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PT、DD和PLT在新型冠状病毒肺炎重症患者预后评估及基于SIC积分系统指导抗凝治疗的价值研究

The prognosis value of PT, DD and PLT and validation of the efficacy of the SIC score on initiating anticoagulant therapy in severe COVID-19 patients

摘要:

目的:研究凝血酶原时间(PT)、D-二聚体(DD)和血小板计数(PLT)在新型冠状病毒肺炎(COVID-19)重症患者预后评估中的应用,并探讨基于脓毒症诱导凝血病(SIC)积分系统指导抗凝治疗的价值。方法:采用回顾性分析方法,选取2020年1月1日至2月11日序贯入住华中科技大学同济医学院附属同济医院诊断为COVID-19且满足重症标准的420例患者作为研究对象,记录重症时PT、DD、PLT、SIC积分以及确认重症后48 h内是否启动长期抗凝等资料,观察终点为28 d生存或死亡事件。依据28 d生存或死亡事件,分为生存组与死亡组;依据确认重症时是否符合SIC,分为SIC组与非SIC组。分析比较生存组与死亡组PT、DD、PLT的差异,并采用logistic回归及受试者工作特征(ROC)曲线分析评估PT、DD、PLT对COVID-19重症患者28 d死亡事件的影响及预测能力;分析比较SIC组与非SIC组中接受抗凝治疗对28 d病死率的影响。结果:(1)死亡组PT较生存组长[15.1(14.2, 16.6)s比14.3(13.6, 15.1)s Z=-5.922, P<0.001],死亡组DD较生存组高[4.52(1.37, 21.0)μg/ml比1.42 (0.77, 3.66)μg/ml,Z=-6.206, P<0.001],死亡组PLT较生存组低[165(120, 226)×10 9/L比218(157, 281)×10 9/L, Z=-5.171, P<0.001]。logistic回归分析显示PT>14.5 s、DD>3.0 μg/ml、PLT<125×10 9/L均为COVID-19重症患者在校正年龄、性别、慢性肺部基础疾病后28 d死亡事件独立危险因素,其 OR值(95% CI)分别为2.697(1.735~4.195)、2.929(1.880~4.562)和2.632(1.549~4.470), P均<0.001,ROC曲线分析显示,PT、DD、PLT对COVID-19重症患者28 d死亡事件均有一定的预测价值,其ROC曲线下面积(AUC)分别为0.676、0.685和0.659,三者联合预测价值更高,AUC为0.729;(2)SIC组中接受抗凝治疗患者28 d病死率低于未接受抗凝治疗患者(40.0%比66.1%,χ2=5.417, P=0.020),而非SIC组中接受抗凝治疗患者较未接受抗凝治疗患者,28 d病死率差异无统计学意义(29.0%比23.9%,χ2=0.713, P=0.398);进一步行logistic回归分析显示,接受抗凝治疗为SIC组在校正年龄、性别、慢性肺部基础疾病后28 d死亡事件独立保护因素( OR=0.304,95% CI0.115~0.802, P=0.016)。 结论:PT>14.5 s、DD>3.0 μg/ml、PLT<125*10 9/L均为COVID-19重症患者28 d死亡事件的独立危险因素;基于SIC积分系统指导下的抗凝治疗可能有益于改善COVID-19重症患者特定人群28 d病死率。

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abstracts:

Objective:To explore the prognosis value of PT, DD and PLT and validation of the efficacy of the SIC score on initiating anticoagulant therapy in severe COVID-19 patients.Methods:We retrospectively enrolled 420 consecutive patients with severe COVID-19 admitted to Tongji Hospital of Huazhong University of Science and Technology in Wuhan from January 1 to February 11, 2020. A retrospective review of the characteristics of these patients(mainly including PT,DD, PLT and SIC score at the point of meeting severity criteria, underlying disease and so on) were collected through the electronic medical record system of our hospital. The medications for anticoagulant therapy and outcomes (28-day mortality event) were also monitored.1.The patients were divided into Survivor group and Non-survivor group based on the event of 28 d motality.the parameters of coagulation tests and clinical characteristics between these two groups were compared. Furthermore, the association between PT, DD, PLT and 28-day mortality were analyzed by logistic regression analysis. The predictive value of PT, DD, PLT for 28-day mortality were explored by ROC curve analysis. 2.Based on the SIC score, the patients were divided into SIC group and Non-SIC group. The 28-day mortality rates were compared among cases which were receiving anticoagulant therapy or not in SIC group and Non-SIC group The logistic regression was performed to validate the receiving anticoagulant therapy and 28-day mortality between SIC group and Non-SIC group.Results:1.PT in Non-survivor group was significantly prolonged compared with Survivor group[15.1(14.2, 16.6)s vs.14.3(13.6, 15.1s, Z=-5.922, P<0.001].DD in Non-survivor group was significantly elevated compared with Survivor group[4.52(1.37, 21.0) μg/ml.vs 1.42 (0.77, 3.66) μg/ml, Z=-6.206, P<0.001].PLT in Non-survivor group was significantly declined compared with Survivor group[165 (120, 226)×10 9/L.vs 218(157, 281)×10 9/L, Z=-5.171, P<0.001].Furthermore, the logistic regression and ROC curve analysis discovered that PT>14.5s, DD>3.0 μg/ml and PLT<125×10 9/L were independent risk factors for 28-day mortality event when adjusted for age, sex and chronic pulmonary disease, the odds ratio(OR), 95% confidence interval(95% CI) and P value were (2.697, 1.735-4.195, P<0.001), (2.929,1.880-4.562, P<0.001), (2.632, 1.549-4.470, P<0.001), respectively, and all these three parameters had some degree of predictive value for 28-day mortality event, the areas under the ROC curve(AUC) were 0.676, 0.685, 0.659, respectively. When combined together, it had the biggest predictive value(AUC= 0.729). 2. In SIC group, patients who receiving anticoagulant therapy had lower mortality rate compared with ones who not receiving anticoagulant therapy (40%.vs 66.1%, χ2=5.417, P=0.020). However, in Non-SIC group, there was no significant difference on mortality rate between ones who receiving anticoagulant therapy and ones who not (29% vs 23.9%, χ2=0.713, P=0.398). The logistic regression showed that when adjusted for age, sex and chronic pulmonary disease, receiving anticoagulant therapy was independent protective factor for 28-day mortality event only in SIC Group, the OR, 95%CI and P value were 0.304, 0.115-0.802, P=0.016, respectively. Conclusions:PT>14.5 s, DD>3.0 μg/ml and PLT<125×10 9/L were independent risk factors for 28-day mortality of severe COVID-19 patients; Initiating anticoagulant therapy guided by SIC score may improve the outcome of the specific patients with severe COVID-19.

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作者: 白欢 [1] 沈玲 [1] 陈星 [1] 龚家乐 [1] 刘为勇 [1] 孙自镛 [1] 唐宁 [1]
期刊: 《中华检验医学杂志》2020年43卷12期 1205-1211页 ISTICPKUCSCDCA
栏目名称: 论著
DOI: 10.3760/cma.j.cn114452-20200323-00290
发布时间: 2021-01-11
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