急性パラカン中毒患者の予後に対する血液検査における早期指標の変化の予測値．

[Predictive value of early indicators changes in blood test on the prognosis of patients with acute paraquat poisoning].

• Linlin Chao
• Zhenning Liu
• Min Zhao
• Mengying Yang
• Yongzhuang Ye
• Guigui Wei

抄録

目的:

血液検査における早期指標の変化が急性パラカン中毒患者の予後に及ぼす影響を検討した。

OBJECTIVE: To investigate the predictive value of early indicators changes in blood test on the prognosis of patients with acute paraquat poisoning.

方法:

2012年1月から2019年6月までに中国医科大学聖京病院救急部に入院した急性パラカン中毒患者の臨床データをレトロスペクティブに分析した。入院後24時間以内の血液検査指標の変化を収集し、白血球数（ΔWBC）、好中球数（ΔNE）、リンパ球数（ΔLY）、単球数（ΔMO）、動脈酸素分圧（ΔPaO）、動脈二酸化炭素分圧（ΔPaCO）、動脈血pH（ΔpH）、重炭酸ラジカル（ΔHCO)、塩基過剰(ΔBE)、乳酸(ΔLac)、総蛋白(ΔTP)、アルブミン(ΔALB)、アラニンアミノトランスフェラーゼ(ΔALT)、アスパラギン酸アミノトランスフェラーゼ(ΔAST)、総ビリルビン(ΔTBil）、直接ビリルビン（ΔDBil）、血中尿素窒素（ΔBUN）、血清クレアチニン（ΔSCr）、血清カルシウム濃度（ΔCa）、および血清カリウム濃度（ΔK）。急性パラカン中毒患者の予後の危険因子を解析するために多変量ロジスティック回帰を用い、パラカン中毒患者の死亡予測値を解析するために受信操作特性（ROC）曲線を作成した。

METHODS: The clinical data of patients with acute paraquat poisoning admitted to emergency department of Shengjing Hospital of China Medical University from January 2012 to June 2019 were retrospectively analyzed. The changes of blood test indexes within 24 hours after admission were collected, including white blood cell count (ΔWBC), neutrophils count (ΔNE), lymphocytes count (ΔLY), monocytes count (ΔMO), arterial partial pressure of oxygen (ΔPaO), arterial partial pressure of carbon dioxide (ΔPaCO), arterial blood pH (ΔpH), bicarbonate radical (ΔHCO), base excess (ΔBE), lactate (ΔLac), total protein (ΔTP), albumin (ΔALB), alanine aminotransferase (ΔALT), aspartate aminotransferase (ΔAST), total bilirubin (ΔTBil), direct bilirubin (ΔDBil), blood urea nitrogen (ΔBUN), serum creatinine (ΔSCr), serum calcium concentration (ΔCa), and serum potassium concentration (ΔK). Multivariate Logistic regression was used to analyze the risk factors of prognosis in patients with acute paraquat poisoning, and receiver operating characteristic (ROC) curve was drawn to analyze the predictive value of ROC curve for the death of patients with paraquat poisoning.

結果:

急性パラカン中毒患者251例が含まれ，99例が死亡し，死亡率は39.4%であった．死亡群では，入院後24時間以内のΔWBC，ΔLac，ΔALT，ΔAST，ΔTBil，ΔDBil，ΔBUN，ΔSCr，ΔKを含むマーカーの増加が生存群に比べて有意に高かった．死亡群のΔＰａＣＯ、ΔＨＣＯ、ΔＢＥ、ΔＴＰ、ΔＡＬＢを含むマーカーの減少は生存群よりも有意に大きかった。上記の単因子分析で統計的に有意な値を示した変数を多変量ロジスティック回帰分析に含めた。その結果、ΔLac、ΔSCr、ΔKは急性パラカン中毒患者の予後の独立した危険因子であった［オッズ比（OR）は1.662（0.997～2.772）、1.045（1.010～1.083）、4.555（1.190～17.429）、いずれもP＜0.05］。急性パラカン中毒患者の死亡を予測するためのΔLac、ΔSCrおよびΔKのROC曲線下面積（AUC）は、それぞれ0.639（95％CIは0.505-0773）、0.811（95％CIは0.704-0.917）、および0.649（95％CIは0.519-0.779）であった。ΔLacのカットオフが1.85mmol/Lのとき、感度は87.9％、特異度は47.7％、診断精度は70.2％であり、ΔSCrのカットオフが37.75μmol/Lのとき、感度は84．また、ΔKのカットオフが0.42mmol/Lのとき、感度は36.6%、特異度は90.7%、診断精度は68.3%であった。また，ΔLac，ΔSCr，ΔKの組み合わせは，単一の指標よりも急性パラカン中毒患者の死亡予測に有効であり，AUCは0.911，95%CIは0.834-0.989であった。

RESULTS: A total of 251 patients with acute paraquat poisoning were included, with 99 cases dead, and the mortality was 39.4%. The increase of the markers including ΔWBC, ΔLac, ΔALT, ΔAST, ΔTBil, ΔDBil, ΔBUN, ΔSCr and ΔK within 24 hours of admission in the death group were significantly higher than that in the survival group; the decrease of the markers including ΔPaCO, ΔHCO, ΔBE, ΔTP, and ΔALB in the death group were significantly greater than those in the survival group. The variables with statistical significance in the above single factor analysis were included in the multivariate Logistic regression analysis. The results showed that ΔLac, ΔSCr and ΔK were independent risk factors for the prognosis of patients with acute paraquat poisoning [odds ratio (OR) and 95% confidence interval (95%CI) were 1.662 (0.997-2.772), 1.045 (1.010-1.083) and 4.555 (1.190-17.429), respectively, all P < 0.05]. The area under the ROC curve (AUC) of ΔLac, ΔSCr and ΔK for predicting death of patients with acute paraquat poisoning was 0.639 (95%CI was 0.505-0773), 0.811 (95%CI was 0.704-0.917), and 0.649 (95%CI was 0.519-0.779), respectively. When the cut-off of ΔLac was 1.85 mmol/L, the sensitivity was 87.9%, the specificity was 47.7%, and the diagnostic accuracy was 70.2%; when the cut-off of ΔSCr was 37.75 μmol/L, the sensitivity was 84.4%, the specificity was 77.9%, and the diagnostic accuracy was 80.5%; when the cut-off of ΔK was 0.42 mmol/L, the sensitivity was 36.6%, the specificity was 90.7%, and the diagnostic accuracy was 68.3%. The efficiency of combination of ΔLac, ΔSCr, and ΔK was greater than a single indicator in predicting death of patients with acute paraquat poisoning, with AUC of 0.911, and 95%CI of 0.834-0.989.

結論:

入院24時間以内のΔLac, ΔSCr, ΔKはすべて急性パラカン中毒患者の予後の独立した危険因子であり，入院24時間以内のΔSCr>37.75μmol/Lは急性パラカン中毒患者の予後不良を予測した．Lac、SCr、Kの複合解析は、単一の指標よりも正確にパラカン中毒患者の予後を予測することができる。

CONCLUSIONS: ΔLac, ΔSCr, ΔK within 24 hours of admission were all independent risk factors for the prognosis of patients with acute paraquat poisoning. ΔSCr > 37.75 μmol/L within 24 hours of admission would predict a poor prognosis in the patients with acute paraquat poisoning. Combined analysis of ΔLac, ΔSCr, and ΔK can predict the prognosis of paraquat poisoning patients more accurately than single index.