翟萌萌
中性粒細(xì)胞與淋巴細(xì)胞比值對(duì)重癥腦出血患者院內(nèi)死亡的預(yù)測(cè)價(jià)值
翟萌萌
鄭州大學(xué)第五附屬醫(yī)院重癥醫(yī)學(xué)科,河南鄭州 450052
探討中性粒細(xì)胞與淋巴細(xì)胞比值(neutrophil-to-lymphocyte ratio,NLR)對(duì)重癥腦出血患者院內(nèi)死亡的預(yù)測(cè)價(jià)值?;仡櫺苑治?020年1月至2021年12月于鄭州大學(xué)第五附屬醫(yī)院住院的急性重癥腦出血患者121例,根據(jù)患者院內(nèi)死亡情況,將其分為院內(nèi)死亡組和院內(nèi)存活組,采用二元Logistic回歸分析探討重癥腦出血患者院內(nèi)死亡的相關(guān)因素,采用受試者操作特征曲線(receiver operator characteristic curve,ROC曲線)分析NLR對(duì)重癥腦出血患者院內(nèi)死亡的預(yù)測(cè)價(jià)值。121例患者中死亡42例,病死率34.7%。兩組患者入院時(shí)格拉斯哥昏迷量表(Glasgow coma scale,GCS)評(píng)分、腦卒中病史、入院時(shí)及入院3d NLR比較,差異均有統(tǒng)計(jì)學(xué)意義(<0.05)。二元Logistic回歸分析結(jié)果顯示,既往腦卒中病史、入院GCS評(píng)分越低及入院時(shí)和入院3d的NLR越高,重癥腦出血患者發(fā)生院內(nèi)死亡的風(fēng)險(xiǎn)越高(<0.05)。ROC曲線結(jié)果顯示,入院時(shí)及入院3d NLR預(yù)測(cè)重癥腦出血患者院內(nèi)死亡的曲線下面積分別為0.568和0.617,當(dāng)入院3d的NLR為10.21時(shí),約登指數(shù)為0.248,敏感度和特異性分別為88.1%和63.3%。入院時(shí)及入院3d NLR升高、入院時(shí)GCS評(píng)分降低及既往腦卒中病史均是重癥腦出血患者院內(nèi)死亡的危險(xiǎn)因素,其中入院3d NLR水平對(duì)院內(nèi)死亡的預(yù)測(cè)價(jià)值更高。
中性粒細(xì)胞與淋巴細(xì)胞比值;腦出血;院內(nèi)死亡;預(yù)測(cè)
腦出血是指非外傷性腦實(shí)質(zhì)內(nèi)出血,發(fā)病率為(12~15)/10萬人年,在我國(guó)約占全部腦卒中的18.8%~47.6%[1-2]。腦出血發(fā)病兇險(xiǎn),發(fā)病30d的病死率高達(dá)35%~52%,僅約20%的患者在6個(gè)月后能夠恢復(fù)生活自理能力[3-4]。重癥腦出血是指格拉斯哥昏迷量表(Glasgow coma scale,GCS)評(píng)分≤8分或血腫量>40ml的嚴(yán)重腦卒中類型,其惡化率、致殘率及病死率更高,給家庭和社會(huì)帶來沉重的經(jīng)濟(jì)與精神負(fù)擔(dān)[1,5-6]。研究表明,腦出血發(fā)生后,血腫對(duì)神經(jīng)組織造成壓迫,同時(shí)白細(xì)胞各亞型通過不同方式參與血腫周圍腦組織的炎癥反應(yīng),導(dǎo)致神經(jīng)功能損害,使患者病情惡化,甚至引發(fā)死亡,幸存者中多數(shù)亦存在不同程度的神經(jīng)功能障礙[7],中性粒細(xì)胞與淋巴細(xì)胞比值(neutrophil-to-lymphocyte ratio,NLR)是炎癥反應(yīng)的重要指標(biāo),在急性腦血管病中的作用逐漸引起關(guān)注。研究表明NLR與腦出血患者出血量、血腫擴(kuò)大和短期病死率相關(guān)[8-9],然而NLR對(duì)腦出血患者院內(nèi)死亡進(jìn)行預(yù)測(cè)仍存在爭(zhēng)議[10-11]。因此,本研究旨在探索不同時(shí)間段NLR對(duì)重癥腦出血患者院內(nèi)死亡的預(yù)測(cè)價(jià)值。
選取2020年1月至2021年12月于鄭州大學(xué)第五附屬醫(yī)院住院的急性重癥腦出血患者121例,納入標(biāo)準(zhǔn):①CT證實(shí)為腦出血;②年齡>18歲;③發(fā)病≤6h;④入院GCS評(píng)分≤8分。排除標(biāo)準(zhǔn):①發(fā)病前2周有感染病史;②繼發(fā)性腦出血患者(外傷、凝血功能異常、動(dòng)靜脈畸形、腦梗死后出血轉(zhuǎn)化等因素);③服用免疫抑制劑等藥物;④白血病等血液系統(tǒng)疾病者;⑤入院5d內(nèi)死亡患者;⑥臨床資料不全者。所有患者知情同意并簽署知情同意書,本研究經(jīng)鄭州大學(xué)第五附屬醫(yī)院倫理委員會(huì)批準(zhǔn)實(shí)施(倫理審批號(hào):2014010207)。
收集患者入院時(shí)的年齡、性別、基礎(chǔ)疾病、血壓、煙酒嗜好、GCS評(píng)分等基線資料,并于入院時(shí)及入院3d、入院5d完善白細(xì)胞計(jì)數(shù)、中性粒細(xì)胞計(jì)數(shù)及淋巴細(xì)胞計(jì)數(shù)檢測(cè),并計(jì)算NLR。根據(jù)患者院內(nèi)結(jié)局,將患者分為院內(nèi)死亡組和院內(nèi)存活組。
121例患者中死亡42例,病死率34.7%。兩組患者的入院時(shí)GCS評(píng)分、腦卒中病史、入院時(shí)及入院3d NLR比較,差異均有統(tǒng)計(jì)學(xué)意義(<0.05),見表1。
以院內(nèi)死亡為因變量,將入院GCS評(píng)分、腦卒中病史、NLR納入二元Logistic回歸分析,結(jié)果顯示既往腦卒中病史、入院GCS評(píng)分越低及入院時(shí)和入院3d NLR越高,重癥腦出血患者發(fā)生院內(nèi)死亡的風(fēng)險(xiǎn)越高(<0.05),見表2、表3。
ROC曲線結(jié)果顯示,入院時(shí)及入院3d NLR預(yù)測(cè)重癥腦出血患者院內(nèi)死亡的曲線下面積分別為0.568和0.617,當(dāng)入院3d NLR為10.21時(shí),約登指數(shù)為0.248,敏感度和特異性分別為88.1%和63.3%,見圖1。
圖1 不同時(shí)間NLR對(duì)重癥腦出血患者院內(nèi)死亡預(yù)測(cè)的ROC曲線
表1 兩組患者的一般臨床資料比較
注:1mmHg=0.133kPa
表2 重癥腦出血患者發(fā)生院內(nèi)死亡的二元Logistic回歸分析(入院時(shí))
表3 重癥腦出血患者發(fā)生院內(nèi)死亡的二元Logistic回歸分析(入院3d)
研究表明,炎癥反應(yīng)是導(dǎo)致繼發(fā)性腦損害的因素之一,其可導(dǎo)致腦功能喪失[12]。腦出血發(fā)生后,中性粒細(xì)胞6~12h即可在血腫周圍浸潤(rùn),48~72h可達(dá)高峰,釋放大量炎癥細(xì)胞因子,破壞細(xì)胞基質(zhì),損傷神經(jīng)元,破壞血-腦脊液屏障完整性,引起繼發(fā)性腦損傷[13–14]。淋巴細(xì)胞是主要的免疫調(diào)節(jié)細(xì)胞,通過調(diào)節(jié)淋巴細(xì)胞分化,可減輕腦出血后早期神經(jīng)炎癥損傷,直接或間接促進(jìn)腦出血后功能恢復(fù)[15]。NLR是不同免疫途徑相互作用的標(biāo)志,是一種復(fù)合的穩(wěn)定有效的炎癥標(biāo)志物[16],已被證實(shí)是心腦血管疾病患者、重癥患者院內(nèi)死亡的獨(dú)立預(yù)測(cè)因子[17–18]。多項(xiàng)研究發(fā)現(xiàn)其對(duì)腦出血患者預(yù)后有一定預(yù)測(cè)價(jià)值,但不同時(shí)間點(diǎn)NLR對(duì)腦出血患者預(yù)后預(yù)測(cè)價(jià)值仍存在爭(zhēng)議[19–20]。本研究發(fā)現(xiàn)NLR升高是重癥腦出血患者院內(nèi)死亡的預(yù)測(cè)因素,而入院3d NLR升高對(duì)重癥腦出血患者院內(nèi)死亡的預(yù)測(cè)價(jià)值更高。正常情況下,免疫系統(tǒng)與神經(jīng)系統(tǒng)保持相對(duì)穩(wěn)態(tài),急性腦出血發(fā)生后,相對(duì)穩(wěn)態(tài)被打破,導(dǎo)致外周炎癥細(xì)胞的初始激活和繼發(fā)性腦部炎癥細(xì)胞浸潤(rùn),進(jìn)而導(dǎo)致血腫擴(kuò)大及神經(jīng)系統(tǒng)受損,進(jìn)而誘導(dǎo)更多炎癥細(xì)胞產(chǎn)生,影響預(yù)后。本研究發(fā)現(xiàn)入院時(shí)及入院3d NLR升高、入院時(shí)GCS評(píng)分降低及既往腦卒中病史均是重癥腦出血患者院內(nèi)死亡的危險(xiǎn)因素,其中入院3d NLR水平對(duì)院內(nèi)死亡的預(yù)測(cè)價(jià)值更高,其最佳預(yù)測(cè)值為10.21,即入院3d NLR水平>10.21時(shí)提示重癥腦出血患者院內(nèi)死亡風(fēng)險(xiǎn)高。
綜上所述,NLR作為一種炎癥標(biāo)志物,對(duì)重癥腦出血患者院內(nèi)死亡具有一定的預(yù)測(cè)價(jià)值,重視入院及入院3d NLR檢測(cè),早期識(shí)別,積極采取干預(yù)措施,有可能改善患者的生存率。
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Predictive value of neutrophil-to-lymphocyte ratio for in-hospital death in patients with severe cerebral hemorrhage
Intensive Care Unit, the Fifth Affiliated Hospital of Zhengzhou University, Zhengzhou 450052, Henan, China
To investigate the predictive value of neutrophil-to-lymphocyte ratio (NLR) for in-hospital death in patients with severe cerebral hemorrhage.A retrospective analysis was performed on 121 patients with severe acute cerebral hemorrhage admitted to the Fifth Affiliated Hospital of Zhengzhou University from January 2020 to December 2021. According to the situation of in-hospital death, the patients were divided into in-hospital death group and in-hospital survival group. Binary Logistic regression was used to explore the related factors of in-hospital death in patients with severe cerebral hemorrhage, and receiver operator characteristic (ROC) curve was used to analyze the predictive value of NLR for in-hospital death in patients with severe cerebral hemorrhage.Of 121 patients, 42 patients died, with a fatality rate of 34.7%. There were significant differences in Glasgow coma scale (GCS)、history of stroke、the NLR at admission and 3 days after admission between the two groups (<0.05). The results of binary Logistic regression analysis showed that the previous stroke history, the lower the admission GCS score, and the higher the NLR at admission and 3 days after admission, the higher the risk of in-hospital death in patients with severe cerebral hemorrhage (<0.05). ROC curve results showed that the area under the curve for predicting in-hospital death of severe cerebral hemorrhage patients at admission and 3 days after admission was 0.568 and 0.617, respectively. When the NLR of 3 days after admission was 10.21, the Joden index was 0.248, and the sensitivity and specificity were 88.1% and 63.3%, respectively.Increased NLR on admission and 3days admission, decreased GCS score on admission and previous history of stroke are all risk factors for in-hospital death in patients with severe cerebral hemorrhage, among which 3days NLR on admission had a higher predictive value for in-hospital death .
Neutrophil-to-lymphocyte ratio; Cerebral hemorrhage; In-hospital death; Predictive
R743.34
A
10.3969/j.issn.1673-9701.2023.07.012
翟萌萌,電子信箱:zdwfyzmm@163.com
(2022–08–03)
(2023–01–31)