ALT/ALP比值、PLR与老年脓毒症休克患者并发肝损伤的关系

doi:10.11958/20240637

摘要/Abstract

摘要：

目的探讨丙氨酸转氨酶（ALT）/碱性磷酸酶（ALP）比值、血小板计数（PLT）与淋巴细胞（LYM）比值（PLR）对老年脓毒症休克并发肝损伤患者预后的预测价值。方法回顾性分析116例脓毒症休克并发肝损伤患者的临床资料，根据肝损伤程度分为轻度组39例、中度组47例和重度组30例。并根据患者入院28 d的存活情况将患者分为死亡组69例和存活组47例。收集急性生理与慢性健康Ⅱ（APACHEⅡ）评分、序贯器官衰竭（SOFA）评分；检测患者外周血中PLT、LYM，计算PLR；测定ALT、ALP，计算ALT/ALP比值；检测白细胞计数、血乳酸、C反应蛋白等实验室指标。采用多因素Logistic回归分析脓毒症休克并发肝损伤患者预后的影响因素，受试者工作特征（ROC）曲线分析ALT/ALP比值、PLR对脓毒症休克并发肝损伤患者预后的预测价值。结果轻度组、中度组和重度组血清ALT、ALP、ALT/ALP比值、PLT、PLR依次升高，LYM依次降低（P<0.05）。死亡组年龄、APACHEⅡ评分、SOFA评分、PLR、ALT/ALP比值、血乳酸水平高于存活组（P<0.05），2组肝损伤程度比较差异有统计学意义（P<0.05）。多因素Logistic回归分析结果显示，高SOFA评分、高PLR、高ALT/ALP比值、中重度肝损伤是脓毒症休克并发肝损伤患者死亡的危险因素。ROC曲线分析显示，联合ALT/ALP比值、PLR的预测效能[曲线下面积为0.915（95%CI：0.849~0.959），敏感度、特异度分别为94.20%、89.36%]优于单一预测（P<0.05）。结论高ALT/ALP比值和PLR与肝损伤程度加重及预后不良有关，可作为预测脓毒症休克并发肝损伤患者预后的潜在标志物。

关键词: 休克, 脓毒性, 老年人, 预后, 丙氨酸转氨酶, 碱性磷酸酶, 肝损伤, 血小板/淋巴细胞比值

Abstract:

Objective To investigate the prognostic value of alanine aminotransferase (ALT)/alkaline phosphatase (ALP) ratio, platelet (PLT) count/lymphocyte (LYM) ratio (PLR) in elderly patients with septic shock complicated with liver injury. Methods The clinical data of 116 patients with septic shock complicated with liver injury were retrospectively analyzed. According to the degree of liver injury, patients were divided into the mild group (39 cases), the moderate group (47 cases) and the severe group (30 cases). According to the survival of patients 28 days after admission, patients were divided into the death group (69 cases) and the survival group (47 cases). Acute physiological score, chronic healthⅡ(APACHE Ⅱ) score and sequential organ failure (SOFA) score were collected. PLT and LYM in peripheral blood were detected, and PLR was calculated. ALT and ALP were measured and ALT/ALP ratio was calculated. White blood cell count, blood lactic acid, C-reactive protein and other laboratory indicators were detected. Multivariate Logistic regression was used to analyze prognostic factors of patients with septic shock complicated with liver injury. The predictive values of ALT/ALP ratio and PLR on the prognosis of patients with septic shock complicated with liver injury were analyzed by receiver operating characteristic (ROC) curve. Results Serum ALT and ALP levels, ALT/ALP ratio, PLT and PLR were increased successively in the mild group, the moderate group and the severe group, while LYM was decreased successively in the three groups (P<0.05). The age, APACHE Ⅱ score, SOFA score, PLR, ALT/ALP ratio and blood lactic acid level were higher in the death group than those in the survival group (P<0.05). There was no significant difference in liver injury degree between the two groups (P<0.05). Multivariate Logistic regression analysis showed that high SOFA score, high PLR, high ALT/ALP ratio and moderate to severe liver injury were risk factors for death in patients with septic shock complicated with liver injury. ROC curve analysis showed that the combined ALT/ALP ratio and PLR prediction efficiency [area under the curve 0.915 (95%CI: 0.849-0.959), sensitivity and specificity 94.20% and 89.36%, respectively] was superior to single prediction (P<0.05). Conclusion Increased ALT/ALP ratio and PLR are associated with aggravation of liver injury and poor prognosis in patients with septic shock. ALT/ALP ratio and PLR can be used as prognostic markers.

Key words: shock, sepsis, elderly, prognosis, alanine aminotransferase, alkaline phosphatase, liver injury, platelet/lymphocyte ratio

中图分类号:

R631

图/表 5

参考文献 22

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组别	n	ALT/（U/L）	ALP/（U/L）	ALT/ALP比值	PLT/（×10⁹/L）	LYM/（×10⁹/L）	PLR
轻度组	39	62.78±7.47	135.20±.89	0.46±0.02	368.27±20.92	2.36±0.10	161.67±20.31
中度组	47	75.05±11.30^a	142.25±6.95^a	0.54±0.06^a	451.07±37.74^a	1.96±0.29^a	231.27±28.72^a
重度组	30	90.06±9.54^ab	147.67±4.08^ab	0.62±0.01^ab	490.80±17.23^ab	1.62±0.09^ab	301.32±8.73^ab
F		67.119^＊	50.598^＊	144.472^＊	173.663^＊	114.590^＊	336.943^＊

组别	n	ALT/（U/L）	ALP/（U/L）	ALT/ALP比值	PLT/（×10⁹/L）	LYM/（×10⁹/L）	PLR
轻度组	39	62.78±7.47	135.20±.89	0.46±0.02	368.27±20.92	2.36±0.10	161.67±20.31
中度组	47	75.05±11.30^a	142.25±6.95^a	0.54±0.06^a	451.07±37.74^a	1.96±0.29^a	231.27±28.72^a
重度组	30	90.06±9.54^ab	147.67±4.08^ab	0.62±0.01^ab	490.80±17.23^ab	1.62±0.09^ab	301.32±8.73^ab
F		67.119^＊	50.598^＊	144.472^＊	173.663^＊	114.590^＊	336.943^＊

组别		n			年龄/岁		性别（男/女）				吸烟史（有/无）	饮酒史（有/无）			体质量指数/ （kg/m²）				高血压（有/无）			高脂血症（有/无）			糖尿病（有/无）			感染部位（肺/腹腔/皮肤及软组织/泌尿系统）
死亡组		69			67.96±2.17		42/27				31/38	29/40			23.01±2.71				30/39			27/42			21/48			28/16/9/16
存活组		47			64.07±2.64		25/22				24/23	18/29			23.52±2.47				24/23			22/25			18/29			15/13/6/13
t或χ²					8.252^＊		0.676				0.422	0.161			1.041				0.647			0.676			0.775			1.015
组别	肝损伤程度（轻度/中度/重度）					APACHEⅡ评分/分			SOFA 评分/分				D-二聚体/（mg/L）				凝血酶原时间/s			INR			WBC/ （×10⁹/L）			PLT/ （×10⁹/L）				LYM/ （×10⁹/L）
死亡组	28/21/20					18.32±2.32			10.10±2.05				0.53±0.11				15.31±1.95			1.58±0.33			9.87±3.01			444.06±97.64				1.88±0.44
存活组	11/26/10					16.01±1.92			6.37±1.39				0.51±0.09				14.48±1.78			1.57±0.28			8.91±2.82			435.94±85.49				1.94±0.38
t或χ²	7.368^＊					5.642^＊			10.886^＊				1.124				1.309			0.041			1.730			0.462				0.753
组别			PLR					尿酸/（μmol/L）						血肌酐/（μmol/L）				尿素氮/（mmol/L）						ALT/（U/L）					ALP/（U/L）
死亡组			232.67±8.01					353.38±62.46						96.00±20.76				6.74±2.22						73.71±20.92					144.06±11.05
存活组			210.70±10.34					352.49±46.73						93.51±20.16				6.31±2.16						71.87±19.60					142.49±10.66
t或χ²			12.882^＊					0.083						0.641				1.026						0.478					0.762
组别				ALT/ALP比值						TBIL/（μmol/L）						CRP/（mg/L）					PCT/（μg/L）						血乳酸/（mmol/L）
死亡组				0.53±0.05						45.93±11.80						20.11±4.39					0.94±0.20						1.95±0.21
存活组				0.51±0.02						41.95±12.50						19.80±4.46					0.96±0.19						1.72±0.18
t或χ²				2.711^＊						1.738						0.375					0.099						5.558^＊

组别		n			年龄/岁		性别（男/女）				吸烟史（有/无）	饮酒史（有/无）			体质量指数/ （kg/m²）				高血压（有/无）			高脂血症（有/无）			糖尿病（有/无）			感染部位（肺/腹腔/皮肤及软组织/泌尿系统）
死亡组		69			67.96±2.17		42/27				31/38	29/40			23.01±2.71				30/39			27/42			21/48			28/16/9/16
存活组		47			64.07±2.64		25/22				24/23	18/29			23.52±2.47				24/23			22/25			18/29			15/13/6/13
t或χ²					8.252^＊		0.676				0.422	0.161			1.041				0.647			0.676			0.775			1.015
组别	肝损伤程度（轻度/中度/重度）					APACHEⅡ评分/分			SOFA 评分/分				D-二聚体/（mg/L）				凝血酶原时间/s			INR			WBC/ （×10⁹/L）			PLT/ （×10⁹/L）				LYM/ （×10⁹/L）
死亡组	28/21/20					18.32±2.32			10.10±2.05				0.53±0.11				15.31±1.95			1.58±0.33			9.87±3.01			444.06±97.64				1.88±0.44
存活组	11/26/10					16.01±1.92			6.37±1.39				0.51±0.09				14.48±1.78			1.57±0.28			8.91±2.82			435.94±85.49				1.94±0.38
t或χ²	7.368^＊					5.642^＊			10.886^＊				1.124				1.309			0.041			1.730			0.462				0.753
组别			PLR					尿酸/（μmol/L）						血肌酐/（μmol/L）				尿素氮/（mmol/L）						ALT/（U/L）					ALP/（U/L）
死亡组			232.67±8.01					353.38±62.46						96.00±20.76				6.74±2.22						73.71±20.92					144.06±11.05
存活组			210.70±10.34					352.49±46.73						93.51±20.16				6.31±2.16						71.87±19.60					142.49±10.66
t或χ²			12.882^＊					0.083						0.641				1.026						0.478					0.762
组别				ALT/ALP比值						TBIL/（μmol/L）						CRP/（mg/L）					PCT/（μg/L）						血乳酸/（mmol/L）
死亡组				0.53±0.05						45.93±11.80						20.11±4.39					0.94±0.20						1.95±0.21
存活组				0.51±0.02						41.95±12.50						19.80±4.46					0.96±0.19						1.72±0.18
t或χ²				2.711^＊						1.738						0.375					0.099						5.558^＊

因素	β	SE	Wald χ²	P	OR（95%CI）
PLR	0.682	0.287	5.647	0.003	1.978（1.127~3.471）
ALT/ALP比值	0.715	0.301	5.643	0.004	2.044（1.133~3.688）
SOFA评分	0.815	0.325	6.289	0.002	2.259（1.195~4.272）
肝损伤程度	0.915	0.357	6.569	<0.001	2.497（1.240~5.026）
常数项	15.325	4.192	13.365	<0.001	4 524 420.23