脓毒症患者发生正常甲状腺性病态综合征的相关因素

doi:10.19723/j.issn.1671-167X.2024.03.021

摘要/Abstract

摘要：

目的: 评估脓毒症患者正常甲状腺性病态综合征(euthyroid sick syndrome, ESS)的患病率及其影响因素。方法: 选择2017年1月—2023年1月上海市第一人民医院急诊危重病科诊断为脓毒症的365例患者的病例资料进行回顾性分析, 收集患者的相关临床数据。根据是否合并ESS, 将患者分为ESS组(103例)和非ESS组(262例)。评估脓毒症患者ESS的患病率, 对其影响因素进行多因素Logistic回归分析, 比较两组患者30 d的生存率, 探索游离三碘甲腺原氨酸(free triiodothyronine, FT3)预测脓毒症患者死亡的最佳截断值。结果: 脓毒症患者中合并ESS者有103例, 占总病例数的28.2%。ESS组脓毒症严重程度重于非ESS组, 差异有统计学意义(P＜0.05);ESS组急性生理学和慢性健康评估Ⅱ(acute physiology and chronic health evaluationⅡ, APACHEⅡ)、序贯器官衰竭(sequential organ failure assessment, SOFA)评分明显高于非ESS组(P < 0.05); ESS组C反应蛋白(C-reactive protein, CRP)、降钙素原(procalcitonin, PCT)、血清淀粉样蛋白A(serum amyloid A, SAA)、白介素-6(interleukin-6, IL-6)均高于非ESS组; ESS组总胆固醇(total cholesterol, TC)、高密度脂蛋白胆固醇(high-density liptein cholesterol, HDL-C)低于非ESS组, 差异有统计学意义(P < 0.05)。多因素Logistic回归分析结果显示, PCT、IL-6、CRP、SAA、部分激活的凝血活酶时间(activated partial thromboplatin time, APTT)是脓毒症患者ESS发生的独立危险因素(OR值分别为1.105、1.006、1.005、1.009、1.033, 95% CI分别为1.044~1.170、1.001~1.012、1.001~1.009、1.005~1.014、1.004~1.062, P < 0.05)。ESS组30 d生存率显著低于非ESS组, Long-rank卡方检验值16.611, 差异有统计学意义(P < 0.05)。脓毒症患者FT3预测死亡的受试者工作特征曲线下面积(area under the curve, AUC)为0.924 (95% CI 0.894~0.954)。血清FT3截断点为3.705 pmol/L, 特异性为0.868, 敏感性为0.950。结论: 脓毒症患者的ESS发生率为28.2%, 且预后不良; PCT、IL-6、CRP、SAA、APTT是脓毒症患者ESS发生的独立危险因素, HDL-C是保护性因素; FT3是脓毒症患者预测死亡的潜在新型生物标志物。

关键词: 正常甲状腺性病态综合征, 脓毒症, 患病率, 影响因素, 预后

Abstract:

Objective: To evaluate the prevalence of euthyroid sick syndrome (ESS) in sepsis patients and to explore its influencing factors. Methods: In the study, 365 patients diagnosed with sepsis in the emergency critical care department of Shanghai First People's Hospital from January 2017 to January 2023 were retrospectively enrolled. The patients were divided into ESS and non-ESS groups based on whether the patients were complicated with ESS.Baseline variables and relevant clinical data of the enrolled patients were collected. The prevalence of ESS in sepsis patients and its influencing factors were evaluated by multivariate Logistic regression analysis, and the 30-day survival rates were compared between the two groups. The optimal cutoff value for free triiodothyronine (FT3) was explored to predict death in the patients with sepsis. Results: There were 103 sepsis patients with ESS, accounting for 28.2% of the total cases. The severity of sepsis in ESS group was significantly higher than that in non-ESS group (P < 0.05). The acute physiology and chronic health evaluationⅡ(APACHEⅡ)score and sequential organ failure assessment (SOFA) score of ESS group were significantly higher than those of non-ESS group (P < 0.05). C-reactive protein (CRP), procalcitonin (PCT), serum amyloid A (SAA) and interleukin-6 (IL-6) in ESS group were higher than those in non-ESS group. total cholesterol(TC)and high-density liptein cholesterol(HDL-C)in ESS group were lower than those in non-ESS group, and the differences were statistically significant (P < 0.05).Multivariate Logistic regression analysis showed that PCT, IL-6, CRP, SAA and activated partial thromboplatin time (APTT) were independent risk factors for ESS in the sepsis patients (OR values were 1.105, 1.006, 1.005, 1.009 and 1.033, respectively; 95% CI were 1.044-1.170, 1.001-1.012, 1.001-1.009, 1.005-1.014, 1.004-1.062, respectively, P < 0.05).The 30-day survival rate in ESS group was significantly lower than that in non-ESS group, the Long-rank chi-square test value was 16.611, and the difference was statistically significant (P < 0.05).The receiver operation characteristic area under the curve (AUCROC)of FT3 predicted death in the patients with sepsis was 0.924 (95% CI 0.894-0.954). The serum FT3 cutoff point was 3.705 pmol/L, the specificity was 0.868, and the sensitivity was 0.950. Conclusion: In this study, the incidence of ESS in sepsis patients was determined to be 28.2% with poor prognosis. The results showed that PCT, IL-6, CRP, SAA and APTT were independent risk factors for ESS in sepsis patients, while HDL-C was a protective factor (P < 0.05). FT3 is a novel potential biomarker for predicting death in patients with sepsis.

Key words: Euthyroid sick syndrome (ESS), Sepsis, Prevalence, Influencing factors, Prognosis

中图分类号:

R459.7

曾媛媛,谢云,陈道南,王瑞兰. 脓毒症患者发生正常甲状腺性病态综合征的相关因素[J]. 北京大学学报（医学版）, 2024, 56(3): 526-532.

Yuanyuan ZENG,Yun XIE,Daonan CHEN,Ruilan WANG. Related factors of euthyroid sick syndrome in patients with sepsis[J]. Journal of Peking University (Health Sciences), 2024, 56(3): 526-532.

图/表 7

图1

表1

患者一般临床资料对比"

Variable	Non-ESS group (n=262)	ESS group (n=103)	t/χ²	P
Age/years, ${\bar x}$ ± s	66.00±17.21	68.50±17.90	-1.220	0.220
Female, n(%)	112 (42.74)	46 (44.66)	0.110	0.740
BMI/(kg/m²)， ${\bar x}$ ± s	23.54±8.28	24.09±10.08	0.408	0.723
History of smoking, n(%)	60 (22.90)	20 (19.41)	0.524	0.699
Hypertension, n(%)	102 (38.90)	33 (32.03)	1.507	0.220
Diabetes, n(%)	91 (34.73)	32 (31.06)	0.444	0.505
Coronary heart disease, n(%)	21 (8.01)	8 (7.76)	0.006	1.000
Hypohepatia, n(%)	16 (6.10)	5 (4.85)	0.213	0.830
Renal inadequacy，n(%)	39 (14.88)	11 (10.67)	1.100	0.370
Sepsis, n(%)	204 (77.87)	66 (64.07)	7.297	0.007
Septic shock, n(%)	58 (22.13)	37 (35.92)
Infection site, n(%)
Pulmonary infection	93 (35.49)	36 (34.95)	1.532	0.170
Intestinal infection	87 (33.20)	28 (27.18)
Urinary tract	25 (9.54)	12 (11.65)
Skin subcutaneous tissue	23 (8.77)	10 (9.70)
Others	34 (12.97)	17 (16.50)
APACHEⅡ, ${\bar x}$ ± s	17.54±9.27	19.86±8.68	2.110	0.035
SOFA, ${\bar x}$ ± s	7.00±4.76	8.37±4.90	2.370	0.018

表1

表2

患者相关临床指标对比"

Variable	Non-ESS group (n=262)	ESS group (n=103)	t/Z	P
CRP/(mg/L), M(P₂₅, P₇₅)	83.9 (29.5，166.9)	115.1 (64.8，235.2)	2.916	0.004
SAA/(mg/L), M(P₂₅, P₇₅)	83.8 (53.9，103.0)	146.9 (86.8，242.4)	5.331	0.000
PCT/(mg/L), M(P₂₅, P₇₅)	2.81 (1.89，8.68)	8.17 (3.24，14.79)	6.508	0.000
IL-6/(ng/L), M(P₂₅, P₇₅)	54.53 (30.13，77.62)	88.17 (40.25，171.00)	2.926	0.003
Lymphocyte count, M(P₂₅, P₇₅)	0.77 (0.42，1.03)	0.77 (0.55，1.48)	1.544	0.123
TC/(mmol/L), ${\bar x}$ ± s	3.17±1.36	2.66±1.05	3.360	0.001
TG/(mmol/L), ${\bar x}$ ± s	1.69±1.24	1.73±1.11	-0.239	0.811
HDL-C/(mmol/L), ${\bar x}$ ± s	1.00±0.08	0.61±0.41	4.950	0.000
LDL-C/(mmol/L), ${\bar x}$ ± s	1.64± 0.97	1.64±1.49	-0.092	0.927
PT/s, ${\bar x}$ ± s	15.51±3.93	16.77±6.15	-1.910	0.057
APTT/s, ${\bar x}$ ± s	35.11±10.19	43.56±16.57	-4.810	0.000
Fibrinogen concentration/(g/L), ${\bar x}$ ± s	2.20±0.91	1.98±0.24	2.090	0.090
Total plasma protein/(g/L), ${\bar x}$ ± s	47.66±17.28	48.77±15.73	-0.584	0.560
Albumin /(g/L), ${\bar x}$ ± s	29.55±5.22	29.56±4.85	-0.031	0.975
Prealbumin/(mg/L), ${\bar x}$ ± s	113.11±57.79	109.61±66.08	0.469	0.640

表2

表3

图2

图3

表4

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FT3-cutoff value	Sensitivity/%	Specificity/%	Youden index
3.280	0.917	0.884	0.801
3.320	0.917	0.868	0.785
3.705	0.950	0.868	0.818
4.270	0.975	0.793	0.768
4.485	0.983	0.702	0.685

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