乳酸、免疫球蛋白在脑出血并发脑心综合征中变化及意义

Xinxiang Medical College

 

Abstract：

Objective:To analyze the changes and significance of lactic acid and immunoglobulin(Ig) in cerebral hemorrhage complicated by cerebro-cardiac syndrome(CCS).Methods:The clinical data of 85 patients with cerebral hemorrhage and CCS admitted to our hospital from January 2018 to July 2020 were retrospectively analyzed(study group) and 50 healthy volunteers(control group) were selected during the same period.The serum lactic acid, immunoglobulin G(IgG) and immunoglobulin M(IgM) levels were compared between the two groups.The prognosis of follow-up was counted, the serum lactate, IgG and IgM levels and the independent risk factors affecting death of patients with cerebral hemorrhage combined with CCS were compared, ROC curve was drawn, and the predictive value of different indicators for death of patients with cerebral hemorrhage with CCS was analyzed.Results:The serum lactic acid level of the study group was significantly higher than that of the control group, and the levels of IgG and IgM were significantly lower than those of the control group(P<0.05).Among 85 patients with cerebral hemorrhage and CCS,14 patients died and 71 patients survived.The serum lactate level of the death group was significantly higher than that of the survival group, and the levels of IgG and IgM were significantly lower than those of the survival group(P<0.05).The Logistic regression analysis showed that the increase of blood glucose and serum lactic acid levels and the decrease of IgG and IgM were risk factors affecting the death of patients with cerebral hemorrhage combined with CCS(P<0.05). The results of ROC curve analysis showed that serum lactic acid, IgG and IgM levels have high predictive value for the death of patients with cerebral hemorrhage combined with CCS, and the area under the combined detection curve was the largest.Conclusion:Serum lactic acid is highly expressed in patients with cerebral hemorrhage complicated by CCS, while IgG and IgM are lowly expressed, which is speculated to be related to the occurrence and development of cerebral hemorrhage complicated by CCS, and can be used as a reference index in evaluating the prognosis.

 

Keyword：

Lactic acid; Immunoglobulin; Cerebral hemorrhage; Cerebral-cardiac syndrome;

 

脑出血是指非外伤性脑实质内的自发性出血，病因多样，绝大多数是高血压小动脉硬化的血管破裂引起，占我国脑血管病的30%[1]。脑心综合征(Cerebro-cardiac syndrome, CCS)是指因急性脑病所引起类似的急性心梗、心内膜下出血、心肌缺血、心力衰竭的统称[2]。脑出血病情严重者可导致心肌细胞组织受损，发生CCS。脑出血并发CCS的机理极其复杂，尚未十分明确。既往研究显示，血清乳酸水平、免疫球蛋白与脑出血患者病情发生、发展关系密切，可有效反应疾病的严重程度[3,4]。基于此，本组研究采用回顾性研究方法对85例脑出血合并CCS患者的临床资料进行总结，分析其乳酸水平、免疫球蛋白指标水平变化情况及其意义，以期为脑出血合并CCS的诊治提供依据。

 

1 资料与方法

1.1 一般资料

回顾性分析本院2018年1月—2020年7月收治的脑出血合并CCS患者的临床资料。纳入标准：(1)均经临床影像学等确诊为脑出血合并CCS;(2)免疫、血液系统功能正常；(3)临床各方面资料无丢失或缺损；(4)无原发性心脏、肝脏等疾病。排除标准：(1)合并其他恶性肿瘤者；(2)合并意识障碍者；(3)合并肾炎、全身变态反应性病史；(4)妊娠期孕妇或哺乳期妇女。最终纳入85例患者(研究组),其中男55例，女30例；年龄42～77岁，平均年龄(59.84±6.45)岁。同期选取50例在本院门诊进行健康体检的志愿者作为对照组，其中男33例，女17例；年龄42～78岁，平均年龄(60.14±7.25)岁。两组研究对象一般资料比较差异无统计学意义(P>0.05),具有可比性。

 

1.2 方法

(1)因子水平检测：抽取所有受检者5ml静脉血，3 000r/min 离心10min, 抽取上清液置于-80℃低温保存，分取上层血清置于AU5800全自动生化分析仪及其配套试剂盒(美国，贝克曼库尔特)测定血清乳酸水平、血糖、总胆固醇(TC)及三酰甘油(TG)水平。(2)免疫球蛋白指标检测：检测指标包括IgG、IgM,以琼脂扩散法检测外周血IgG、IgM水平。采用北京科兴医用试剂开发中心提供的免疫单扩散定量检测板。(3)预后评估标准：对患者进行2个月电话随访，根据患者死亡或生存分为死亡组与生存组。

 

1.3 观察指标

(1)比较两组血清乳酸、IgG及IgM水平；(2)分析不同预后患者血清乳酸、IgG及IgM水平及影响脑出血合并CCS死亡的独立危险因素；(3)绘制受试者工作特征曲线(Receiver operating characteristic curve, ROC),分析上述因子水平对脑出血合并CCS死亡的预测价值。

 

1.4 统计学方法

采用SPSS22.0统计软件包处理数据。计量资料以(x¯±s)表示，采用t检验，计数资料采用率(%)进行描述；绘制ROC曲线分析血清乳酸、IgG及IgM水平对脑出血合并CCS患者死亡的预测价值，影响因素采用多元Logistic回归分析，P<0.05为差异具有统计学意义。

 

2 结果

2.1 两组血清乳酸、IgG及IgM水平比较

研究组血清乳酸水平显著高于对照组，IgG、IgM水平均明显低于对照组，组间比较差异具有统计学意义(P<0.05)。见表1。

 

2.2 死亡组与存活组血清乳酸、IgG及IgM水平比较

85例脑出血合并CCS患者中，死亡14例(16.47%),生存71例(83.53%)。死亡组血清乳酸水平显著高于生存组，IgG、IgM水平均明显低于生存组，组间比较差异具有统计学意义(P<0.05)。见表2。

 

2.3 影响脑出血合并CCS患者死亡的危险因素分析

经Logistic回归模型分析得，血糖、血清乳酸水平上升及IgG、IgM降低是影响脑出血合并CCS患者死亡的危险因素(P<0.05)。见表3。

 

2.4 血清乳酸、IgG及IgM水平对脑出血合并CCS患者死亡的预测价值

 

ROC曲线分析结果显示，血清乳酸、IgG及IgM水平对脑出血合并CCS患者死亡具有高预测价值，其中以联合检测的曲线下面积最大，为0.738。见表4与图1。

 

3 讨论

脑出血是临床上常见的一种疾病，且发病率呈不断上升趋势，起病急、发展快，以脑部循环障碍为主[5]。临床症状较多，表现为嗜睡、昏迷、失语等，可伴有神经系统阳性体征，如神经病理征阳性等。在临床上，因脑出血导致的心肌细胞损伤、心律失常、功能障碍称为CCS,对患者生命安全造成严重威胁，提高早期诊疗水平具有重要意义[6,7]。乳酸是氧供给不足和组织灌溉的早期敏感生化指标，由葡萄糖代谢生成，其产生越多，人体获得的能量也越多，在人体各项生命活动中具有一定的作用，但若人体乳酸存在过多，会破坏人体内环境的稳定，导致人体的酸碱平衡被打破，发生乳酸酸中毒，严重时可导致患者死亡[8,9]。Nishi K等[10]研究发现血清中乳酸水平的波动可反映机体氧供情况。Weller JM等[11]研究结果发现，乳酸的水平不仅可反映心脑血管疾病的严重程度，还可作为患者预后评估的指标。免疫球蛋白是具有抗体活性的动物蛋白，IgG、IgM及IgA是免疫球蛋白常见的三种类型。其中IgA有血清型与分泌型之分，分泌型主要与机体黏膜防御系统有关，与本组研究病例关系不大[12,13],血清型含量极低，意义不大。IgG是人体血清免疫球蛋白的主要成分，是初级免疫应答中最持久、最重要的抗体，其主要发挥调理作用[14]。IgM是在初次免疫应答中最早出现的抗体，主要用于疾病的早期诊断，在机体的早期防御中起重要作用[15]。但目前关于血清乳酸、IgG及IgM在脑出血并发CCS中变化及意义的研究甚少。

 

本研究中，与对照组体检者比较，研究组血清乳酸水平更高，IgG、IgM水平更低，与Pandey P等[16]研究报道结果相符，表明在脑出血并发CCS中，血清乳酸水平呈上升趋势，IgG、IgM水平呈下降趋势，存在免疫功能改变。其血清乳酸水平上升分析原因可能是因为发生脑出血时，患者脑内血气交换受阻，进入无氧酵解过程，糖的转化分解减少，并导致血清乳酸大量聚集[17,18]。

 

通过比较不同预后患者血清乳酸、IgG及IgM水平发现，死亡组血清乳酸水平显著高于生存组，IgG、IgM水平均明显低于生存组；且血清乳酸水平上升及IgG、IgM降低亦是影响脑出血合并CCS患者死亡的危险因素。进一步ROC曲线分析显示，血清乳酸、IgG及IgM水平预测对脑出血并发CCS患者死亡的曲线下面积分别为0.679、0.720、0.688,在预后评估方面有较高的价值，与Nakase T等[19]报道结果相似。但本组研究发现，联合检测上述因子对脑出血并发CCS患者的诊断及预后评估的价值最佳，可提高整体效能。

 

综上所述，脑出血并发CCS患者中血清乳酸呈高表达，IgG、IgM呈低表达，推测与脑出血并发CCS发生、发展有关，可作为评估其预后的参考指标。

 

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