血浆皮质醇与老年性社区获得性肺炎预后的关系研究
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摘要
目的 :探讨血浆皮质醇质量浓度与老年性社区获得性肺炎(community-acquired pneumonia, CAP)患者预后的关系。方法:前瞻性选取2014年1—12月南通大学附属医院急诊科收住院符合CAP诊断的老年患者,入选后第1个24 h内对CAP患者进行CURB-65评分、血浆皮质醇、促肾上腺皮质激素(adrenocorticotropic hormone, ACTH)、C反应蛋白(C-reactive protein, CRP)、白细胞等指标的检测,并记录患者的一般资料、既往病史、达到临床稳定的时间,以28 d是否存活为二分法分为存活组和死亡组,比较28 d存活组与死亡组患者之间各指标的差异,通过Logistic回归进行相关统计学分析。结果:研究最终入选CAP患者60例,所有患者的28 d病死率为25%,Logistic回归分析显示28 d病死率的独立危险因素是血浆皮质醇及血钠,血浆皮质醇比值比(odds ratio, OR)1.016,95%CI(1.005, 1.028),血钠OR0.893,95%CI(0.812, 0.983)。与存活组相比,死亡组的血浆皮质醇较有明显增高,而血钠显著降低(P<0.05)。结论:血浆皮质醇、血钠是老年住院CAP患者判断临床预后的独立危险因素,血浆皮质醇升高和血钠水平的降低与不良预后有关。
Objective: To evaluate the relationships between the prognosis of community-acquired pneumonia(CAP) and plasma cortisol. Methods: A prospective observational study was conducted, elderly patients who fulfillied the CAP criteria admitted to the ED of Affiliated Hospital of Nantong University from January to December 2014 were enrolled. The elderly whose physical examination were healthy at the same period were chosen as the control group. Plasma cortisol, adrenocorticotropic hormone(ACTH), C-reactive protein(CRP), leucocyte count and other indicators were detected and CURB-65 scores were calculated at enrollment. Record the patients′ general characteristics, past history, the time to clinical stability. Various indicators were compared between patients with survivors and non-survivors. The differences were assessed by Logistic regression analysis. Results: 60 CAP patients were included in the study. The 28-day mortality of all the CAP patients was25%. In Logistic regression analysis, serum sodium and plasma cortisol levels were independently associated with 28-day mortality(P<0.05). Plasma cortisol levels in non-survivors were significantly higher than survivors(P<0.05), while serum sodium levels were significantly lower in non-survivors( P <0.05). Conclusion: Plasma cortisol and serum sodium are independently associated with the clinical outcomes in hospitalised CAP elderly patients. The increase of plasma cortisol together with low serum sodium are associated with poor prognosis.
Objective: To evaluate the relationships between the prognosis of community-acquired pneumonia(CAP) and plasma cortisol. Methods: A prospective observational study was conducted, elderly patients who fulfillied the CAP criteria admitted to the ED of Affiliated Hospital of Nantong University from January to December 2014 were enrolled. The elderly whose physical examination were healthy at the same period were chosen as the control group. Plasma cortisol, adrenocorticotropic hormone(ACTH), C-reactive protein(CRP), leucocyte count and other indicators were detected and CURB-65 scores were calculated at enrollment. Record the patients′ general characteristics, past history, the time to clinical stability. Various indicators were compared between patients with survivors and non-survivors. The differences were assessed by Logistic regression analysis. Results: 60 CAP patients were included in the study. The 28-day mortality of all the CAP patients was25%. In Logistic regression analysis, serum sodium and plasma cortisol levels were independently associated with 28-day mortality(P<0.05). Plasma cortisol levels in non-survivors were significantly higher than survivors(P<0.05), while serum sodium levels were significantly lower in non-survivors( P <0.05). Conclusion: Plasma cortisol and serum sodium are independently associated with the clinical outcomes in hospitalised CAP elderly patients. The increase of plasma cortisol together with low serum sodium are associated with poor prognosis.
引文
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[13] ANNANE D, BRIEGEL J, SPRUNG CL. Corticosteroid insufficiency in acutely ill patients[J]. N Engl J Med, 2003,348(21):2157-2159.
[14] MUELLER C, BLUM CA, TRUMMLER M, et al. Association of adrenal function and disease severity in community-acquired pneumonia[J]. PLoS One, 2014, 9(6):e99518.
[15] KOLDITZ M, HALANK M, SCHULTE-HUBBERT B, et al. Adrenal function is related to prognosis in moderate community-acquired pneumonia[J]. Eur Respir J, 2010, 36(3):615-621.
[16] NICKLER M, OTTIGER M, STEUER C, et al. Time-dependent association of glucocorticoids with adverse outcome in community-acquired pneumonia:a 6-year prospective cohort study[J]. Crit Care, 2017, 21(1):72.
[2] DANDONA P, NIX D, WILSON MF, et al. Procalcitonin increase after endotoxin injection in normal subjects[J]. J Clin Endocrinol Metab, 1994, 79(6):1605-1608.
[3] CHRIST-CRAIN M, STOLZ D, JUTLA S, et al. Free and total cortisol levels as predictors of severity and outcome in community-acquired pneumonia[J]. Am J Respir Crit Care Med, 2007, 176(9):913-920.
[4] SALLUH JI, SHINOTSUKA CR, SOARES M, et al. Cortisol levels and adrenal response in severe community-acquired pneumonia:a systematic review of the literature[J]. J Crit Care, 2010, 25(3):541.e1-541.e8.
[5]中华医学会呼吸病学分会.社区获得性肺炎诊断和治疗指南(草案)[J].中华结核和呼吸杂志, 1999, 29(4):6-8.
[6] ALIBERTI S, PEYRANI P, FILARDO GA, et al. Association between time to clinical stability and out comes after discharge in hospitalized patients with community-acquired pneumonia[J]. Chest, 2011, 140(2):482-488.
[7] SCHUETZ P, CHRIST-CRAIN M, THOMANN R, et al.Effect of procalcitonin-based guidelines vs standard guidelines on antibiotic use in lower respiratory tract infections:the ProHOSP randomized controlled trial[J]. JAMA, 2009,302(10):1059-1066.
[8] MANDELL LA, WUNDERINK RG, ANZUETO A, et al.Infectious diseases society of America/American thoracic society consensus guidelines on the management of community-acquired pneumonia in adults[J]. Clin Infect Dis,2007, 44(Suppl 2):S27-S72.
[9] GIBBISON B, ANGELINI GD, LIGHTMAN SL. Dynamic output and control of the hypothalamic-pituitary-adrenal axis in critical illness and major surgery[J]. Br J Anaesth,2013, 111(3):347-360.
[10] VENKATESH B, COHEN J, HICKMAN I, et al. Evidence of altered cortisol metabolism in critically ill patients:a prospective study[J]. Intensive Care Med, 2007, 33(10):1746-1753.
[11] HO JT, AL-MUSALHI H, CHAPMAN MJ, et al. Septic shock and sepsis:a comparison of total and free plasma cortisol levels[J]. J Clin Endocrinol Metab, 2006, 91(1):105-114.
[12] WEISSMAN C. The metabolic response to stress:an overview and update[J]. Anesthesiology, 1990, 73(2):308-327.
[13] ANNANE D, BRIEGEL J, SPRUNG CL. Corticosteroid insufficiency in acutely ill patients[J]. N Engl J Med, 2003,348(21):2157-2159.
[14] MUELLER C, BLUM CA, TRUMMLER M, et al. Association of adrenal function and disease severity in community-acquired pneumonia[J]. PLoS One, 2014, 9(6):e99518.
[15] KOLDITZ M, HALANK M, SCHULTE-HUBBERT B, et al. Adrenal function is related to prognosis in moderate community-acquired pneumonia[J]. Eur Respir J, 2010, 36(3):615-621.
[16] NICKLER M, OTTIGER M, STEUER C, et al. Time-dependent association of glucocorticoids with adverse outcome in community-acquired pneumonia:a 6-year prospective cohort study[J]. Crit Care, 2017, 21(1):72.