【作者】 黄平；

【导师】 刘晓燕；

【作者基本信息】 重庆医科大学 ， 临床医学（专业学位）， 2021， 硕士

【摘要】 目的:探讨儿童川崎病休克综合征（KDSS）的临床特征,对比KDSS患儿与未发生休克的川崎病（KD）患儿的临床、实验室及影像学指标,分析可能的危险因素及预测值。方法:回顾分析2013年5月至2020年10月期间在重庆医科大学附属儿童医院住院诊断为KDSS患儿（n=29）的临床资料,并以同一时期（KDSS病例入院前后2周）确诊为KD但血流动力学稳定的患儿（n=51）作为对照组,分析比较两组患儿的临床特点,包括人口学、临床表现、实验室指标、影像学指标、治疗、预后及随访。采用多因素Logistic回归方法分析可能的危险因素。采用受试者工作特征曲线（ROC曲线）分析危险因素对KD发生休克的预测价值。结果:KDSS组患儿29例,男16例,女13例,平均年龄49.0月（范围3-128月）,休克前后指标在血红蛋白（Hb）、中性粒细胞百分比、丙氨酸氨基转移酶（ALT）、白蛋白（Alb）、超敏肌钙蛋白I（Tn I）、降钙素原（PCT）水平上差异有统计学意义（P<0.05）。与KD组比较,二者年龄有统计学意义（P<0.05）。两组在性别、不完全川崎病（IKD）比例、热峰、住院时发热时间、KD的5个主要临床表现、确诊时热程上均无统计学意义（P>0.05）。KDSS组患儿中性粒细胞计数、中性粒细胞百分比、血小板平均体积（MPV）、血小板分布宽度（PDW）、大血小板比率（LPCR）、丙氨酸氨基转移酶（ALT）、天门冬氨酸氨基转移酶（AST）、血尿素氮（Ur）、血肌酐（Cr）、超敏肌钙蛋白I（Tn I）、B型利钠肽（BNP）、D-二聚体（D-dimer）、C反应蛋白（CRP）、降钙素原（PCT）水平均高于对照组,血小板（PLT）、血小板压积、Alb、总蛋白（TP）、血钠（Na）、血钾（K）、血磷（P）水平低于对照组（P<0.05）。KDSS组患儿均接受液体复苏治疗,26例（89.3%,26/29）予白蛋白治疗,16例（55.2%,16/29）患儿使用了血管活性药物和（或）强心药物。KDSS组患儿总热程及总住院时间均较对照组延长,使用第二次静脉注射丙种球蛋白（IVIG）、激素的比例均较对照组高,急性期心血管异常发生率更高,出现多脏器功能损害比例更大（P值均<0.05）。8例（27.6%,8/29）患儿入ICU治疗,2例（6.9%,2/29）使用了呼吸机支持治疗,2例（6.9%,2/29）行血浆置换,1例（3.4%,1/29）行血液透析及血液滤过治疗。多因素Logistic回归分析结果显示MPV（OR=13.001,95%CI:1.887～89.568,回归系数2.565,Wald=6.785,P<0.01）、Alb（OR=0.514,95%CI:0.314～0.842,回归系数-0.665,Wald=6.990,P<0.01）为KD患儿发生休克的危险因素。ROC曲线分析显示,Alb、MPV联合预测KD发生休克的曲线下面积（AUC）为0.989（95%CI:0.973～1.000）,敏感度93.1%,特异度98.0%。Alb值为32.2g·L^-1时敏感度和特异度分别为82.8%和90.2%,MPV值为9.85f L时敏感度和特异度分别为96.6%和64.7%。结论:KDSS患儿具有更严重的炎症反应,更多的心血管系统受累及多器官系统受累表现,需要临床医生及时诊断及治疗。Alb、MPV对KD发生休克有预测价值,且二者联合时预测价值更大,Alb低于32.2g·L^-1,且MPV高于9.85f L时KD发生休克的可能性更大。更多还原

【Abstract】 Objective:To investigate the clinical features of Kawasaki disease shock syndrome（KDSS）in children,compare the clinical,laboratory and imaging indexes of Kawasaki disease（KD）children with and without shock,and analyze the possible risk factors and predictive values.Methods:29 patients with KDSS（KDSS group）and 51 Kawasaki disease patients（control group）in the same period（2 weeks before and after admission）with stable hemodynamics from the Children’s hospital affiliated to Chongqing Medical University between May 2013 to October2020 were enrolled in the study.The demography,clinical features,laboratory and imaging examinations,treatment,prognosis and follow-up of all the patients were observed and compared between the two groups.Multivariate logistic regression was used to analyze the possible risk factors.Receiver operating characteristic curve（ROC curve）was used to analyze the predictive value of risk factors for shock in KD.Results:There were 29 children in KDSS group,including 16 males and 13 females,with an average age was 49.0 months（range:3 to 128months）.There were significant differences in hemoglobin（Hb）,neutrophil percentage,alanine aminotransferase（ALT）,albumin（Alb）,high-sensitivity troponin I（Tn I）and procalcitonin（PCT）levels before and after shock（P<0.05）.Compared with KD group,the age of the two groups was statistically significant（P<0.05）.There was no significant difference in gender,ratio of incomplete Kawasaki disease（IKD）,fever peak,fever time in hospital,five main clinical manifestations of KD and fever course at diagnosis between the two groups（P>0.05）.The levels of neutrophil count,percentage of neutrophils,mean platelet volume（MPV）,platelet distribution width（PDW）,large platelet ratio（LPCR）,alanine aminotransferase（ALT）,aspartate aminotransferase（AST）,blood urea nitrogen（Ur）,serum creatinine（Cr）,high-sensitivity troponin I（Tn I）,B-type natriuretic peptide（BNP）,D-dimer,C-reactive protein and procalcitonin（PCT）of KDSS were higher than the control group,while the levels of platelet（PLT）,thrombocytocrit,Alb,total protein（TP）,sodium（Na）,potassium（K）and phosphorus（P）of KDSS group were lower than control group（P<0.05）.In KDSS group,26 cases（89.3%,26/29）were treated with albumin,and 16 cases（55.2%,16/29）were treated with vasoactive drugs and（or）cardiotonics.Compared with the control group,the total fever course and hospital stay of KDSS group were longer,the proportion of the second IVIG and hormone were higher,the incidence of cardiovascular abnormalities in acute phase was higher,and the proportion of multiple organ dysfunction was higher（P<0.05）.8 cases（27.6%,8/29）were treated in intensive care unit,2 cases（6.9%,2/29）were treated with ventilator,2 cases（6.9%,2/29）were treated with plasma exchange,and 1case（3.4%,1/29）was treated with hemodialysis and hemofiltration.Multivariate logistic regression analysis showed that MPV（OR=13.001,95%CI:1.887～89.568,regression coefficient 2.565,Wald=6.785,P<0.01）,Alb（OR=0.514,95%CI:0.314～0.842,regression coefficient-0.665,Wald=6.990,P<0.01）were risk factors for shock in children with KD.ROC curve analysis results showed that the area under the curve（AUC）of Alb combine with MPV in predicting the shock in KD was 0.989（95%CI:0.973-1.000）,sensitivity of 93.1%and specificity of 98.0%.The sensitivity and specificity were 82.8%and 90.2%when ALB was 32.2g·L^-1,and96.6%and 64.7%when MPV was 9.85f L,respectively.Conclusion:Children with KDSS have more severe inflammatory reaction,more cardiovascular system involvement and more multiple organ system involvement,which need timely diagnosis and treatment by clinicians.Alb and MPV have predictive value for the occurrence of shock in KD,and their combined predictive value is greater.When Alb is lower than 32.2g·L-1,and MPV is higher than 9.85fl,shock is more likely to occur in KD.更多还原