本文選題：系統(tǒng)性紅斑狼瘡　切入點(diǎn)：血栓彈力圖　出處：《北京協(xié)和醫(yī)學(xué)院》2013年碩士論文

【摘要】：目的 應(yīng)用血栓彈力圖(Thrombelastography, TEG)檢測(cè)系統(tǒng)性紅斑狼瘡(Systemic lupus erythematosus, SLE)患兒的總體出凝血紊亂狀態(tài),探討SLE患兒不同的疾病狀態(tài)與出凝血的關(guān)系,評(píng)價(jià)糖皮質(zhì)激素對(duì)SLE患兒出凝血狀態(tài)的影響,以期利用簡(jiǎn)便高效的TEG監(jiān)測(cè)SLE患兒臨床出血或血栓事件,并指導(dǎo)臨床針對(duì)性用藥。 方法 選取明確診斷的SLE患兒51例,正常對(duì)照10例,結(jié)合SLE患兒臨床表現(xiàn)和各項(xiàng)實(shí)驗(yàn)室指標(biāo),按照SLEDAI評(píng)分進(jìn)行病情狀態(tài)分組。采用對(duì)照分析的方法,分別對(duì)糖皮質(zhì)激素治療前、后,以及疾病活動(dòng)期、緩解期的患兒進(jìn)行TEG檢測(cè)。分析SLE患兒與正常人,不同疾病活動(dòng)狀態(tài)下SLE患兒TEG結(jié)果的差異。糖皮質(zhì)激素應(yīng)用不同時(shí)間、劑量等對(duì)SLE患兒TEG結(jié)果的影響。 結(jié)果 1.56例入選患兒中,1例發(fā)生出血,2例發(fā)生血栓事件,其TEG的圖形顯著地不同。 2. SLE患兒TEG結(jié)果分析：與正常對(duì)照組相比,SLE患兒TEG中R、K縮短,α角增大(即凝血因子激活增強(qiáng),血凝塊形成速率增快),LY30減小(即纖維蛋白溶解減弱),CI增大,凝血功能整體呈高凝狀態(tài)(P0.05)。 3.疾病活動(dòng)狀態(tài)與TEG相關(guān)分析：重度活動(dòng)SLE患兒與基本無(wú)活動(dòng)患兒相比,R、K明顯地縮短,α角、CI顯著地增大(P0.01)；重度活動(dòng)SLE患兒與輕度活動(dòng)患兒相比,R、K明顯地縮短,α角、CI顯著地增大(P0.01),顯示凝血狀態(tài)比活動(dòng)度較輕的患兒呈高凝狀態(tài)。SLEDAI評(píng)分與TEG中R、K呈負(fù)相關(guān)(r=-0.532,-0.457,P均0.01),與α角、CI呈正相關(guān)(r=0.535,0.520,P均0.01)。 4.血小板計(jì)數(shù)與TEG中MA的關(guān)系：血小板增多組較血小板正常組MA明顯增大(P0.01)。血小板減少組與血小板正常組相比,MA值差異無(wú)明顯統(tǒng)計(jì)學(xué)意義(P0.05)。 5.糖皮質(zhì)激素治療對(duì)SLE患兒凝血狀態(tài)的影響的研究：應(yīng)用激素時(shí)間不同SLE患兒的TEG結(jié)果差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。足量激素組比小劑量組R縮短(P0.01),MA增大(P0.01)。TEG其他參數(shù)上差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05)。行甲基強(qiáng)的松龍沖擊治療的SLE患兒沖擊治療前后TEG結(jié)果差異無(wú)統(tǒng)計(jì)學(xué)意義(P0.05),但有2例患兒沖擊治療后發(fā)生血栓事件。 結(jié)論 1.SLE患兒體內(nèi)出凝血呈紊亂狀態(tài),既可表現(xiàn)為高凝和血栓,也可表現(xiàn)為出血,通過(guò)TEG可以清晰地檢測(cè)出來(lái)。 2.SLE患兒與正常人比,總體凝血狀態(tài)呈高凝,由凝血因子激活增強(qiáng)(R縮短)、血凝塊形成速率增快(K縮短,α角增大)以及纖維蛋白溶解減弱(LY30減小)所造成。 3.SLE患兒凝血狀態(tài)與疾病活動(dòng)度程度相關(guān),活動(dòng)度高者高凝狀態(tài)更明顯,隨著SLEDAI評(píng)分的增加,凝血因子激活增強(qiáng)(R縮短)、血凝塊形成速率增快(K縮短,α角增大),總體凝血功能更偏向高凝狀態(tài)。 4.血小板增多的SLE患兒與血小板計(jì)數(shù)正常者相比,血凝塊強(qiáng)度增強(qiáng)(MA增大)；血小板減少的SLE患兒與血小板計(jì)數(shù)正常者相比,血凝塊強(qiáng)度并無(wú)減低。提示血小板減少的SLE患兒無(wú)明顯的出血傾向。 5.激素應(yīng)用劑量對(duì)SLE患兒凝血狀態(tài)有影響,足量激素組比小劑量組凝血因子激活增強(qiáng),血凝塊強(qiáng)度增大。大劑量甲基強(qiáng)的松龍沖擊前后,SLE患兒的TEG雖無(wú)統(tǒng)計(jì)學(xué)差異,但沖擊治療后有血栓事件的發(fā)生,需要?jiǎng)討B(tài)監(jiān)測(cè)出凝血狀態(tài)的變化。 6.推薦TEG作為評(píng)價(jià)SLE出凝血紊亂狀態(tài)的方便易行的總體指標(biāo)。
[Abstract]:objective
Application of Thrombelastogram (Thrombelastography, TEG) in patients with systemic lupus erythematosus (Systemic lupus, erythematosus, SLE) in the whole blood coagulation disorder, to investigate the disease status of children with SLE and the relationship between different blood coagulation, evaluation of glucocorticoid on SLE patients influence the coagulation state, in order to make use of convenient and efficient TEG monitoring SLE children with clinical bleeding or thrombotic events, and to guide clinical targeted drugs.
Method
A total of 51 cases of SLE were diagnosed, 10 cases of normal controls, combined with SLE patients clinical and laboratory indicators, according to the SLEDAI score of the disease state. The control packet analysis method respectively before glucocorticoid therapy, and disease activity, after remission were detected by TEG SLE analysis. Children and normal people, the difference of SLE in children with TEG disease activity results in different conditions. Application of glucocorticoid for different periods of time and dose effect on SLE in children with TEG results.
Result
Of the 1.56 children, 1 had bleeding and 2 had thrombus events, and the figures of TEG were significantly different.
The results of TEG analysis of 2. SLE children: compared with the normal control group, R and K in TEG of SLE patients were shortened, and the alpha angle increased (i.e. coagulation factor activation increased, blood clotting rate increased), LY30 decreased (fibrinolysis decreased), CI increased, and coagulation function showed hypercoagulable state (P0.05).
3. disease activity status and TEG correlation analysis: severe active SLE patients and no active children compared to R, K decreased, CI alpha angle, significantly increased (P0.01); severe active SLE patients compared with mild activity in children with R, K significantly shortened, alpha angle, CI significantly increased (P0.01), showed coagulation activity less than patients with hypercoagulable state and.SLEDAI score in TEG R, K was negatively correlated (r=-0.532, -0.457, P 0.01), and the alpha angle, CI was positively correlated (r=0.535,0.520, P 0.01).
4., the relationship between platelet count and MA in TEG: MA in thrombocytosis group was significantly higher than that in platelet normal group (P0.01). There was no significant difference in MA between thrombocytopenia group and normal platelet group (P0.05).
5. study on the effects of glucocorticoid therapy on blood coagulation in children with SLE: no significant use of hormone in children with SLE TEG results in different time difference (P0.05). The adequate amount of hormone group than in low dose group (P0.01), R shortened MA increases (P0.01).TEG on the other parameters had no significant difference (P0.05). Statistical significance before and after SLE treatment in children with shock stosstherapy for methyl strong differences in outcome of TEG (P0.05), thrombotic events but with shock treatment in 2 cases.
conclusion
The blood clotting of 1.SLE children is in disorder state, which can be manifested as hypercoagulability and thrombus, and may also be manifested as bleeding. It can be clearly detected by TEG.
Compared with normal controls, the overall coagulation state of 2.SLE children is hypercoagulable, increased by coagulation factor activation (R shortening), and the rate of blood clots growth is increased (K shortening, alpha angle increasing) and fibrinolysis (LY30 decrease).
The coagulation status of children with 3.SLE is related to the degree of disease activity. The hypercoagulability state is more obvious in those with high activity. With the increase of SLEDAI score, coagulation factor activation is enhanced (R shortening), the rate of blood clots growth is increased (K shortens, alpha Jiao Zengda), and the overall coagulation function is more highly hypercoagulable.
4., compared with those with normal platelet count, the blood clot intensity increased (MA increased) in SLE children with thrombocytopenia. The blood clot intensity of SLE children with thrombocytopenia was not decreased compared with those with normal platelet count. There was no obvious bleeding tendency in SLE children with thrombocytopenia.
5. application of hormone dose effect on SLE blood coagulation state, enough hormone group than in low dose group of blood coagulation factor activation, increased blood clot strength. Before and after high dose methylprednisolone, TEG have no statistical difference with SLE, but the occurrence of thrombotic events after the treatment of shock, need a dynamic monitoring of changes of blood coagulation.
6. TEG is recommended as a convenient and easy general indicator for evaluating the state of coagulation disorders in SLE.

【學(xué)位授予單位】：北京協(xié)和醫(yī)學(xué)院
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2013
【分類(lèi)號(hào)】：R725.5

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