNP水平變化研究

宋根紅1，賀曉龍2(延安大學(xué)附屬醫(yī)院：1.重癥醫(yī)學(xué)科;2.呼吸內(nèi)科，陜西延安 716000)

目的 觀察肺炎合并與未合并全身炎性反應(yīng)綜合征(SIRS)患者C反應(yīng)蛋白(CRP)、N-末端腦鈉肽前體(NT-proBNP)水平變化情況及臨床意義。方法 選取2012年9月至2014年2月該院呼吸科收治的肺炎患者60例以及本院同期健康體檢者30例，按照是否合并SIRS，分為SIRS組30例，非SIRS組30例以及健康體檢組(對照組)30例。全部患者均于入院時抽取靜脈血,采用酶聯(lián)免疫吸附法(ELISA)測定2組患者的血清CRP、NT-proBNP水平，并行肺炎嚴(yán)重指數(shù)評分,以住院最后1 d資料判斷多系統(tǒng)器官功能衰竭(MSOF)。結(jié)果 入院24 h血糖、CRP以及NT-proBNP水平比較，SIRS組明顯高于非SIRS組與對照組(P<0.01)，而非SIRS組與對照組比較差異無統(tǒng)計(jì)學(xué)意義(P>0.05),CRP水平明顯高于對照組(P<0.01)；肺炎患者NT-proBNP水平與患者體溫、心率、CO2分壓、中性粒細(xì)胞分?jǐn)?shù)、肺炎嚴(yán)重度指數(shù)(PSI)評分密切相關(guān)。結(jié)論 患者血糖和CRP水平與肺炎嚴(yán)重程度密切相關(guān),臨床上聯(lián)合應(yīng)用CRP和血糖這2項(xiàng)指標(biāo)對于判斷肺炎的轉(zhuǎn)歸和療效具有一定的意義；合并有SIRS的患者NT-proBNP水平明顯超過普通肺炎患者和健康者，可依據(jù)NT-proBNP的水平對肺炎是否合并有SIRS加以區(qū)分，臨床意義重大。

肺炎； 全身炎性反應(yīng)綜合征； N-末端腦鈉肽前體； C反應(yīng)蛋白； 血糖

肺炎全身炎性反應(yīng)綜合征(SIRS)是由于多種因素(感染或非感染)刺激機(jī)體產(chǎn)生的失控性全身炎性反應(yīng)，病情相對嚴(yán)重，臨床表現(xiàn)為高動力循環(huán)、高代謝與過度炎性反應(yīng)[1-2]。肺炎合并SIRS最終將發(fā)展成多系統(tǒng)器官功能衰竭(MSOF)，故對肺炎合并SIRS的早期診斷對疾病的預(yù)后具有重大意義。臨床上常常用C反應(yīng)蛋白(CRP)等指標(biāo)對全身炎性反應(yīng)進(jìn)行評估[3]。N-末端腦鈉肽前體(NT-proBNP)是由心臟分泌的一種氨基酸，其濃度的高低能夠反映心臟的功能[4]。近年研究顯示，NT-proBNP水平除了能反映心臟功能的強(qiáng)弱，在肺炎的預(yù)后也具有較重大的意義，是評價肺炎的危險因素之一[5-6]。本研究通過對60例肺炎患者臨床資料的回顧性分析，探討肺炎合并SIRS患者的CRP和NT-proBNP水平變化情況及臨床意義。

1 資料與方法

1.1 一般資料 本研究為回顧性分析，從病案庫選取2012年9月至2014年2月本院以肺炎為診斷而收入院患者60例作為研究組,另取同期健康體檢者30例作為對照組，按照住院期間是否合并全身炎性反應(yīng)，分為SIRS組30例,其中男16例，女14例，年齡25～74歲，平均(57.4±7.8)歲，體溫(37.8±1.6)℃，心率(91.4±13.7)次/分，呼吸頻率(23.2±2.1)次/分；非SIRS組30例，其中男13例，女17例，年齡24～75歲，平均(60.5±8.2)歲，體溫(36.3±0.8)℃，心率(77.2±11.8)次/分，呼吸率(19.3±1.5)次/分；健康體檢組30例，其中男18例，女12例，年齡26～70歲，平均(55.4±6.7)歲，體溫(35.8±0.5)℃，心率(75.5±10.5)次/分，呼吸頻率(18.2±1.4)次/分。3組患者的一般資料差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，具有可比性?；颊咦栽竻⑴c本研究，并簽署知情同意書。

1.2 方法

1.2.1 診斷標(biāo)準(zhǔn) 依據(jù)中華醫(yī)學(xué)會呼吸病學(xué)分會《肺炎診斷及治療指南》中肺炎合并SIRS診斷標(biāo)準(zhǔn)[7]：(1)體溫大于38 ℃；(2)心率大于90次/分；(3)呼吸頻率大于20次/分；(4)白細(xì)胞計(jì)數(shù)大于12×109/L。符合以上診斷標(biāo)準(zhǔn)2項(xiàng)及以上者。

1.2.2 觀察指標(biāo) 納入標(biāo)準(zhǔn)：(1)患者年齡20～75歲；(2)無心、腎等臟器功能不全；(3)無嚴(yán)重肝膽疾病者；(4)排除惡性腫瘤以及嚴(yán)重精神疾病者；(5)積極參與本研究者。排除標(biāo)準(zhǔn)：(1)心、腎功能不全；(2)肝、膽嚴(yán)重疾?。?3)惡性腫瘤；(4)神志異常者；(5)不愿參與本研究者。觀察一般生命體征體溫、心率、血壓、呼吸頻率和血液檢查指標(biāo)，如血常規(guī)：中性粒細(xì)胞和白細(xì)胞計(jì)數(shù)；紅細(xì)胞沉降率；24 h內(nèi)行空腹血糖、血清鈉、CRP水平檢測。各指標(biāo)正常區(qū)間:血糖3.6～6.1 mmol/L,血鈉35～155 mmol/L,CRP 0～6 mg/L。

1.2.3 NT-proBNP檢測 空腹抽取靜脈血，以3 000 r/min低速離心10 min，取血清，應(yīng)用配套試劑盒，采用酶聯(lián)免疫吸附(ELISA)法檢測。

1.2.4 療效判定標(biāo)準(zhǔn) 采用肺炎嚴(yán)重指數(shù)(PSI)評分系統(tǒng)對肺炎患者進(jìn)行評分[8]。(1)并發(fā)癥：腫瘤(+30)，肝膽疾病(+20)，心力衰竭(+10)，腦血管疾病(+10)，腎臟疾病(+10)；(2)查體：精神狀態(tài)改變(+20)，呼吸頻率不低于30次/分(+20)，收縮壓小于90 mm Hg(+10)，體溫不低于40 ℃(+15)，脈搏不低于120次/分(+10)；(3)實(shí)驗(yàn)室檢查：pH<7.35(+30)，尿素氮大于10.7 mmol/L(+20)，血清鈉小于130 mmol/L(+10)，空腹血糖大于13.9 mmol/L(+10)，氧分壓小于60 mm Hg(+10)。PSI評分為所得積分相加之和。

2 結(jié) 果

2.1 入院24 h內(nèi)血糖、CRP以及NT-proBNP水平比較 SIRS組入院24 h內(nèi)首次測定血糖、CRP以及NT-proBNP水平明顯高于非SIRS組和對照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.01)；非SIRS組的血糖與對照組比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05),CRP水平明顯高于對照組(P<0.01)。見表1。

2.2 SIRS組患者NT-proBNP水平與實(shí)驗(yàn)室檢查相關(guān)性分析 SIRS組患者的體溫為(37.4±1.2)℃、心率為(82.3±15.4)次/分、CO2分壓為(37.6±6.8)mm Hg、中性粒細(xì)胞分?jǐn)?shù)為(0.7±0.2)%、PSI評分為(62.6±21.2)分。NT-proBNP水平與患者的體溫、心率、CO2分壓、中性粒細(xì)胞分?jǐn)?shù)、PSI評分密切相關(guān)，r值分別為0.201、0.218、-0.181、-0.075、0.288，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；與呼吸頻率、白細(xì)胞計(jì)數(shù)、血沉及空腹血糖等指標(biāo)無明顯相關(guān)性。

表1 入院24 h內(nèi)血糖、CRP以及NT-proBNP 濃度比較

注：與對照組比較，△P<0.01。

3 討 論

肺炎合并SIRS，又稱重癥肺炎，是臨床常見死亡原因之一，臨床表現(xiàn)為高代謝、過度炎性反應(yīng)與高動力循環(huán)。研究表明，過度的炎性反應(yīng)可導(dǎo)致血清中CRP水平明顯升高,正常情況下血清中CRP水平較低,當(dāng)發(fā)生細(xì)菌感染、急性損傷及外傷手術(shù)時,CRP水平迅速升高[8-9]。根據(jù)重癥肺炎的臨床表現(xiàn)，患病初期以高代謝為主,本研究結(jié)果顯示，SIRS組患者與非SIRS組與正常組比較，血糖明顯升高，推測其高代謝導(dǎo)致血糖需求量增加，機(jī)體應(yīng)激性升高血糖，表現(xiàn)在血清高血糖上[10]。3組CRP以及NT-proBNP水平比較中，非SIRS組和對照組明顯低于SIRS組，與對照組比較，非SIRS組的血糖無差異,但CRP水平明顯高于對照組；肺炎患者合并SIRS患者NT-proBNP水平與呼吸頻率、白細(xì)胞計(jì)數(shù)、紅細(xì)胞沉降率及空腹血糖等指標(biāo)無明顯相關(guān)性，與患者體溫、心率、CO2分壓、中性粒細(xì)胞分?jǐn)?shù)、PSI評分密切相關(guān)。肺炎合并SIRS時患者腎上腺皮質(zhì)激素、胰高血糖素等激素分泌增高,機(jī)體分解能力亢進(jìn),導(dǎo)致血糖激增,造成腦水腫及組織壞死,可致意識障礙甚至昏迷[11-12]。SIRS各種炎性介質(zhì)的失控性釋放,使許多生理生化和免疫通路被激活,這些變化超過機(jī)體耐受可引起MODS[13-14]。NT-proBNP在心室肌內(nèi)完成合成與分泌，其主要代謝途徑為肝、腎臟代謝[15-16]。有關(guān)文獻(xiàn)顯示，肺炎患者NT-proBNP水平明顯高于健康者[17-18]。肺炎合并SIRS患者NT-proBNP水平明顯高于急性支氣管炎患者，且與患者住院時間呈正相關(guān)，進(jìn)一步研究提示NT-proBNP為肺炎患者死亡及治療失敗的危險因素之一，與單獨(dú)使用PSI評分相比較，PSI評分聯(lián)合NT-proBNP的預(yù)測價值更為確切[19]。

綜上所述，肺炎合并與未合并SIRS患者CRP、NT-proBNP水平變化情況，對肺炎的轉(zhuǎn)歸以及療效具有一定的臨床意義，臨床上聯(lián)合應(yīng)用CRP和血糖這2項(xiàng)指標(biāo)對肺炎病情嚴(yán)重度進(jìn)行判斷，并依據(jù)NT-proBNP的水平來區(qū)分肺炎是否合并有SIRS。但受臨床研究一般條件的制約，由于研究時間和樣本含量的不充分，本研究上存在一定的不足，望今后的研究加以改進(jìn)，完善研究方案，使研究結(jié)果更加科學(xué)與嚴(yán)謹(jǐn)。

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Research on changes of CRP and NT-proBNP levels in patients with pneumonia complicating systemic inflammatory response

SONGGen-hong1,HEXiao-long2

(1.DepartmentofIntensiveCareMedicine;2.DepartmentofRespiration,AffiliatedHospitalofYan′anUniversity,Yan′an,Shaanxi716000,China)

Objective To observe the changes of C-reactive protein(CRP) and N-terminal pro-brain natriuretic peptide(NT-proBNP) levels and their clinical significance in the patients with pneumonia complicating systemic inflammatory response(SIRS).Methods 60 cases of pneumonia in the respiration department of our hospital were selected and divided into the pneumonia complicating systemic inflammatory response group(SIRS group,30 cases) and the non-complicating systemic inflammatory response group(non-SIRS group,30 cases) according to whether complicating systemic inflammatory response.Contemporaneous 30 individuals undergoing the physical health examination were selected as the control group.The venous blood sample was collected at admission in all the patients and the serum CRP and NT-proBNP levels were detected by using enzyme-linked immunosorbent assay (ELISA),the pneumonia severity index score was evaluated and the multiple systemic organ failure(MSOF) was judged according to the data on last day of hospitalization.Results The blood glucose within 24 h after admission,CRP and NT-proBNP levels in the SIRS group were significantly higher than those in the non-SIRS group and the control group (P<0.01),while which had no statistical differences between the non-SIRS group and the control group (P>0.05);the CRP level in the SIRS group was significantly higher than that in the control group (P<0.01);the NT-proBNP level in the patients with pneumonia was closely related with the body temperature,heart rate,CO2partial pressure,neutrophil fraction and PSI score.Conclusion The blood glucose and CRP levels in the patients with pneumonia are closely associated with the pneumonia severity,the clinical combined application of CRP and blood glucose has certain significance for judging the pneumonia outcome and curative effect;the NT-proBNP level in the patients with complicating SIRS is significantly higher than that in the patients with ordinary pneumonia and healthy people.Therefore,pneumonia whether complicating SIRS could be distinguished according to the NT-proBNP level,which showing important significance.

pneumonia; systemic inflammatory response; N-terminal pro brain natriuretic peptide; C-reactive protein; blood glucose

宋根紅，男，主治醫(yī)師，本科，主要從事重癥醫(yī)學(xué)方面的臨床工作。

10.3969/j.issn.1672-9455.2015.16.027

A

1672-9455(2015)16-2366-03

2015-02-18

2015-04-16)