【作者】 王彩霞；

【导师】 盛光耀；

【作者基本信息】 郑州大学 ， 儿科学， 2018， 硕士

【摘要】 目的儿童免疫性血小板减少症与再生障碍性贫血是儿科常见的血小板减少导致出血的疾病,血小板输注是预防和治疗血小板减少的重要措施,目前临床输注血小板多是经验性的,受很多因素影响。本研究通过大样本回顾性分析儿童免疫性血小板减少症和再生障碍性贫血血小板输注情况,总结规律,以期有助于临床合理有效地进行血小板输注。方法分别病案检索河南某综合性医院儿内科2013年08月01日至2017年08月01日期间收治的免疫性血小板减少症和再生障碍性贫血的患儿,采用统一的临床资料调查表,调查内容包括患儿性别、年龄、发病情况、临床表现、实验室检查、血小板输注情况及其他治疗方法。按照病种、输注情况等进行分组,定量资料采用独立样本t检验,检验水准为α=0.05,p<0.05为差异有统计学意义;对临床上可能影响输注血小板效果的潜在因素利用逐步向前法进行筛选,再将筛选出的变量纳入Logistic回归模型(进入标准α=0.05,剔除标准α=0.10),以分析影响血小板输注效果的因素。统计学软件采用SPSS23.0。结果1 ITP与血小板输注1.1对ITP患儿血小板数目进行独立样本t检验,输组与未输血组治疗前血小板数目、治疗后血小板数目、治疗前后血小板增加量比较,分别得出(t=4.28,p=0.00)、(t=5.49,p=0.00)、(t=5.15,p=0.00),差异均有统计学意义,且输血组血小板增加量较未输血组少。1.2对ITP输血患儿血小板数目进行独立样本t检验,血小板数目≤10×10~9/L组与>10×10~9/L组治疗前血小板数目比较显示t=6.52、p=0.00,提示两组治疗前血小板数目差异有统计学意义;血小板数目≤10×10~9/L组与>10×10~9/L组治疗后血小板数目、治疗前后血小板增加量比较,分别得出(t=2.23,p=0.30)、(t=1.57,p=0.28),差异均无统计学意义。2 AA与血小板输注2.1对AA患儿血小板数目进行独立样本t检验,输血组与未输血组治疗前血小板数目、治疗后血小板数目、治疗前后血小板增加量比较,分别得出(t=10.38,p=0.02)、(t=6.39,p=0.00)、(t=9.64,p=0.00),差异均有统计学意义,且输血组血小板增加量较未输血组多。2.2对AA输血患儿血小板数目进行独立样本t检验,≤10×10~9/L组与>10×10~9/L组治疗前血小板数目、治疗后血小板数目、治疗前后血小板增加量比较,分别得出(t=13.17,p=0.00)、(t=6.18,p=0.00)、(t=3.41,p=0.00),差异均有统计学意义,且>10×10~9/L组血小板增加量较≤10×10~9/L组多。3 ITP与AA3.1分别对ITP组与AA组患儿外周血免疫球蛋白补体水平进行独立样本t检验,ITP组与AA组患儿外周血IgA、Ig E、C3水平比较,分别得出(t=3.45,p=0.00)、(t=2.88,p=0.01)、(t=2.74,p=0.01),提示差异均有统计学意义,其中AA组IgA、IgE、C3水平高于ITP组;两组患儿外周血IgG、IgM、C4水平比较,分别得出(t=0.81,p=0.42)、(t=1.26,p=0.21)、(t=1.03,p=0.31),差异均无统计学意义。3.2分别对ITP组与AA组患儿外周血淋巴细胞亚群水平进行独立样本t检验,ITP组与AA组外周血T淋巴细胞、TS淋巴细胞、B淋巴细胞及NK细胞比较,分别得出(t=6.48,p=0.00)、(t=4.68,p=0.00)、(t=4.81,p=0.00)、(t=1.99,p=0.04),差异均有统计学意义,其中ITP组外周血T淋巴细胞、TS淋巴细胞水平低于AA组,而B淋巴细胞、NK细胞高于AA组;两组外周血TH淋巴细胞、TH/TS水平比较,分别得出(t=1.69,p=0.09)、(t=1.75,p=0.08),差异均无统计学意义。4综合分析影响血小板输注效果的因素首先对自变量(病种、性别、血型、脾脏大小、感染情况、出血程度、输血次数)按照向前逐步法进行筛选,筛选出影响临床血小板输注效果的5个因素:病种、感染情况、出血程度及输注次数,将其纳入Logistic回归模型,病种(Walsχ~2=0.7156、p=0.007、OR=2.302、OR95%CI=1.250~4.241)、感染情况(Walsχ~2=4.998、p=0.025、OR=1.870、OR95%CI=1.080~3.239)、出血程度(Walsχ~2=46.629、p=0.000、OR=8.861、OR95%CI=4.737~16.574)、输血次数(Walsχ~2=10.527、p=0.001、OR=3.311、OR95%CI=1.606~6.826)有统计学意义。结论1.ITP患儿输注血小板影响血小板数目的增加,且ITP患儿血小板输注阈值≤10×10~9/L与>10×10~9/L相比输血效果无明显差别。2.AA患儿输注血小板有益于血小板数目的增加,AA患儿血小板输注阈值>10×10~9/L较≤10×10~9/L输血效果更好。3.ITP和AA患儿免疫功能存在差异。4.ITP、感染、严重出血及多次输血与临床血小板输注无效相关。更多还原

【Abstract】 Objective Childhood immune thrombocytopenia and aplastic anemia are common pediatric thrombocytopenia leading to bleeding.Platelet transfusion is an important measure to prevent and treat thrombocytopenia.Currently,clinical platelet transfusions are mostly empirical and are affected by many factors.In this study,a large sample was used to retrospectively analyze children’s ITP and AA platelet transfusions,and the rules were summarized in order to facilitate clinically effective platelet transfusions.Methods Medical records were retrieved from a comprehensive hospital in Henan Province.Children with immune thrombocytopenia and aplastic anemia treated from August 01,2013 to August 01,2017 used a uniform clinical data questionnaire.Including children with gender,age,incidence,clinical manifestations,laboratory tests,platelet transfusion and other treatment methods.Grouping according to the type of disease,infusion,etc,the quantitative data were analyzed by independent sample t-test.The test levels were all equal to 0.05,p<0.05 was considered statistically significant;Potential factors affecting the platelet transfusion effect were screened using the stepwise forward method,and the selected variables were included in the Logistic regression model(into the standard α=0.05,rejecting the standard α=0.10)to analyze factors influencing the effect of platelet transfusion..Statistical software uses SPSS23.0.Results 1 ITP and platelet transfusion 1.1 An independent sample t-test was performed on the number of platelets in children with ITP.The number of platelets before treatment,the number of platelets after treatment,and the increase in platelet counts before and after treatment were compared between the transfusion group and the non-transfusion group,respectively(t=4.28,p=0.00),(t=5.49,p=0.00),(t=5.15,p=0.00),the differences were statistically significant,and blood transfusion group increased less platelets than the non-transfusion group.1.2 An independent sample t-test was performed on the number of platelets in children with ITP transfusion.The number of platelets in the group with thrombocytopenia ≤10×109/L and >10×109/L was compared before treatment.t=6.52 and p=0.00,suggesting that the two groups before treatment The number of platelets was statistically significant;platelet numbers ≤10×109/L and >10×109/L,and platelet counts and platelet increments before and after treatment were compared,respectively(t=2.23,p=0.30).(t=1.57,p=0.28),the difference was not statistically significant.2 AA and platelet transfusion 2.1 An independent sample t-test was performed on the platelet counts of AA children.The number of platelets before treatment,the number of platelets after treatment,and the increase in platelet counts before and after treatment in the transfusion group and non-transfusion group were compared(t=10.38,p=0.02),(t=6.39,p=0.00),(t=9.64,p=0.00),the differences were statistically significant,and blood transfusion group increased more platelets than the non-transfusion group.2.2 An independent sample t-test was performed on the number of platelets in children with AA blood transfusion.The number of platelets before treatment,blood platelet count after treatment,and the platelet increase before and after treatment were found to be less than or equal to 10×109/L and >10×109/L,respectively(t=13.17,p=0.00),(t=6.18,p=0.00),(t=3.41,p=0.00),the difference was statistically significant,and >10×109/L group platelet increase was less than 10 × 109 / L group and more.3 ITP and AA 3.1 An independent sample t-test was performed on peripheral blood Ig complement levels in the ITP group and the AA group.The levels of Ig A,Ig E,and C3 in the peripheral blood of the ITP group and the AA group were compared,respectively.(t=3.45,p= 0.00),(t=2.88,p=0.01),(t=2.74,p=0.01),indicating that the differences were statistically significant.Among them,the levels of Ig A,Ig E,and C3 in AA group were higher than those in ITP group;The levels of blood Ig G,Ig M,and C4 were found to be(t=0.81,p=0.42),(t=1.26,p=0.21),and(t=1.03,p=0.31),respectively,with no statistically significant difference.3.2 An independent sample t-test was performed on the peripheral blood lymphocyte subsets in the ITP group and the AA group.The T lymphocytes,TS lymphocytes,B lymphocytes,and NK cells in the peripheral blood of the ITP group and the AA group were compared,respectively.(t=6.48,p=0.00),(t=4.68,p=0.00),(t=4.81,p=0.00),(t=1.99,p=0.04),and the differences were statistically significant,including the ITP group The levels of T lymphocytes and TS lymphocytes in blood were lower than those in AA group,while B lymphocytes and NK cells were higher than in AA group;the levels of TH lymphocytes and TH/TS in peripheral blood of the two groups were compared respectively(t=1.69,p=0.09),(t=1.75,p=0.08),the difference was not statistically significant.4 Comprehensive analysis of the factors affecting the effect of platelet transfusion Firstly,the independent variables(disease type,gender,blood type,spleen size,infection,bleeding degree,and number of blood transfusions)were screened according to the step-by-step method to screen out five factors affecting the clinical platelet transfusion effect: disease type,infection,bleeding,and number of infusions were included in the logistic regression model,disease type(Wals X2=0.7156,P=0.007,OR=2.302,OR95%CI=1.250 to 4.241),infection(Wals X2=4.998,P=0.025,OR=1.870,OR95%CI=1.080 to 3.239),degree of bleeding(Wals X2=46.629,P=0.000,OR=8.861,OR95%CI=4.737 to 16.574),number of blood transfusions (Wals X2=10.527,P=0.001,OR=3.311,OR95%CI=1.606 to 6.826)were statistically significant.Conclusion 1.Platelets were affected by infusion of platelets in children with ITP,and the threshold of platelet transfusion in children with ITP was not significantly different from ≤10×109/L and >10×109/L.2.Infusion of platelets in patients with AA is beneficial to increase the number of platelets.Platelet transfusion threshold in patients with AA is >10×10 9 /L better than ≤10×10 9 /L.3.There are differences in immune function between children with ITP and AA.4.ITP,infection,severe bleeding,and multiple transfusions were associated with ineffective platelet transfusions.更多还原