川崎病患兒并發(fā)冠狀動脈損傷的危險因素探討及分析
發(fā)布時間：2018-08-17 10:56
【摘要】：研究背景川崎病(Kawasaki diseases,KD),即皮膚黏膜淋巴結綜合征(mucocutaneous lymphnode syndrome,MCLS),是一種主要發(fā)生在5歲以下嬰幼兒的急性發(fā)熱性出疹性疾病,以全身中小血管炎變?yōu)橹饕±砀淖僛1]。病因及發(fā)病機制仍未完全清楚,目前認為KD是一種免疫介導的血管炎綜合征。由于該病可發(fā)生嚴重的心血管病變,越來越引起人們重視。近年來,隨著該病發(fā)病率的上升,其引起的冠狀動脈損傷(coronary artery lesions,CAL)已成為兒童后天性心臟病的首要病因,可能與成年后缺血性心臟病關系密切,未經正規(guī)治療的KD患兒CAL發(fā)生率達15%～25%[6]。靜脈注射人免疫球蛋白(IVIG)和口服阿司匹林(ASP)的標準治療后不僅可以明顯的縮短熱程,緩解臨床癥狀,還可以明顯減少CAL的發(fā)生率,然而部分患兒在治療后仍有持續(xù)發(fā)熱,且出現冠狀動脈并發(fā)癥。超聲心動圖是診斷和評估CAL的最敏感、簡便、無創(chuàng)的方法。研究目的本文對山東大學齊魯醫(yī)院臨床確診的367例KD患兒的臨床資料、相關實驗室檢測指標及超聲心動圖檢查結果進行回顧性的分析,旨在分析探討KD并發(fā)CAL的危險因素,以便兒科臨床醫(yī)師早期干預,預防及減少CAL的發(fā)生率,改善患兒的生活質量及預后。材料與方法1、回顧性分析山東大學齊魯醫(yī)院2006年2月-2016年2月確診KD的住院患兒367例。其中男性257例,女性110例,男女之比為2.34:1;年齡為1個月-11歲,平均年齡為31.59±27.64個月。367例KD的診斷均符合2004年美國心臟病學會(AHA)及美國兒科學會(AAP)聯合制定的KD診療指南。367例包括典型川崎病(313例)和不典型川崎病(54例)。將此367例KD患兒按年齡分為0～18個月齡組、18個月-3歲組、大于3歲組,分別為162、86、119例,比較3組冠狀動脈損害發(fā)生率的差異。將此367例KD患兒根據在初始治療中是否合用糖皮質激素分為兩組:一組單獨應用人免疫球蛋白(nGCs),另一組應用人免疫球蛋白聯合糖皮質激素(Dex 0.1-0.2mg/kg·d,療程1-3天)(GCs),并應用心臟彩色多普勒超聲來評估兩組KD患兒冠狀動脈損害(CAL)的情況。其中nGCs組218例,GCs組149例。再將此367例根據心臟彩色多普勒超聲檢查結果分為KD并發(fā)冠狀動脈損害組(CAL組)和KD未并發(fā)冠狀動脈損害組(nCAL組)。其中CAL組122例,nCAL組245例。CAL診斷標準采用日本KD研究組提出的標準。2、統計被納入367例KD患兒的性別、年齡、臨床診斷、白細胞計數(WBC)、中性粒細胞比例(N%)、血紅蛋白計數(HGB)、血小板計數(PLT)、紅細胞沉降率(ESR)、C-反應蛋白(CRP)、谷丙轉氨酶(ALT)、乳酸脫氫酶(LDH)、谷草轉氨酶(AST)、前白蛋白(PA)、白蛋白(ALB)、球蛋白(GLB)、肌酸激酶(CK)、肌酸激酶同工酶(CK-MB)、甘油三酯(TG)、低密度脂蛋白(LDH-C)、高密度脂蛋白(HDL-C)、總膽固醇(Cho)、血鈉(血Na)、纖維蛋白原、血漿D-二聚體(D__Di)、初始治療是否合用激素及二維心臟彩色多普勒超聲測量的冠狀動脈內徑值等資料,并將其納入研究對象,分析KD并發(fā)冠狀動脈病變的危險因素。3、將所收集的367例KD患兒的臨床病歷資料,采用統計軟件SPSS 19.0進行處理,其中計數資料數據以例數(百分率)[n(%)]表示,計數資料組間比較采用x2檢驗。計量資料用均數土標準差(X土SD)表示,采用獨立樣本t檢驗,可信區(qū)間取95%,P0.05有統計學意義。對篩選出的有意義的變量分別與冠狀動脈內徑值進行線性相關性分析,得出各自相關系數及P值,其中P0.05為差異,即有統計學意義。結果1、統計2006-2015年每年KD的總例數、完全性KD、不完全性KD的發(fā)病例數,結果如下:2006(6,6,0),2007(15,11,4),2008(19,19,0),2009(17,16,1),2010(25,24,1),2011(30,29,1),2012(41,40,1),2013(50,41,9),2014(68,56,12),2015(81,62,19)。2、統計各個年齡組發(fā)病情況,結果顯示:0-18個月齡組162例,發(fā)生率為44.1%,其中CAL組49例,nCAL組113例,CAL發(fā)生率30.2%;18個月-3歲組86例,發(fā)生率為23.4%,其中CAL組27例,nCAL組59例,CAL發(fā)生率31.4%;3歲以上組119例,發(fā)生率為32.4%,其中CAL組46例,nCAL組73例,CAL發(fā)生率38.6%。采用x2檢驗,兩兩比較得出,P0.05,差異無統計學意義。3、通過統計兩組臨床診斷得出,典型川崎病313例,其中CAL組112例(35.8%),nCAL組201例(64.2%),不典型川崎病54例,其中CAL組10例(18.5%),nCAL組44例(81.5%)。采用x2檢驗,P0.05,差異有統計學意義。4、通過統計兩組性別得出CAL組122例,其中男90例,占73.7%,女32 "例,占26.3%;nCAL組245例,其中男157例,占64.1%,女88例,占35.9%。利用X2檢驗,P0.05,性別構成差異有統計學意義。5、相關實驗室檢測指標中,WBC、PLT、CRP、AST、ALB、Na以上這6個變量在CAL組與nCAL組中差異有統計學意義(P0.05);ESR、ALT、LDH、D_Di以上這4個變量在KD患兒均明顯升高,但在CAL組與nCAL組中差異無統計學意義(P0.05);PA、HDL-C在KD患兒均明顯下降,但在CAL組與nCAL組中差異無統計學意義(P0.05);N%、HGB、GLB、CK、CK-MB、Cho、TG、LDL-C、Fib在KD患兒中變化不明顯,且在CAL組與nCAL組中比較差異無統計學意義。6、通過統計KD患兒在初始治療過程中是否合用糖皮質激素(GCs)與冠狀動脈損害的關系得出,nCAL組(245例)中合用GCs有138例(占56.3%),未合用GCs有107例(占43.7%);CAL組(122例)中合用GCs有80例(占65.6%),未合用GCs有42例(占34.4%),采用x2檢驗,P0.05,差異無統計學意義。7、對于篩選出的變量進行線性相關分析,其中性別、KD的臨床診斷(完全性KD、不完全性KD)不滿足正態(tài)分布,采用spearman相關分析。WBC、PLT、CRP、AST、ALB、Na滿足正態(tài)分布,采用pearson相關分析。得出各自的相關系數及P值,P0.05差異有統計學意義。結果顯示對所有年齡組KD患兒,KD典型/不典型、WBC、ALB與冠狀動脈內徑值顯著相關;5歲者KD典型/不典型、WBC、ALB與冠狀動脈內徑值顯著相關,≥5歲者WBC、PLT與冠狀動脈內徑值顯著相關。結論1、本組病例研究顯示,對所有年齡組KD患兒,典型KD、WBC、ALB為KD合并CAL的危險因素;對5歲年齡組患兒,典型KD、WBC、ALB為KD合并CAL的危險因素;對≥5歲年齡組患兒,WBC、PLT為KD合并CAL的危險因素。2、本組病例研究顯示,KD患兒初始治療合用糖皮質激素并未增加CAL發(fā)生率。
[Abstract]:Background Kawasaki disease (KD), or mucocutaneous lymph node syndrome (MCLS), is an acute febrile eruptive disease mainly occurring in infants under 5 years old. The main pathological changes are systemic small and medium-sized vasculitis. D is a kind of immune-mediated vasculitis syndrome. It has attracted more and more attention because of its serious cardiovascular disease. In recent years, with the increasing incidence of the disease, coronary artery lesions (CAL) have become the primary cause of acquired heart disease in children, and may be related to ischemic heart disease in adulthood. The incidence of CAL in children with KD without regular treatment is 15%-25%[6].Standard treatment with intravenous human immunoglobulin (IVIG) and oral aspirin (ASP) can not only significantly shorten the course of fever, alleviate clinical symptoms, but also significantly reduce the incidence of CAL. Coronary artery complications occur. Echocardiography is the most sensitive, simple and noninvasive method for the diagnosis and evaluation of CAL. Objective To retrospectively analyze the clinical data, laboratory test indexes and echocardiographic results of 367 children with KD diagnosed in Qilu Hospital of Shandong University. Materials and Methods 1. 367 hospitalized children with KD diagnosed in Qilu Hospital of Shandong University from February 2006 to February 2016 were retrospectively analyzed. Among them, 257 were males, 110 were females, and the ratio of males to females was 2.34:1. 367 children with KD were divided into 0 to 18 months of age group, 18 months to 3 years of age group, older group. The incidence of coronary artery lesions was compared in 162,86,119 children aged 3 years. The 367 children with KD were divided into two groups according to whether glucocorticoids were used in the initial treatment: one group was given human immunoglobulin alone (nGCs), the other group was given human immunoglobulin combined with glucocorticoids (Dex 0.1-0.2 mg/kg.d, 1-3 days of treatment) (GC). Coronary artery lesions (CAL) were assessed by color Doppler echocardiography (CDUS) in 218 children with KD and 149 children with GCs. The 367 patients were divided into two groups according to the results of CDUS: KD with coronary artery lesions (CAL group) and KD without coronary artery lesions (nCAL group). The diagnostic criteria for CAL were sex, age, clinical diagnosis, white blood cell count (WBC), neutrophil ratio (N%), hemoglobin count (HGB), platelet count (PLT), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), alanine aminotransferase (ALT), lactate dehydrogenase (L). DH, AST, prealbumin (PA), albumin (ALB), globulin (GLB), creatine kinase (CK), creatine kinase isozyme (CK-MB), triglyceride (TG), low density lipoprotein (LDH-C), high density lipoprotein (HDL-C), total cholesterol (Cho), serum sodium (Na), fibrinogen, plasma D-dimer (D_ Di), whether hormone and two-dimensional treatment are combined or not The data of coronary artery diameter measured by color Doppler echocardiography were included in the study. The risk factors of coronary artery disease complicated by KD were analyzed. 3. The clinical data of 367 KD patients were processed by statistical software SPSS 19.0. The counting data were represented by the number of cases (percentage) [n(%) and counted. Data were compared by x2 test. Measurements were expressed by mean soil standard deviation (X SD). Independent sample t test showed that the confidence interval was 95% and P 0.05 was statistically significant. Linear correlation analysis was conducted between the selected significant variables and the coronary artery diameter, and the correlation coefficients and P values were obtained. P 0.05 was the difference, i.e. P 0.05 was the difference. Results 1. The total number of KD cases, complete KD cases and incomplete KD cases in 2006-2015 were statistically analyzed. The results were as follows: 2006 (6,6,0), 2007 (15,11,4), 2008 (19,19,0), 2009 (17,16,1), 2010 (25,24,1), 2011 (30,29,1), 2012 (41,40,1), 2013 (50,41,9), 2014 (68,56,12), 2015 (81,62,19). The results showed that the incidence of CAL was 34.1% in 162 cases of 0-18 months old group, including 49 cases of CAL group, 113 cases of nCAL group, the incidence of CAL was 30.2%; 86 cases of 18-3 months old group, the incidence of CAL was 23.4%; 27 cases of CAL group, 59 cases of nCAL group, the incidence of CAL was 31.4%; 119 cases of over 3 years old group, the incidence of CAL was 32.4%, 46 cases of CAL group, 73 cases of nCAL group, the incidence of CAL was 38.6%. There were 313 cases of typical Kawasaki disease, including 112 cases in CAL group (35.8%), 201 cases in nCAL group (64.2%) and 54 cases of atypical Kawasaki disease, including 10 cases in CAL group (18.5%) and 44 cases in nCAL group (81.5%). There were 122 cases in CAL group, including 90 males, accounting for 73.7%, 32 females, accounting for 26.3%; 245 cases in nCAL group, including 157 males, accounting for 64.1%, 88 females, accounting for 35.9%. ESR, ALT, LDH, D_Di above the four variables in KD children were significantly increased, but there was no significant difference between the CAL group and nCAL group (P 0.05); PA, HDL-C in KD children were significantly decreased, but there was no significant difference between CAL group and nCAL group (P 0.05); N%, HGB, GLB, CK, CK-MB, Cho, TG, LDL-C, Fib in KD children did not change significantly, and in CAL group and nCAL group and nCAL group. There was no significant difference between the two groups. According to the statistics of the relationship between the use of glucocorticoid (GCs) and coronary artery lesion, 138 (56.3%) of the patients in the nCAL group (245 cases), 107 (43.7%) of the patients in the CAL group (122 cases), 80 (65.6%) of the patients in the CAL group (80 cases) and 42 (42 cases) in the non-use of GC. There was no significant difference between x2 test, P 0.05 and P 0.7. Linear correlation analysis was used to analyze the selected variables. The clinical diagnosis of gender and KD (complete KD, incomplete KD) did not satisfy the normal distribution. WBC, PLT, CRP, AST, ALB and Na met the normal distribution. Pearson correlation analysis was used to obtain their respective phases. The results showed that KD typical / atypical, WBC, ALB and coronary artery diameter were significantly correlated in all age groups; KD typical / atypical, WBC, ALB and coronary artery diameter were significantly correlated in 5-year-olds; WBC, ALB and coronary artery diameter were significantly correlated in over 5-year-olds; WBC, PLT and coronary artery diameter were significantly correlated in over 5-year-olds. The results showed that typical KD, WBC and ALB were risk factors for KD and CAL in all age groups; typical KD, WBC and ALB were risk factors for KD and CAL in 5-year-old children; WBC and PLT were risk factors for KD and CAL in children over 5-year-old children; and WBC and PLT were risk factors for KD and CAL in children over 5-year-old children. Rate of birth.
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R725.4
[Abstract]:Background Kawasaki disease (KD), or mucocutaneous lymph node syndrome (MCLS), is an acute febrile eruptive disease mainly occurring in infants under 5 years old. The main pathological changes are systemic small and medium-sized vasculitis. D is a kind of immune-mediated vasculitis syndrome. It has attracted more and more attention because of its serious cardiovascular disease. In recent years, with the increasing incidence of the disease, coronary artery lesions (CAL) have become the primary cause of acquired heart disease in children, and may be related to ischemic heart disease in adulthood. The incidence of CAL in children with KD without regular treatment is 15%-25%[6].Standard treatment with intravenous human immunoglobulin (IVIG) and oral aspirin (ASP) can not only significantly shorten the course of fever, alleviate clinical symptoms, but also significantly reduce the incidence of CAL. Coronary artery complications occur. Echocardiography is the most sensitive, simple and noninvasive method for the diagnosis and evaluation of CAL. Objective To retrospectively analyze the clinical data, laboratory test indexes and echocardiographic results of 367 children with KD diagnosed in Qilu Hospital of Shandong University. Materials and Methods 1. 367 hospitalized children with KD diagnosed in Qilu Hospital of Shandong University from February 2006 to February 2016 were retrospectively analyzed. Among them, 257 were males, 110 were females, and the ratio of males to females was 2.34:1. 367 children with KD were divided into 0 to 18 months of age group, 18 months to 3 years of age group, older group. The incidence of coronary artery lesions was compared in 162,86,119 children aged 3 years. The 367 children with KD were divided into two groups according to whether glucocorticoids were used in the initial treatment: one group was given human immunoglobulin alone (nGCs), the other group was given human immunoglobulin combined with glucocorticoids (Dex 0.1-0.2 mg/kg.d, 1-3 days of treatment) (GC). Coronary artery lesions (CAL) were assessed by color Doppler echocardiography (CDUS) in 218 children with KD and 149 children with GCs. The 367 patients were divided into two groups according to the results of CDUS: KD with coronary artery lesions (CAL group) and KD without coronary artery lesions (nCAL group). The diagnostic criteria for CAL were sex, age, clinical diagnosis, white blood cell count (WBC), neutrophil ratio (N%), hemoglobin count (HGB), platelet count (PLT), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), alanine aminotransferase (ALT), lactate dehydrogenase (L). DH, AST, prealbumin (PA), albumin (ALB), globulin (GLB), creatine kinase (CK), creatine kinase isozyme (CK-MB), triglyceride (TG), low density lipoprotein (LDH-C), high density lipoprotein (HDL-C), total cholesterol (Cho), serum sodium (Na), fibrinogen, plasma D-dimer (D_ Di), whether hormone and two-dimensional treatment are combined or not The data of coronary artery diameter measured by color Doppler echocardiography were included in the study. The risk factors of coronary artery disease complicated by KD were analyzed. 3. The clinical data of 367 KD patients were processed by statistical software SPSS 19.0. The counting data were represented by the number of cases (percentage) [n(%) and counted. Data were compared by x2 test. Measurements were expressed by mean soil standard deviation (X SD). Independent sample t test showed that the confidence interval was 95% and P 0.05 was statistically significant. Linear correlation analysis was conducted between the selected significant variables and the coronary artery diameter, and the correlation coefficients and P values were obtained. P 0.05 was the difference, i.e. P 0.05 was the difference. Results 1. The total number of KD cases, complete KD cases and incomplete KD cases in 2006-2015 were statistically analyzed. The results were as follows: 2006 (6,6,0), 2007 (15,11,4), 2008 (19,19,0), 2009 (17,16,1), 2010 (25,24,1), 2011 (30,29,1), 2012 (41,40,1), 2013 (50,41,9), 2014 (68,56,12), 2015 (81,62,19). The results showed that the incidence of CAL was 34.1% in 162 cases of 0-18 months old group, including 49 cases of CAL group, 113 cases of nCAL group, the incidence of CAL was 30.2%; 86 cases of 18-3 months old group, the incidence of CAL was 23.4%; 27 cases of CAL group, 59 cases of nCAL group, the incidence of CAL was 31.4%; 119 cases of over 3 years old group, the incidence of CAL was 32.4%, 46 cases of CAL group, 73 cases of nCAL group, the incidence of CAL was 38.6%. There were 313 cases of typical Kawasaki disease, including 112 cases in CAL group (35.8%), 201 cases in nCAL group (64.2%) and 54 cases of atypical Kawasaki disease, including 10 cases in CAL group (18.5%) and 44 cases in nCAL group (81.5%). There were 122 cases in CAL group, including 90 males, accounting for 73.7%, 32 females, accounting for 26.3%; 245 cases in nCAL group, including 157 males, accounting for 64.1%, 88 females, accounting for 35.9%. ESR, ALT, LDH, D_Di above the four variables in KD children were significantly increased, but there was no significant difference between the CAL group and nCAL group (P 0.05); PA, HDL-C in KD children were significantly decreased, but there was no significant difference between CAL group and nCAL group (P 0.05); N%, HGB, GLB, CK, CK-MB, Cho, TG, LDL-C, Fib in KD children did not change significantly, and in CAL group and nCAL group and nCAL group. There was no significant difference between the two groups. According to the statistics of the relationship between the use of glucocorticoid (GCs) and coronary artery lesion, 138 (56.3%) of the patients in the nCAL group (245 cases), 107 (43.7%) of the patients in the CAL group (122 cases), 80 (65.6%) of the patients in the CAL group (80 cases) and 42 (42 cases) in the non-use of GC. There was no significant difference between x2 test, P 0.05 and P 0.7. Linear correlation analysis was used to analyze the selected variables. The clinical diagnosis of gender and KD (complete KD, incomplete KD) did not satisfy the normal distribution. WBC, PLT, CRP, AST, ALB and Na met the normal distribution. Pearson correlation analysis was used to obtain their respective phases. The results showed that KD typical / atypical, WBC, ALB and coronary artery diameter were significantly correlated in all age groups; KD typical / atypical, WBC, ALB and coronary artery diameter were significantly correlated in 5-year-olds; WBC, ALB and coronary artery diameter were significantly correlated in over 5-year-olds; WBC, PLT and coronary artery diameter were significantly correlated in over 5-year-olds. The results showed that typical KD, WBC and ALB were risk factors for KD and CAL in all age groups; typical KD, WBC and ALB were risk factors for KD and CAL in 5-year-old children; WBC and PLT were risk factors for KD and CAL in children over 5-year-old children; and WBC and PLT were risk factors for KD and CAL in children over 5-year-old children. Rate of birth.
【學位授予單位】：山東大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R725.4
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