本文關(guān)鍵詞：LBP基因多態(tài)性、APACHEⅡ評(píng)分和降鈣素原對(duì)ARDS預(yù)警作用的初步研究　出處：《第三軍醫(yī)大學(xué)》2014年碩士論文　論文類型：學(xué)位論文

  更多相關(guān)文章： 急性呼吸窘迫綜合征（ARDS） 脂多糖結(jié)合蛋白（LBP） APACHE‖評(píng)分 降鈣素原（PCT）

【摘要】：背景：急性呼吸窘迫征（Acute respiratory distress syndrome，ARDS）是一種由肺部感染、創(chuàng)傷及急性胰腺炎等多種肺內(nèi)、外致病因素導(dǎo)致的肺部炎癥反應(yīng)，，以肺順應(yīng)性降低、頑固性低氧血癥及非心源性肺水腫為主要臨床表現(xiàn)，預(yù)后差。盡管近年對(duì)ARDS的發(fā)病機(jī)制有了深入的理解，臨床治療ARDS的策略也有一定的改進(jìn)，但其死亡率仍沒(méi)有明顯下降。因此，如能早期甄別ARDS高�；颊�，及時(shí)進(jìn)行ARDS的防治，可望降低ARDS發(fā)病率、改善其預(yù)后。然而，由于ARDS的發(fā)病因素復(fù)雜，影響疾病進(jìn)展的因素多，目前尚無(wú)理想的ARDS預(yù)警模型。目前的研究表明，僅依靠患者臨床資料或一些肺部炎癥反應(yīng)、細(xì)胞損傷相關(guān)的生物標(biāo)志物并不能取得滿意的預(yù)測(cè)效果。因此，本研究擬分別從與ARDS發(fā)病相關(guān)的基因及臨床資料聯(lián)合生物標(biāo)志物兩方面著手，探討LBP基因多態(tài)性、APACHEⅡ評(píng)分和降鈣素原對(duì)急性呼吸窘迫綜合征的預(yù)警作用。 研究目的：本研究擬探討LBP基因多態(tài)性、APACHEⅡ評(píng)分和降鈣素原對(duì)急性呼吸窘迫綜合征的預(yù)警作用，以期得到較為理想的ARDS預(yù)警模型。 研究?jī)?nèi)容和方法： 1.實(shí)驗(yàn)設(shè)計(jì)：本研究分為以下兩個(gè)部分：(1)以222例內(nèi)毒素血癥患者為研究對(duì)象，通過(guò)snapshot方法檢測(cè)LBP15個(gè)SNP位點(diǎn)的基因多態(tài)性，結(jié)合患者是否發(fā)展為ARDS，尋找LBP與ARDS易感性相關(guān)的SNP位點(diǎn)及基因型。(2)以78例肺部感染患者為研究對(duì)象，結(jié)合患者是否發(fā)展為ARDS，繪制受試者工作特征曲線，探討APACHEⅡ評(píng)分、降鈣素原對(duì)肺部感染患者發(fā)展為ARDS的預(yù)測(cè)價(jià)值。 2.外周血的處理和DNA提取：在患者入住ICU24小時(shí)內(nèi)采集5ml EDTA抗凝靜脈血，分離血漿并進(jìn)行內(nèi)毒素檢測(cè)。提取DNA，于-80℃冰箱保存?zhèn)溆谩?3. snapshot方法檢測(cè)患者LBP基因15個(gè)SNP位點(diǎn)信息。 4.記錄患者的臨床基線資料，包括APACHEⅡ評(píng)分，年齡、性別、病人來(lái)源，慢性合并癥，入院診斷等基本人口學(xué)資料和采集血液標(biāo)本時(shí)患者的細(xì)菌培養(yǎng)結(jié)果。其中肺部感染患者還需記錄動(dòng)脈血?dú)�、血沉、C-反應(yīng)蛋白、乳酸、降鈣素原及1周內(nèi)的痰培養(yǎng)結(jié)果。 5.統(tǒng)計(jì)方法：每個(gè)SNP的等位基因及基因型的頻率根據(jù)基因檢測(cè)結(jié)果計(jì)算得到，基因型分布的檢驗(yàn)通過(guò)HWE（Hardy Weinberg Equilibrium,哈迪-溫伯格平衡定律）檢驗(yàn)得到，P0.05表示符合哈迪-溫伯格平衡定律。LD圖的構(gòu)建通過(guò)Haploview軟件制作得到。rs2232618與ARDS易感性的分析通過(guò)卡方檢驗(yàn)獲得。年齡、性別、內(nèi)毒素濃度等混雜因素的影響通過(guò)logistic回歸方法排除。正態(tài)分布資料的組間比較采用t檢驗(yàn)或方差分析，非正態(tài)分布資料的組間比較采用秩和檢驗(yàn)。預(yù)測(cè)作用采用受試者工作特征曲線（ROC曲線）方法，兩預(yù)測(cè)指標(biāo)的聯(lián)合采用二元Logistic回歸方法。 研究結(jié)果： 1.基因預(yù)警實(shí)驗(yàn)中，總共納入內(nèi)毒素血癥患者222例，其中男性154例，女性58例，年齡61.0±17.3（17～93）歲。7天內(nèi)發(fā)展為ARDS的患者49例，ARDS發(fā)生率為22.1%。革蘭陰性菌感染66例，占29.7%；其他病原菌及混合感染46例，占21.1%；未得到明顯致病菌110例，占49.2%。 2.222例內(nèi)毒素血癥患者15個(gè)SNP位點(diǎn)的MAF與HapMap數(shù)據(jù)庫(kù)中相似。其中13個(gè)SNP位點(diǎn)基因型的分布符合哈迪-溫伯格平衡定律(P0.05)，提示其等位基因及基因型頻率在人群中的遺傳是恒定的。APACHEII評(píng)分在rs2232618位點(diǎn)不同的基因型中無(wú)差異（P0.05）。 3.僅rs2232618與ARDS的易感性有關(guān)。攜帶有等位基因C（基因型CC/CT）的患者其發(fā)生ARDS的概率明顯高于不攜帶等位基因C（基因型TT）的患者（P=0.001）。通過(guò)logistic回歸分析發(fā)現(xiàn)，在排除年齡、性別、內(nèi)毒素濃度等影響后，rs2232618與ARDS的易感性仍密切相關(guān)(P=0.002)。 4.臨床資料及生物標(biāo)志物預(yù)警實(shí)驗(yàn)中，總共納入肺部感染患者78例，其中男性患者60例，女性患者18例，年齡65.2±17.6(25～93)歲。7天內(nèi)發(fā)展為ARDS的患者有33例，ARDS發(fā)生率42.3%。ARDS組APACHEⅡ評(píng)分和降鈣素原顯著高于非ARDS組，分別為[(19.9±8.3) vs (15.6±6.0), P=0.013]和(12.6±11.4)ng/L vs (7.5±10.5)ng/L, P=0.046]，氧合指數(shù)低于非ARDS組，為[(109.9±82.6) vs (252.1±92.4), P=0.003]。 5. APACHEⅡ評(píng)分和降鈣素原對(duì)肺部感染誘發(fā)ARDS的預(yù)測(cè)作用相當(dāng)（AUROC:0.651vs0.657，P=0.929），且兩者聯(lián)合后，對(duì)ARDS的預(yù)測(cè)作用較兩者單獨(dú)的預(yù)測(cè)作用無(wú)顯著提高。 結(jié)論： 1. LBP基因rs2232618位點(diǎn)攜帶等位基因Ｃ（基因型CC+TC）的患者更易發(fā)生內(nèi)毒素性ARDS。該位點(diǎn)T→C的突變可能是預(yù)測(cè)內(nèi)毒素性ARDS的一個(gè)較為理想的預(yù)警指標(biāo)。 2. APACHEⅡ評(píng)分和血漿中降鈣素原的表達(dá)與肺部感染患者的ARDS發(fā)生率密切相關(guān)。兩者對(duì)肺部感染誘發(fā)的ARDS均有一定的預(yù)測(cè)價(jià)值，但兩者聯(lián)合后的預(yù)測(cè)價(jià)值并無(wú)明顯提高。
[Abstract]:Background: acute respiratory distress syndrome (Acute respiratory distress syndrome, ARDS) is a lung infection, trauma and acute pancreatitis such as lung, lung inflammation leads to external pathogenic factors, to reduce lung compliance, refractory hypoxemia and non cardiogenic pulmonary edema were the main clinical manifestations, despite the depth of poor prognosis. The understanding of the pathogenesis of ARDS in recent years, the clinical treatment of ARDS strategy also has some improvement, but the mortality rate is still not decreased significantly. Therefore, if early screening high-risk patients with ARDS, timely prevention and treatment of ARDS, is expected to reduce the incidence of ARDS, improve the prognosis. However, due to the incidence of ARDS complex which factors influence the progress of the disease, there is no ideal ARDS early warning model. The present study shows that only rely on the clinical data of patients or some lung inflammation, related biomarkers of cell injury It can not achieve satisfactory prediction effect. Therefore, this study is going to start from two aspects of gene and clinical data combined with biomarkers associated with the pathogenesis of ARDS, and explore the early warning effect of LBP gene polymorphism, APACHE II score and procalcitonin on acute respiratory distress syndrome.
Research purposes: the purpose of this study is to explore the early warning effect of LBP gene polymorphism, APACHE II score and procalcitonin on acute respiratory distress syndrome, in order to get an ideal ARDS early warning model.
Research contents and methods:
1. experimental design: This study is divided into the following two parts: (1) in 222 cases of patients with endotoxemia as the research object, through the snapshot method for detection of LBP15 gene polymorphism SNP loci, according to whether patients developed ARDS, LBP associated with ARDS susceptibility loci and SNP genotype (2) in. 78 cases of pulmonary infection patients as the research object, according to whether patients developed ARDS, receiveroperating characteristic curve of APACHE score, procalcitonin in patients with pulmonary infection for the development of the predictive value of ARDS.
2. peripheral blood treatment and DNA extraction: 5ml EDTA anticoagulation venous blood was collected in patients ICU24 hours, plasma was separated and endotoxin test was carried out. DNA was extracted and stored in the refrigerator at -80 degrees.
The 3. snapshot method was used to detect the 15 SNP loci information of the patient's LBP gene.
The baseline clinical data of 4. patients were recorded, including APACHE score, age, gender, source of patients, chronic complications, admission diagnosis and other basic demographic data and blood samples were collected in bacterial culture also recorded. Results of the arterial blood gas of patients with pulmonary infection, blood sedimentation, C- reactive protein, lactate and procalcitonin and within 1 weeks the results of sputum culture.
5. statistical methods: allele and genotype frequencies of each SNP was calculated according to the results of gene detection, test the genotype distribution by HWE (Hardy Weinberg Equilibrium, the Hardy Weinberg equilibrium test), P0.05 Hardy - Weinberg said in accordance with building balance law.LD map by Haploview software and.Rs2232618 analysis the susceptibility of ARDS obtained by chi square test. The age, gender, effects of endotoxin concentration of such confounding factors by logistic regression method to eliminate. Normal distribution data was compared using the t test or analysis of variance, compared with non normal distribution data between groups using the Wilcoxon rank sum test and prediction function. The receiver operating characteristic curve (ROC curve) method, combined with two yuan Logistic two prediction index regression method.
The results of the study:
1. gene warning experiment, included a total of 222 cases of patients with endotoxemia, including 154 cases of male, female 58 cases, age 61 + 17.3 (17 ~ 93) at the age of.7 days for the development of the 49 cases of ARDS patients, the incidence rate of ARDS was 66 22.1%. leather cases, gram-negative bacteria infection accounted for 29.7%; and other pathogens 46 cases of mixed infection, accounting for 21.1%; has not been significantly pathogens in 110 cases, accounting for 49.2%.
Similar to 2.222 cases of 15 SNP loci in endotoxemia patients with MAF and HapMap database. The distribution of 13 SNP loci genotype with Hardy - Weinberg equilibrium (P0.05), suggesting that the genetic allele and genotype frequencies in the population is constant.APACHEII score no difference in genotype rs2232618 of different sites in (P0.05).
Only about 3. rs2232618 and the susceptibility to ARDS. Carrying the C allele (CC/CT genotype) in patients with ARDS was significantly higher than the probability of not carrying the C allele (TT genotype) patients (P=0.001). The logistic regression analysis showed that gender, age are excluded, effects of endotoxin concentration etc. and susceptibility to rs2232618 and the ARDS are still closely related (P=0.002).
4. clinical data and biomarkers of early warning experiment, included a total of 78 patients with pulmonary infection, including 60 cases of male patients, 18 female patients, age 65.2 + 17.6 (25 ~ 93) at the age of.7 days for the development of ARDS in 33 patients, the incidence of ARDS in group 42.3%.ARDS, APACHE score and calcitonin the original is significantly higher than that in group ARDS, respectively [(19.9 + 8.3) vs (15.6 + 6), and P=0.013] (12.6 + 11.4) ng/L vs (7.5 + 10.5) ng/L, P=0.046], oxygenation index lower than non ARDS group, for [(109.9 + 82.6) vs (252.1 + 92.4), P=0.003].
5., APACHE II score and procalcitonin played a similar role in predicting ARDS induced by pulmonary infection (AUROC:0.651vs0.657, P=0.929), and the prediction effect of ARDS on them was not significantly higher than that of either group.
Conclusion:
1. LBP rs2232618 gene carrying allele C (genotype CC+TC) mutations were more susceptible to endotoxin induced ARDS. T, the site of C may be an ideal index to predict early warning of endotoxin induced ARDS.
2., the APACHE II score and the expression of procalcitonin in serum are closely related to the incidence of ARDS in patients with pulmonary infection. Both of them have certain predictive value for ARDS induced by pulmonary infection, but the predictive value of combination of them is not significantly improved.

【學(xué)位授予單位】：第三軍醫(yī)大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2014
【分類號(hào)】：R563.8

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本文編號(hào)：1360840