D-二聚体、P-选择素、CNP在创伤性颅脑损伤患者中的表达水平及临床意义

doi:10.3877/cma.j.issn.2095-9141.2019.06.003

目的

探讨创伤性颅脑损伤（TBI）患者血清D-二聚体（D-D）、P-选择素（P-selectin）、C型利钠多肽（CNP）浓度的水平变化与TBI临床症状相关性及临床意义，为进一步研究TBI发病机制及治疗提供具有临床价值的信息。

方法

回顾性分析自2015年3月至2019年5月蚌埠市第一人民医院神经外科收治的80例TBI患者的病例资料，根据病情严重程度分为轻度组（n=27）、中度组（n=33）、重度组（n=20），并随机选取同时期内非外伤颅脑疾病患者30例作为对照组，比较各组患者D-D、P-selectin、CNP水平并分析各指标间相关性；从入院治疗后对患者随访1年，根据随访期间生存情况分为存活组（n=71）与死亡组（n=9），比较2组患者D-D、P-selectin、CNP水平，采用Spearman相关系数分析D-D、P-selectin、CNP与TBI临床症状的相关性，多因素Logistic回归分析患者短期死亡危险因素，构建ROC曲线分析比较D-D、P-selectin、CNP对TBI的诊断价值。

结果

轻度组、中度组、重度组的D-D、P-selectin水平高于对照组，中度组、重度组的CNP水平低于轻度组，差异有统计学意义（P<0.05）。D-D、P-selectin与TBI严重程度呈显著正相关（P<0.05），CNP与TBI严重程度呈显著负相关（P<0.05）；1年随访期间，死亡患者共9例（11.25%）；死亡组D-D、P-selectin高于生存组，CNP低于生存组，差异均具有统计学意义（P<0.05）；D-D、P-selectin、CNP是TBI死亡的独立危险因素（P<0.05）；D-D与P-selectin、CNP均呈显著相关关系（P<0.05）；D-D、P-selectin、CNP联合检测对TBI的诊断价值高于单独检测（P<0.05）。

结论

D-D、P-selectin、CNP水平与TBI发生和发展密切相关，在诊断和治疗过程中应关注其水平变化；且D-D、P-selectin、CNP联合检测可进一步提高对该病的诊断和预测价值。

关键词: 创伤性颅脑损伤, D-二聚体, P-选择素, C型利钠多肽

Objective

To investigate the expression levels and clinical significance of D-dimer (D-D), P-selectin and C-type natriuretic polypeptide (CNP) in patients with traumatic brain injury (TBI) and provide the information of clinical value to further study the pathogenesis and treatment of TBI.

Methods

The data of 80 TBI patients in Bengbu First People’s Hospital from March 2015 to May 2019 were retrospectively analyzed. Patients were divided into groups according to the severity, namely, mild group (n=27), moderate group (n=33), severe group (n=20). Thirty patients with non-traumatic brain diseases were randomly selected as the control group. The levels of D-D, P-selectin and CNP in each group were compared and the correlation among the indexes was analyzed; The patients were followed up for 1 year after admission, and were divided into survival group (n=71) and death group (n=9) according to their survivals. The levels of D-D, P-selectin and CNP were compared between groups. Spearman correlation coefficient was used to analyze the correlation between D-D, P-selectin, CNP and TBI clinical symptoms. Multivariate logistic regression was used to analyze the risk factors of short-term mortality. The diagnostic value of D-D, P-selectin and CNP were determined by ROC curve.

Results

The CNP level of D-D and P-selectin in the control group was lower than that in the mild group, moderate group and the severe group, while the level of CNP in the mild group was higher than that in the moderate group and severe group (P<0.05). D-D and P-selectin were positively correlated with TBI severity (P<0.05), while CNP was negatively correlated with TBI severity (P<0.05). During the one-year follow-up period, 9 patients died (11.25%). D-D and P-selectin in death group were higher than those in survival group and CNP was lower than those in survival group (P<0.05). D-D, P-selectin and CNP were independent risk factors for TBI death (P<0.05); D-D was significantly correlated with P-selectin and CNP (P<0.05); The predictive value of combined detection of D-D, P-selectin and CNP in the diagnosis of TBI was higher than that of single detection (P<0.05).

Conclusion

The levels of D-D, P-selectin and CNP are closely related to the occurrence and development of TBI. In the diagnosis and treatment process, attention should be paid to the change of its level and combined detection of D-D, P-selectin and CNP can further improve the diagnosis and prediction value of the disease.

Key words: Traumatic brain injury, D-dimer, P-selectin, C-type natriuretic polypeptide

表1 4组患者的D-D、P-selectin、CNP水平比较（±s）

组别	例数	D-D(ng/L)	P-selectin(mg/L)	CNP(ng/L)
对照组	30	1.19±0.13	15.03±2.06	15.03±4.25
轻度组	27	2.33±0.48^a	18.97±5.54^a	6.42±2.36^a
中度组	33	4.57±1.20^ab	22.64±7.73^ab	4.01±1.04^ab
重度组	20	6.89±3.37^abc	26.87±10.32^abc	2.35±0.56^abc
F值	?	193.943	54.008	90.935
P值	?	<0.001	<0.001	<0.001

表1 4组患者的D-D、P-selectin、CNP水平比较（±s）

组别	例数	D-D(ng/L)	P-selectin(mg/L)	CNP(ng/L)
对照组	30	1.19±0.13	15.03±2.06	15.03±4.25
轻度组	27	2.33±0.48^a	18.97±5.54^a	6.42±2.36^a
中度组	33	4.57±1.20^ab	22.64±7.73^ab	4.01±1.04^ab
重度组	20	6.89±3.37^abc	26.87±10.32^abc	2.35±0.56^abc
F值	?	193.943	54.008	90.935
P值	?	<0.001	<0.001	<0.001

图1 D-D、P-selectin、CNP与TBI严重程度相关性

表2 生存组和死亡组临床资料比较（±s）

临床资料	生存组(n=71)	死亡组(n=9)	t/χ²值	P值
性别（男/女）	35/36	4/5	0.006	0.937
年龄（岁）	53.57±5.30	55.62±6.61	1.063	0.291
BMI(kg/m²)	22.41±3.54	21.97±3.47	0.352	0.726
病程（月）	2.05±0.61	2.11±0.74	0.272	0.787
住院时间(d)	10.41±2.54	13.67±3.88	3.402	0.001
GCS评分（分）	10.22±1.59	14.71±3.65	6.656	<0.001
D-D(ng/L)	2.54±1.02	7.11±2.30	10.630	<0.001
P-selectin(mg/L)	20.10±6.69	28.64±8.58	3.494	0.001
CNP(ng/L)	5.65±1.87	1.04±0.05	7.354	<0.001

表2 生存组和死亡组临床资料比较（±s）

临床资料	生存组(n=71)	死亡组(n=9)	t/χ²值	P值
性别（男/女）	35/36	4/5	0.006	0.937
年龄（岁）	53.57±5.30	55.62±6.61	1.063	0.291
BMI(kg/m²)	22.41±3.54	21.97±3.47	0.352	0.726
病程（月）	2.05±0.61	2.11±0.74	0.272	0.787
住院时间(d)	10.41±2.54	13.67±3.88	3.402	0.001
GCS评分（分）	10.22±1.59	14.71±3.65	6.656	<0.001
D-D(ng/L)	2.54±1.02	7.11±2.30	10.630	<0.001
P-selectin(mg/L)	20.10±6.69	28.64±8.58	3.494	0.001
CNP(ng/L)	5.65±1.87	1.04±0.05	7.354	<0.001

表3 死亡危险因素的Logistic回归分析

因素	偏回归系数	标准误	Wald值	P值	OR(95%CI)
D-D	0.538	0.274	3.866	0.049	1.039(1.001~1.078)
P-selectin	0.671	0.263	6.478	0.011	2.778(0.672~0.925)
CNP	0.531	0.239	4.929	0.026	1.670(1.448~4.924)
住院时间	-0.014	0.056	0.060	0.807	0.534(1.102~2.135)
GCS评分	0.173	0.218	0.630	0.427	1.025(1.001~1.050)

表3 死亡危险因素的Logistic回归分析

因素	偏回归系数	标准误	Wald值	P值	OR(95%CI)
D-D	0.538	0.274	3.866	0.049	1.039(1.001~1.078)
P-selectin	0.671	0.263	6.478	0.011	2.778(0.672~0.925)
CNP	0.531	0.239	4.929	0.026	1.670(1.448~4.924)
住院时间	-0.014	0.056	0.060	0.807	0.534(1.102~2.135)
GCS评分	0.173	0.218	0.630	0.427	1.025(1.001~1.050)

图2 D-D、P-selectin与CNP相关性

图3 D-D、P-selectin、CNP诊断TBI的ROC曲线

表4 D-D、P-selectin、CNP诊断创伤性颅脑损伤的效能指标

项目	AUC	敏感性(%)	特异性(%)	约登指数	AUC的95%CI
D-D	0.855	100.0	58.8	0.588	0.775~0.934
P-selectin	0.629	55.2	72.5	0.277	0.500~0.758
CNP	0.961	86.2	96.1	0.823	0.923~1.000
联合	0.980	93.1	96.1	0.892	0.955~1.000

表4 D-D、P-selectin、CNP诊断创伤性颅脑损伤的效能指标

项目	AUC	敏感性(%)	特异性(%)	约登指数	AUC的95%CI
D-D	0.855	100.0	58.8	0.588	0.775~0.934
P-selectin	0.629	55.2	72.5	0.277	0.500~0.758
CNP	0.961	86.2	96.1	0.823	0.923~1.000
联合	0.980	93.1	96.1	0.892	0.955~1.000

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Expression level and clinical significance of D-D, P-selectin and CNP in patients with traumatic brain injury

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Expression level and clinical significance of D-D, P-selectin and CNP in patients with traumatic brain injury