摘要
目的评估D-二聚体对动脉瘤性蛛网膜下腔出血(aSAH)患者预后的影响。方法回顾性分析2013年12月至2019年6月于四川大学华西医院被首次诊断为aSAH的患者资料,共1658例,所有患者根据D-二聚体水平中位数和四分位数分为Q_(1)~Q_(4)4组,分别为415例、414例、414例、415例。通过倾向性评分匹配法(PSM)对Q_(2)、Q_(3)、Q_(4)和Q_(1)分别进行匹配,采用logistic回归模型分析D-二聚体与各个结局的关联。由于目前临床尚无通用的D-二聚体分类标准,本研究尝试根据目前临床参考值上限的1、3、5、10倍将患者再次分为q1(<0.55 mg/L,94例)、q2(0.55~1.65 mg/L,435例)、q3(1.65~5.50 mg/L,650例)和q4(>5.50 mg/L,303例)4组,同样作PSM及logistic回归分析,以检验不同的D-二聚体分类方法下,D-二聚体是否仍然与aSAH预后相关。结果1658例aSAH患者年龄(57±12)岁,男1068例,女590例。根据D-二聚体水平中位数和四分位数法分组PSM后,4组例数分别为318例、318例、251例、229例。Q_(4)组(>4.95 mg/L)患者与Q_(1)(<1.23 mg/L)组相比,Q_(4)组患者院内感染(OR=2.14,95%CI:1.47~3.11,P<0.001);肺部感染(OR=2.22,95%CI:1.51~3.28,P<0.001)、尿道感染(OR=1.75,95%CI:1.12~2.75,P=0.014)以及颅内再出血(OR=3.59,95%CI:1.30~9.91,P=0.013)风险较高。Q_(4)组患者发生不良预后结局的风险也高于Q_(1)组,不良预后结局包括出院时预后不良(OR=2.12,95%CI:1.43~3.14,P<0.001);住院期间死亡(OR=3.03,95%CI:1.26~7.33,P=0.014);90 d内死亡(OR=2.33,95%CI:1.29~4.22,P=0.005);180 d内死亡(OR=1.92,95%CI:1.12~3.29,P=0.018);1年内死亡(OR=2.07,95%CI:1.23~3.47,P=0.006)以及最长随访期内死亡(OR=1.97,95%CI:1.26~3.09,P=0.003)。在根据目前临床参考值作二次分组并进行PSM后,4组例数分别为90例、87例、90例、43例。q4组患者的院内感染(OR=2.26,95%CI:1.14~4.45,P=0.019)、血行感染(OR=8.86,95%CI:1.08~72.78,P=0.042)、出院时预后不良(OR=4.92,95%CI:2.18~11.07,P<0.001)、180 d内死亡(OR=3.39,95%CI:1.04~11.08,P=0.043)、1年内死亡(OR=3.23,95%CI:1.10~9.49,P=0.033)以及最长随访期内死亡风险(OR=3.28,95%CI:1.34~8.01,P=0.009)仍然高于q1组患者。结论高D-二聚体的aSAH患者住院期间并发症发生风险及病死率更高,临床预后更差。
Objective To evaluate the effect of D-dimer on the prognosis of patients with aneurysmal subarachnoid hemorrhage(aSAH).Methods A total of 1658 patients who were first diagnosed with aSAH in West China Hospital of Sichuan University from December 2013 to June 2019 were retrospectively analyzed.All patients were divided into four groups according to the median and quartiles of D-dimer level,including 415 cases,414 cases,414 cases,and 415 cases in groups Q_(1),Q_(2),Q_(3),and Q_(4),respectively.Groups Q_(2),Q_(3),Q_(4),and group Q_(1) were matched by propensity score matching(PSM),and the correlation between D-dimer and each outcome was analyzed by logistic regression.Since there is no general clinical classification standard for D-dimer,this study attempted to reclassify patients into groups q1(<0.55 mg/L,94 cases),q2(0.55-1.65 mg/L,435 cases),q3(1.65-5.50 mg/L,650 cases)and q4(>5.50 mg/L,303 cases)based on 1,3,5,10 times of the upper limit of the current clinical reference value.Results The age of 1658 aSAH patients were(57±12)years,including 1068 males and 590 females.After PSM based on the median and quartiles of D-dimer level,there were 318 cases,318 cases,251 cases,and 229 cases in groups Q_(1),Q_(2),Q_(3),and Q_(4),respectively.Compared with group Q_(1)(<1.23 mg/L),the risk of in-hospital infection(OR=2.14,95%CI:1.47-3.11,P<0.001),pneumonia(OR=2.22,95%CI:1.51-3.28,P<0.001),urinary tract infection(OR=1.75,95%CI:1.12-2.75,P=0.014)and intracranial rebleeding(OR=3.59,95%CI:1.30-9.91,P=0.013)group Q_(4)(>4.95 mg/L)was higher.Likewise,the risk of adverse outcomes in group Q_(4) was also higher than that in group Q_(1),including unfavorable outcome at discharge(OR=2.12,95%CI:1.43-3.14,P<0.001),mortality during hospitalization(OR=3.03,95%CI:1.26-7.33,P=0.014),mortality within 90 days(OR=2.33,95%CI:1.29-4.22,P=0.005),mortality within 180 days(OR=1.92,95%CI:1.12-3.29,P=0.018),mortality within 1 year(OR=2.07,95%CI:1.23-3.47,P=0.006)and mortality during the longest follow-up period(OR=1.97,95%CI:1.26-3.09,P=0.003).After secondary grouping and PSM based on current clinical reference values,there were 90 cases,87 cases,90 cases,and 43 cases,respectively in groups q1,q2,q3 and q4.The risk of nosocomial infection(OR=2.26,95%CI:1.14-4.45,P=0.019),blood-borne infection(OR=8.86,95%CI:1.08-72.78,P=0.042),poor prognosis at discharge(OR=4.92,95%CI:2.18-11.07,P<0.001),death within 180 days(OR=3.39,95%CI:1.04-11.08,P=0.043),death within 1 year(OR=3.23,95%CI:1.10-9.49,P=0.033),and death within the longest follow-up period(OR=3.28,95%CI:1.34-8.01,P=0.009)was still higher in group q4 than that in group q1.Conclusion aSAH patients with high D-dimer level have a higher risk of complications and mortality during hospitalization and worse clinical prognosis.
作者
张仁杰
闫思宇
胡鑫
李浩
刘翼
伍聪
贺民
马潞
游潮
田蕊
Zhang Renjie;Yan Siyu;Hu Xin;Li Hao;Liu Yi;Wu Cong;He Min;Ma Lu;You Chao;Tian Rui(Department of Neurosurgery,West China Hospital,Sichuan University,Chengdu 610041,China)
出处
《中华医学杂志》
CAS
CSCD
北大核心
2022年第29期2256-2264,共9页
National Medical Journal of China
基金
国家重点研发计划(2018YFA0108603,2018YFA0108604)
四川大学华西医院学科卓越发展1·3·5工程临床研究孵化项目(2021HXFH014)
华西医院院-企合作临床研究创新项目(2019HXCX07)。
作者简介
通信作者:田蕊,Email:tianrui17419@wchscu.cn。
