趙益?zhèn)?管亞飛 崔曙東 章 曄 邵曉松

早產(chǎn)兒生后2周糞鈣衛(wèi)蛋白動(dòng)態(tài)變化及其影響因素

趙益?zhèn)?管亞飛2崔曙東2章 曄2邵曉松2

目的 了解早產(chǎn)兒生后2周糞鈣衛(wèi)蛋白(FC)水平及其影響因素。方法 納入2011年3～6月南京大學(xué)第一附屬醫(yī)院及溫州醫(yī)科大學(xué)附屬樂清醫(yī)院新生兒科住院的早產(chǎn)兒病例，排除嚴(yán)重的胃腸和全身疾病者。采集早產(chǎn)兒生后2、3、4、5、6、7和14 d的7個(gè)日齡糞便標(biāo)本，采用ELISA法測定FC水平。結(jié)果 42例早產(chǎn)兒進(jìn)入分析，其中男25例，女17例，中位胎齡34.5(28～36.4)周，中位出生體重2 200(930～3 200)g。①胎糞(生后2 d)FC水平為(84.7±15.8) μg·g-1，3～7、14 d FC水平分別為(76.5±12.4)、(86.0±17.6)、(77.5±17.4)、(82.2±15.5)、(84.3±16.1)和(80.3±19.6)μg·g-1；7個(gè)日齡FC水平總體差異無統(tǒng)計(jì)學(xué)意義。②胎糞FC水平剖宮產(chǎn)兒顯著低于自然分娩兒，差異有統(tǒng)計(jì)學(xué)意義(t=-2.56,P=0.01)，生后2周內(nèi)不同日齡FC水平與性別、孕齡及出生體重?zé)o顯著相關(guān)性；生后3～14日齡FC水平還與分娩方式無顯著相關(guān)性。結(jié)論 生后2周早產(chǎn)兒不同日齡FC水平相近，分娩方式對(duì)胎糞FC水平有影響。

早產(chǎn)兒； 糞鈣衛(wèi)蛋白； 影響因素

新生兒壞死性小腸結(jié)腸炎(NEC)為早產(chǎn)兒常見的危重癥，其診斷主要依靠臨床表現(xiàn)及腹部X線征象，但當(dāng)臨床表現(xiàn)及X線表現(xiàn)明顯時(shí)，病情常已極危重，目前尚無特異性的診斷指標(biāo)可早期診斷NEC。鈣衛(wèi)蛋白為一種非糖基化蛋白，分子量36.5 kD，存在于中性粒細(xì)胞、單核細(xì)胞及巨噬細(xì)胞中，占中性粒細(xì)胞細(xì)胞質(zhì)蛋白的60%。成人炎癥性腸病(IBD)、腸道感染時(shí)，中性粒細(xì)胞跨膜遷移入腸腔，糞鈣衛(wèi)蛋白(FC)水平升高，F(xiàn)C已作為IBD診斷及活動(dòng)度指標(biāo)[1]。由此推測，F(xiàn)C亦可能是評(píng)價(jià)新生兒腸道狀態(tài)的標(biāo)志物。近年來，國外已陸續(xù)有足月兒及早產(chǎn)兒FC的報(bào)道，有文獻(xiàn)提示FC對(duì)NEC具一定診斷價(jià)值[2]，亦有相反結(jié)論[3]。在明確FC診斷價(jià)值前，了解FC在早產(chǎn)兒腸道的正常水平很必要。本研究動(dòng)態(tài)監(jiān)測生后2周內(nèi)不同日齡早產(chǎn)兒FC水平，以期了解早產(chǎn)兒FC正常水平及其變化趨勢。

1 方法

1.1 倫理 本研究經(jīng)南京醫(yī)科大學(xué)第一附屬醫(yī)院及溫州醫(yī)科大學(xué)附屬樂清醫(yī)院倫理委員會(huì)審核同意。

1.2 病例納入標(biāo)準(zhǔn) ①2011年3～6月兩家醫(yī)院新生兒科住院早產(chǎn)兒的連續(xù)病例；②胎齡<37周；③監(jiān)護(hù)人口頭知情同意參與本研究。

1.3 病例排除標(biāo)準(zhǔn) 嚴(yán)重胃腸和全身疾?。喊∟EC、喂養(yǎng)不耐受、消化道畸形、呼吸窘迫綜合征、敗血癥、窒息、休克和DIC等。

1.4 糞標(biāo)本采集方法 在新生兒病房，于生后2、3、4、5、6、7和14 d共7個(gè)日齡時(shí)點(diǎn)分別用無菌棉簽采集尿布中糞便標(biāo)本100～200 mg，放入無菌塑料管中，立即置于-20℃冰箱內(nèi)備用。

1.5 FC測定方法 糞便標(biāo)本統(tǒng)一送至南京大學(xué)第一附屬醫(yī)院采用ELISA法行FC水平測定。人鈣衛(wèi)蛋白ELISA試劑盒購自美國R&D公司，實(shí)驗(yàn)操作嚴(yán)格按照說明書進(jìn)行。

1.6 FC影響因素分析 基于文獻(xiàn)報(bào)道FC的可能影響因素，從住院病史中提取性別、胎齡、出生體重和分娩方式(自然分娩和剖宮產(chǎn))等資料。

2 結(jié)果

2.1 一般情況 符合納入和排除標(biāo)準(zhǔn)的42例早產(chǎn)兒進(jìn)入分析,其中溫州醫(yī)科大學(xué)附屬樂清醫(yī)院新生兒科32例，南京醫(yī)科大學(xué)第一附屬醫(yī)院新生兒科10例。男25例，女17例，中位胎齡34.5(28.0～36.4)周，中位出生體重2 200(930～3 200)g。由于采集糞便量<100 mg或未采集到糞便等原因，7個(gè)日齡時(shí)點(diǎn)共采集到224份糞便標(biāo)本，2、3、4、5、6、7和14 d分別采集到42、30、30、30、31、32和30份標(biāo)本。

2.2 早產(chǎn)兒生后2周內(nèi)不同日齡FC水平比較 早產(chǎn)兒生后2周內(nèi)FC在45.79～115.74 μg·g-1，其中4例<50 μg·g-1；2～14 d的7個(gè)日齡時(shí)點(diǎn)FC水平分別為(84.7±15.8)、(76.5±12.4)、(86.0±17.6)、(77.5±17.4)、(82.2±15.5)、(84.3±16.1)和(80.3±19.6) μg·g-1, 總體上差異無統(tǒng)計(jì)學(xué)意義(F=1.57,P=0.16)。7個(gè)日齡FC水平的分布如圖1所示。

圖1 7個(gè)日齡FC水平的分布

Fig 1 Distribution of FC levels in 7 observational points

2.3 生后2周不同日齡FC水平的影響因素分析 表1顯示，早產(chǎn)兒生后2周7個(gè)日齡時(shí)點(diǎn)FC水平男女間差異均無統(tǒng)計(jì)學(xué)意義；生后2 d胎糞FC水平剖宮產(chǎn)兒顯著低于自然分娩兒，79.1vs90.8 μg·g-1，t=-2.56,P=0.01，余日齡時(shí)點(diǎn)FC水平在不同分娩方式早產(chǎn)兒差異無統(tǒng)計(jì)學(xué)意義。表2顯示，F(xiàn)C總體水平與胎齡和出生體重?zé)o顯著相關(guān)性，不同日齡FC水平與出生體重、胎齡均無顯著相關(guān)性。

FactorDay2Day3Day4Day5Day6Day7Day14TotalGenderMale88.3±15.9(25)78.9±13.1(17)81.7±17.8(17)75.2±18.1(17)82.8±16.9(21)83.2±15.8(23)83.9±20.5(20)82.5±17.0(140)Female79.4±14.3(17)73.5±11.3(13)91.6±16.5(13)80.54±16.7(13)80.9±12.8(10)87.1±17.4(9)73.0±16.2(10)80.8±15.8(85)t1.841.19-1.55-0.370.33-0.621.470.74P0.070.250.130.710.750.540.150.45ModeofdeliveryCaesareansection79.1±13.5(22)76.4±12.4(18)84.0±17.8(16)78.0±16.7(18)78.9±13.8(18)80.1±17.3(15)85.7±20.9(13)80.0±15.8(120)Naturallabor90.8±16.1(20)76.8±12.9(12)88.2±17.9(14)76.7±19.3(12)86.9±17.0(13)88.0±14.5(17)76.2±18.1(17)83.9±17.2(105)t-2.56-0.10-0.65-0.26-1.45-0.521.33-1.79P0.010.930.520.800.160.610.200.74

表2 早產(chǎn)兒不同日齡FC水平與出生體重和胎齡的相關(guān)性

Tab 2 The correlation between FC levels and birthweight and gestational age within 2 weeks after birth

FactorDay2Day3Day4Day5Day6Day7Day14TotalBirthweightr0.1490.329-0.0980.1650.2740.073-0.1640.121P0.3460.0750.6050.3830.1350.690.3870.069Gestationalager0.160.062-0.226-0.067-0.003-0.006-0.1050.053P0.3110.7430.230.7240.9860.9730.5820.431

3 討論

3.1 早產(chǎn)兒FC水平 以“Fecal Calprotectin、Noenates、Perterms”檢索PubMed數(shù)據(jù)庫，檢索起止時(shí)間為建庫至2015年4月，匯總報(bào)道無腸道疾病的早產(chǎn)兒FC水平文獻(xiàn)11篇[4～13](表3)。文獻(xiàn)[4,5]報(bào)道的早產(chǎn)兒胎糞FC平均水平在145.2～178.1 μg·g-1，高于本研究的平均水平[ (84.7±15.8) μg·g-1]?？紤]與研究對(duì)象不同有關(guān)，文獻(xiàn)[4]同時(shí)納入了部分足月兒，文獻(xiàn)[6]納入的早產(chǎn)兒體重較輕。本研究結(jié)果及匯總文獻(xiàn)結(jié)果顯示，早產(chǎn)兒胎糞FC水平均高于成人FC值(<50 μg·g-1)，其原因可能是由于早產(chǎn)兒不成熟腸黏膜的通透性較成人高，致中性粒細(xì)胞易于遷移至腸腔，致腸腔中FC水平升高。早產(chǎn)兒腸道通透性也高于足月兒，盡管有研究[14]發(fā)現(xiàn)早產(chǎn)兒生后1周內(nèi)，腸道黏膜屏障功能不斷完善，通透性顯著下降，但早產(chǎn)兒不成熟腸黏膜通透性升高仍可部分解釋其胎糞FC水平的升高。

StudynGA/weeksBW/gSamplingtimeFC/μg·g-1Laforgia[4]131NA1)1040-4670meconium145.2±78.5Zoppelli[5]14024.4-35.71145±253meconium(≤3d)178.1Ourstudy4228-36.4930-3200meconium(2d)84.7±15.8Nissen[6]1131-3-18d150(81-221)Josefsson[7]5223.0-33.7519-14421-8weeks253(9-1867)Campeotto[8]1927-34780-29001-8weeks160(<15-650)Campeotto[9]9527.4-35730-27501-4weeks206(16-1240)Carroll[10]730NA<3weeks98±61Yang[11]823-30630-15001-4weeks122±98Rouge[12]2328.1±1.81057±2601-4weeks103±90Reisinger[13]3325-41.3585-35701-4weeks79.6(1.0-625.1)Ourstudy4228-36.4930-32003-14d81.2±16.7

Notes NA: not available; 1) including 47 perterm and 84 term infants

本研究除胎糞外的6個(gè)日齡FC水平在45.79～115.74 μg·g-1，僅有4例<50 μg·g-1，平均水平在75～90 μg·g-1。表3所示：綜述文獻(xiàn)[6～12]早產(chǎn)兒FC研究，F(xiàn)C平均值在98～253 μg·g-1，高于本研究結(jié)果。2012年Reisinger等[13]報(bào)道16例非NEC早產(chǎn)兒FC中位數(shù)為79.6 μg·g-1，與本研究相近，但FC值的離散度較大。各文獻(xiàn)間FC值相差很大的原因有研究認(rèn)為與標(biāo)本采集于尿布，尿布會(huì)吸取部分水分有關(guān)。但Olafsdottir等[15]認(rèn)為此種收集標(biāo)本的方式增加FC濃度<30%，此差異遠(yuǎn)低于不同研究間的差異，因此標(biāo)本采集方式并不能完全解釋各研究間的差異。腸壁通透性升高及腸管相關(guān)淋巴組織的發(fā)育可致腸壁中性粒細(xì)胞升高，從而導(dǎo)致FC升高；同時(shí)喂養(yǎng)方式、腸道細(xì)菌的定植、腸壁對(duì)食物抗原的反應(yīng)等均可能改變FC水平，可能導(dǎo)致不同研究間FC的差異較大。

3.2 不同日齡FC水平比較 本研究早產(chǎn)兒不同日齡FC水平差異無統(tǒng)計(jì)學(xué)意義，生后3 d時(shí)點(diǎn)FC水平低于其他日齡，考慮可能為過渡糞便有關(guān)，有待進(jìn)一步積累病例加以明確。有研究報(bào)道[5]胎齡26～32周早產(chǎn)兒生后FC水平進(jìn)行性下降，6～8日齡FC水平最低，隨后逐步上升，與本研究結(jié)果不一致，可能與研究對(duì)象胎齡不同有關(guān)，本研究胎齡<34周早產(chǎn)兒僅19例，并未進(jìn)行分層分析。

3.3 早產(chǎn)兒FC影響因素 本文結(jié)果顯示早產(chǎn)兒胎糞FC水平與分娩方式相關(guān)，胎糞FC水平自然分娩兒顯著高于剖宮產(chǎn)兒，但未發(fā)現(xiàn)早產(chǎn)兒其他后續(xù)日齡FC水平與分娩方式相關(guān)， Josefsson等[16]發(fā)現(xiàn)剖宮產(chǎn)兒胎糞后的FC水平高于自然分娩兒，認(rèn)為剖宮產(chǎn)延遲了細(xì)菌在腸道的定植；與本文研究結(jié)果不同，是否與孕母分娩前狀態(tài)(如感染)相關(guān)，仍有待進(jìn)一步研究。

Laforgia等[4]發(fā)現(xiàn)，胎糞FC水平與胎齡、出生體重呈負(fù)相關(guān)。本研究發(fā)現(xiàn)生后2周內(nèi)各時(shí)點(diǎn)早產(chǎn)兒FC水平與胎齡、出生體重和胎齡無顯著相關(guān)性，與Josefsson等[16]的報(bào)道一致。此外喂養(yǎng)方式是否對(duì)FC存在影響仍有爭議。Baldassarre等[17]及Rosti等[18]研究，未發(fā)現(xiàn)母乳喂養(yǎng)和混合喂養(yǎng)兒的FC水平差異有統(tǒng)計(jì)學(xué)意義。Dorosko等[19]及Savino等[20]研究發(fā)現(xiàn)母乳喂養(yǎng)兒生后3月齡內(nèi)FC水平高于混合喂養(yǎng)及人工喂養(yǎng)兒。本研究納入的住院早產(chǎn)兒多為混合喂養(yǎng)，故未對(duì)此作進(jìn)一步分析。此外，有研究[21]表明產(chǎn)前使用抗生素母親的新生兒FC水平較產(chǎn)前未使用抗生素母親的新生兒低，本文未收集產(chǎn)前母親的抗生素使用情況，結(jié)果顯示早產(chǎn)兒不論胎糞FC值還是其他日齡FC值均低于國外研究報(bào)告，是否與此相關(guān)尚不清楚，有待后續(xù)進(jìn)一步的研究。

本研究的不足之處和局限性：①僅分析了胎齡 、 出生體重等對(duì)FC水平的影響，未涉及孕母相關(guān)因素的分析；②未納入足月兒進(jìn)行FC水平的比較分析；③樣本量較小，仍需累積更多樣本。

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(本文編輯：丁俊杰)

Dynamic changes and influence factors of fecal calprotectin within 2 weeks of life in preterm newborns

ZHAOYi-wei1,GUANYa-fei2,CUIShu-dong2,ZHANGYe2,SHAOXiao-song2

(1DepartmentofPediatric,YueqingHospitalAffiliatedtoWenzhouMedicalUniversity,Yueqing325600; 2DepartmentofPediatric,TheFirstAffiliatedHospitalofNanjingMedicalUniversity,Nanjing210029,China)

CUI Shu-dong，E-mail:csd9758@126.com

ObjectiveTo study the baseline level of fecal calprotectin (FC) and the factors that may affect the FC levels in preterm newborns within 2 weeks of life.MethodsPreterm newborns were recruited from March 2011 to May 2011 from Yueqing Hospital Affiliated to Wenzhou Medical University and The first affiliated Hospital of Nanjing Medical University. Neonates who were suffered from severe gastrointestinal disease and the other severe didease were excluded. Feces were collected in 2, 3, 4, 5, 6, 7, 14 days of life. FC was detected by ELISA.Results A total of 42 patients including 25 males were recruited with the median gestational age (GA) of 34.5(28-36.4) weeks and median birth weight (BW) of 2 200(930-3 200) g. ①The mean FC level in meconium was (84.7±15.8) μg·g-1, the mean FC levels in 3, 4, 5, 6, 7, 14 days of life were (76.5±12.4), (86.0±17.6), (77.5±17.4), (82.2±15.5), (84.3±16.1) and (80.3±19.6) μg·g-1, respectively. There was no significant difference of FC level among different days of life in preterm newborns. ② There was significant difference of meconium FC level between caesarean section and natural labor newborns. There was no evidence that the meconium FC was influenced by gender, GA and BW and that FC levels in 3, 4, 5, 6, 7 and 14 days of life were not influenced by age, gender, GA, BW or delivery mode in preterm newborns.ConclusionThe FC levels within 2 weeks of life in the preterm newborns did not vary with age. The delivery mode could influence fecal FC.

Preterm; Fecal calprotectin; Influential factor

10.3969/j.issn.1673-5501.2015.05.007

1 溫州醫(yī)科大學(xué)附屬樂清醫(yī)院兒科 樂清，325600；2 南京醫(yī)科大學(xué)第一附屬醫(yī)院兒科 南京，210029

崔曙東，E-mail:csd9758@126.com

2015-05-17

2015-07-30)