外周血pH降低与H7N9感染者的死亡风险相关性分析
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摘要
目的流感A H7N9病毒感染是死亡率高、致残率高的临床重症疾病,是目前我国新发突发传染病方面的重点防控疾病。因此,临床中探索及发现导致重症患者死亡的高危因素至关重要。本文拟通过对H7N9感染患者临床特点的分析,探究与死亡风险和预后密切相关的临床指标,为指导临床工作中对重症H7N9感染者的治疗提供思路,减少病死率,提高患者的生存质量。方法本研究共纳入2013年3月—2016年3月在浙江大学医学院附属第一医院感染科住院治疗的121例实验室确诊流感A H7N9病毒感染的患者,根据临床结局将所有患者分为生存组82例和死亡组39例,从电子医疗病例摘录所有患者的临床数据(包括人口学特点及实验室检测结果),并在2组间进行比较。使用逻辑回归分析的研究方法探索潜在的与死亡风险与预后相关的各项指标。结果相比于生存组,死亡组患者的eGFR、PCT、血钙、血pH更低(均P<0.05),而年龄、CRP、BNP、血肌酐的峰值更高,血钠、血氯、血钾更高(均P<0.05)。死亡组患者的插管率、ECMO及CRRT的使用率均高于生存组(均P<0.05)。逻辑回归分析进一步证明血pH降低与死亡风险增高密切相关(P<0.001)。血pH每降低0.1个单位,患者死亡风险增加0.304。结论外周血pH降低是H7N9患者死亡风险增高的一个独立危险因素,在临床工作中,监测患者外周血pH并及时纠正患者酸碱失衡可能是H7N9感染患者治疗的重点。
Objective Epidemic of influenza A H7 N9 occurs in mainland China during the annual winter and spring seasons. The increasing tendency of human infection and high mortality leads to a growing focus on the exploration of prognostic factors associating with risk of death in H7 N9 human infection. Our research is to explore the prognostic factors associating with risk of death in H7 N9 infection cases, to decrease the mortality of severe H7 N9 patients and to increase their life qualities. Methods A total of 121 laboratory-confirmed patients were divided into survival and death groups. Clinical data of enrolled patients were compared between two groups. Logistics regressions were conducted to explore the association of death risk and potential prognostic factors. Results Lower level of GFR, PCT, low value of calcium and low value of blood pH were found in death group(all P<0.05). However, higher level of age, CRP, BNP, peak and low value of sodium, chlorine and low value of potassium were also found in death group(all P<0.05). Larger proportion of death cased were given intubation, ECMO and CRRT(all P<0.05). Logistics regression further validated low value of blood pH was associated with death risk(P<0.001). When 0.1 unit of the minimal value of blood pH decrease, the risk of death increased 0.304 folds. Conclusion Decline of blood pH is an independent risk factor associating with death in H7 N9 infection, indicating that monitoring blood pH and keeping acid-base balance in H7 N9 infected patients maybe a key therapeutic strategy in clinic.
Objective Epidemic of influenza A H7 N9 occurs in mainland China during the annual winter and spring seasons. The increasing tendency of human infection and high mortality leads to a growing focus on the exploration of prognostic factors associating with risk of death in H7 N9 human infection. Our research is to explore the prognostic factors associating with risk of death in H7 N9 infection cases, to decrease the mortality of severe H7 N9 patients and to increase their life qualities. Methods A total of 121 laboratory-confirmed patients were divided into survival and death groups. Clinical data of enrolled patients were compared between two groups. Logistics regressions were conducted to explore the association of death risk and potential prognostic factors. Results Lower level of GFR, PCT, low value of calcium and low value of blood pH were found in death group(all P<0.05). However, higher level of age, CRP, BNP, peak and low value of sodium, chlorine and low value of potassium were also found in death group(all P<0.05). Larger proportion of death cased were given intubation, ECMO and CRRT(all P<0.05). Logistics regression further validated low value of blood pH was associated with death risk(P<0.001). When 0.1 unit of the minimal value of blood pH decrease, the risk of death increased 0.304 folds. Conclusion Decline of blood pH is an independent risk factor associating with death in H7 N9 infection, indicating that monitoring blood pH and keeping acid-base balance in H7 N9 infected patients maybe a key therapeutic strategy in clinic.
引文
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[15] TILLMANN B W,KLINGEL M L,IANSAVICHENE A E,et al.Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era:A systematic review[J].J Crit Care,2017,41:64-71.
[16] HONORE P M,JACOBS R,HENDRICKX I,et al.Prevention and treatment of sepsis-induced acute kidney injury:an update[J].Ann Intensive Care,2015,5:51.
[17] YANG M,GAO H,CHEN J,et al.Bacterial coinfection is associated with severity of avian influenza A (H7N9),and procalcitonin is a useful marker for early diagnosis[J].Diagn Microbiol Infect Dis,2016,84(2):165-169.
[2] ZHOU L,REN R,YANG L,et al.Sudden increase in human infection with avian influenza A(H7N9) virus in China,September-December 2016[J].Western Pac Surveill Response J:WPSAR,2017,8(1):6-14.
[3] TANNER W D,TOTH D J,GUNDLAPALLI A V.The pandemic potential of avian influenza A(H7N9) virus:a review[J].Epidemiol Infect,2015,143(16):3359-3374.
[4] VAN R D,LEIJTEN L M,DE G M,et al.Novel avian-origin influenza A (H7N9) virus attaches to epithelium in both upper and lower respiratory tract of humans[J].Am J Pathol,2013,183(4):1137.
[5] XIANG N,LI X,REN R,et al.Assessing change in avian influenza A(H7N9) virus infections during the fourth epidemic-China,September 2015-August 2016[J].Mmwr Morb Mortal Wkly Rep,2016,65(49):1390-1394.
[6] WANG X,JIANG H,WU P,et al.Epidemiology of avian influenza A H7N9 virus in human beings across five epidemics in mainland China,2013-2017:an epidemiological study of laboratory-confirmed case series[J].Lancet Infect Dis,2017,17(8):822-832.
[7] IULIANO A D,JANG Y,JONES J,et al.Increase in human infections with avian influenza a(h7n9) virus during the fifth epidemic-China,October 2016-February 2017[J].Mmwr-Morbid Mortal W,2017,66(9):254-255.
[8] SU S,GU M,LIU D,et al.Epidemiology,evolution,and pathogenesis of h7n9 influenza viruses in five epidemic waves since 2013 in China[J].Trends Microbiol,2017,25(9):713-728.
[9] NIE Q,ZHANG D,WU W,et al.Extracorporeal membrane oxygenation for avian influenza A (H7N9) patient with acute respiratory distress syndrome:a case report and short literature review[J].BMC Pulm Med,2017,17(1):38.
[10] POOVORAWAN Y.Epidemic of avian influenza A (H7N9) virus in China[J].Pathog Glob Health,2014,108(4):169-170.
[11] WANG H,XIAO X,LU J,et al.Factors associated with clinical outcome in 25 patients with avian influenza A (H7N9) infection in Guangzhou,China[J].BMC Infect Dis,2016,16(1):534.
[12] CHENG Q L,DING H,SUN Z,et al.Retrospective study of risk factors for mortality in human avian influenza A(H7N9) cases in Zhejiang Province,China,March 2013 to June 2014[J].Int J Infect Dis,2015,39:95-101.
[13] JI H,GU Q,CHEN L L,et al.epidemiological and clinical characteristics and risk factors for death of patients with avian influenza A H7N9 virus infection from Jiangsu Province,eastern China[J].PLoS One,2014,9(3):e89581.
[14] PHAM T,COMBES A,ROZE H,et al.Extracorporeal membrane oxygenation for pandemic influenza A(H1N1)-induced acute respiratory distress syndrome:a cohort study and propensity-matched analysis[J].AM J Resp Crit Care,2013,187(3):276-285.
[15] TILLMANN B W,KLINGEL M L,IANSAVICHENE A E,et al.Extracorporeal membrane oxygenation (ECMO) as a treatment strategy for severe acute respiratory distress syndrome (ARDS) in the low tidal volume era:A systematic review[J].J Crit Care,2017,41:64-71.
[16] HONORE P M,JACOBS R,HENDRICKX I,et al.Prevention and treatment of sepsis-induced acute kidney injury:an update[J].Ann Intensive Care,2015,5:51.
[17] YANG M,GAO H,CHEN J,et al.Bacterial coinfection is associated with severity of avian influenza A (H7N9),and procalcitonin is a useful marker for early diagnosis[J].Diagn Microbiol Infect Dis,2016,84(2):165-169.