【作者】 陆召辉；

【导师】 戴路明；

【作者基本信息】 昆明医学院 ， 内科学， 2009， 硕士

【摘要】 目的本研究旨在探讨血清淀粉样蛋白A(serum amyloid A,SAA)联合C-反应蛋白(C-reactive protein,CRP)在慢性阻塞性肺疾病急性加重期(acute exacerbationof chronic obstructive pulmonary disease,AECOPD)的临床应用价值。方法在昆明医学院第一附属医院呼吸内科招募患者参加我们的研究,经过病史询问、体格检查、胸片和肺功能检查。符合纳入标准的中一极重度慢性阻塞性肺疾病(chronic obstructive pulmonary disease,COPD)患者112例(GOLDⅡ—Ⅳ级)(因中—重度极易反复急性加重),其中男67例,女45例;AECOPDⅠ级、AECOPDⅡ/Ⅲ级患者各56例[依据2004年美国胸科学会/欧洲呼吸学会(ATS/ERS)的COPD诊治指南:Ⅰ级,不需住院治疗;Ⅱ级,需住院治疗;Ⅲ级,存在呼吸衰竭。并以此标准作为判断住院与否的金标准]。AECOPDⅠ级患者在急性加重期、稳定期测血清SAA、CRP水平;AECOPDⅡ/Ⅲ级患者在急性加重期、恢复期、稳定期测血清SAA、CRP水平,其中9例于用糖皮质激素24小时后再检测SAA、CRP水平,且住院后至少做3次痰涂片及培养;被纳入的所有患者均检测肺炎支原体抗体;并随机抽取同期我院体检的健康对照者20例,其中男13人,女7人,测血清SAA、CRP水平。结果纳入的AECOPD患者血清SAA水平明显高于CRP水平,差异有统计学意义(P＜0.05)。根据接收者工作特征(the receiver operatingcharacteristic,ROC)曲线分析,SAA、CRP均不能很好地将AECOPDⅠ级同COPD稳定期区分开,因为其ROC曲线下面积(AUC)分别为0.69、0.63;SAA与CRP相比能更好地将AECOPDⅡ/Ⅲ级同COPD稳定期区分开,因为其AUC值分别为0.91、0.80。糖皮质激素治疗前后血清SAA、CRP水平无统计学差异(P＞0.05)。有脓痰或痰培养阳性者血清SAA、CRP水平明显升高。细菌感染组SAA、CRP水平高于肺炎支原体感染组,肺炎支原体感染组SAA、CRP水平高于急性加重的其他诱因组(P＜0.05)。SAA、CRP水平均升高时,静滴抗生素5天左右后症状明显好转者,出院后继续口服抗生素3天组和住院静滴抗生素10-14天组,12个月随访的再住院次数、急性加重次数在两组间差异无统计学意义(P＞0.05)。CRP基本正常、SAA升高时,用与不用抗生素组预后差异无统计学意义(P＞0.05)。结论在AECOPD中SAA是较CRP更敏感的一个炎症标志物,有利于疾病的诊断与病情观察和治疗的判断,且SAA联合CRP有利于指导抗生素的应用,使用糖皮质激素治疗对患者的血清CRP、SAA水平无影响。更多还原

【Abstract】 Objective To probe clinical application of serum amyloid A combinating C-reactive protein in acute exacerbation of chronic obstructive pulmonary disease.Methods Through disease history inquiry,physical examination,chest X-ray and pulmonary function test,we recruited 112 patients admitted to the Department of Respiratory Medicine,the First Affiliated Hospital of Kunming Medical College.Patients with COPD(GOLDⅡ-Ⅳlevel)include fifty six patients of AECOPDⅠlevel and fifty six patients AECOPDⅡ/Ⅲ(according to 2004 year ATS/ERS guide:levelⅠ,treated at home;levelⅡ,requires hospitalization;levelⅢ,leads to respiratory failure.The criteria is regarded golden criteria to decide wether patients require hospitalization.).There are 67 male patients,45 female patients.The concentrations of SAA and CRP in the serum were measured in patients with levelⅠAECOPD both acute exacerbation and stable stage and in twenty healthy volunteers(13 male,7 female);they were also measured in patients with AECOPD of levelⅡ/Ⅲamong acute exacerbation,stage of recovery,stable stage.The concentrations of SAA and CRP in the serum were measured again after twenty-four hours using glucocorticoid.And sputum smear and cluture were done three times at least after hospitalization.A11 AECOPD patients were measured antibody of Mycoplasma pneumoniae.Results The concentration of SAA was significantly higher than that of CRP in patients with AECOPD(P＜0.05).According to the receiver operating characteristic curves(ROC curves) analysis principle,both SAA and CRP modestly distinguished levelⅠAECOPD from stable COPD,as ROC analysis generated AUC values of 0.69 for SAA and 0.63 for CRP;SAA was significantly better at differentiating levelⅡ/ⅢAECOPD from stable COPD with an AUC value of 0.91 versus CRP with an AUC value of 0.80(P＜0.05). The concentrations of SAA and CRP before and after using glucocorticoid are not different in statistics.The concentrations of SAA and CRP in the serum were significantly higher when sputum was purulent or bacteria found. The concentrations of SAA and CRP in group of bacterial infection are higher than those of group of Mycoplasma pneumoniae infection,the concentrations of SAA and CRP in group of Mycoplasma pneumoniae infection are higher than those of group of other incentives(P＜0.05).When SAA and CRP were both higher than normal level,one group used ivtravenous antibiotic about five days and symptom was significantly improved,then altered oral antibiotic using three days and the other group used ivtravenous antibiotic about 10-14 days in hospital.Times of hospitalization and acute exacerbation were not significantly different between the two groups after twelve months follow-up visit (P＞0.05).Wether using antibiotic was not significantly different by twelve months follow-up visit when SAA was high and CRP was normal(P＞0.05).Conclusion SAA is more sensitive inflammation marker than CRP in AECOPD,and is availed to diagnose disease and estimate therapy.Moreover, SAA combinating CRP can profit to direct application of antibiotic.The concentrations of SAA and CRP will not be affected by using glucocorticoid.更多还原