İç hastalıkları yYoğun bakım ünitesinde sepsis ve septik şok tanısı ile izlenen hastalarda mortalite belirteçleri ve poliklonal intravenöz immünoglobulin tedavisinin sağkalım üzerine etkisinin değerlendirilmesi
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Tarih
2021
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Ege Üniversitesi, Tıp Fakültesi
Erişim Hakkı
info:eu-repo/semantics/openAccess
Özet
Giriş ve Amaç: Sepsis, enfeksiyöz bir sürece karşı vücudun oluşturduğu immünolojik yanıt sonucu ortaya çıkan organ yetmezliği ve ölüme yol açabilen medikal bir acildir. Sepsis ile ilgili yapılan büyük epidemiyolojik çalışmaların sonucuna göre mortalite yaklaşık %35'tir. Mortalitenin azaltılması adına birçok ek tedavi modalitesi üzerine çalışmalar mevcuttur. Poliklonal IVIg tedavisi bu ek tedavilerden biri olarak dikkat çekmektedir. Ek tedavi ihtiyaçlarının yanında prognozu erken dönemde tahmin edilmesinde ve bu ek tedavilerin uygulanabileceği hastaların seçilmesi için biyobelirteçlere ihtiyaç duyulmaktadır. Bu retrospektif kohort çalışması ile sepsiste mortalite ile ilişkili parametrelerin bulunması ve poliklonal IVIg tedavisinin etkinliğinin değerlendirilmesi amaçlanmıştır. Gereç ve Yöntem: Bu çalışma; Eylül 2013- Şubat 2021 tarihleri arasında Ege Üniversitesi Tıp Fakültesi Hastanesi İç Hastalıkları Anabilim Dalı yoğun bakım biriminde sepsis tanısı ile takip edilen n=245 hastanın retrospektif incelenmesiyle yapıldı. Sepsis tanısı sepsis-3 kriterlerine göre oluşturulmuştur. Hastaların demografik bilgileri, komorbid durumları, vital bulguları, organ yetmezliği skorlamaları, biyokimyasal ve mikrobiyolojik parametreleri, IVIg tedavisi alıp almadığı, bu tedaviyle ilgili bilgiler, 30, 60, 90 günlük mortalite sonuçları kaydedilmiştir. Bulgular: Çalışmadaki toplam hasta sayısı n=245. Çalışmanın IVIg tedavisinin mortaliteye etkisinin değerlendirildiği bölümde 102 hastanın IVIg tedavisi aldığı, 143 hastanın IVIg tedavisi almadığı görüldü. Yapılan mortalite analizlerinde IVIg tedavisi alan ve almayan grup arasında mortalite farkı görülmedi (%51 vs %49 p=0,94). Sadece 1. ve 2. günde IVIg tedavisi alan hastalar analize dahil edildiğinde benzer şekilde tedavi almayan grupla mortalite farkı tespit edilemedi (%49,7 vs %44,8 p=0,643). Yapılan alt grup analizlerinde XDR patojen üremesi olan hastalarda; IVIg tedavisini 1. ve 2. gün alan grupta tedavi almayan gruba göre 60 gün mortalitesi anlamlı olarak daha düşük olarak saptanmıştır (%95,5 vs %66,7 p=0,33). Yapılan cox regresyon analizinde; SOFA skorunun 7'nin üzerinde olması, başvuru sırasında vazopressör ihtiyacının olması, immünsupresif tedavi uygulanması, nötropenik ateş varlığı, hematolojik malignite varlığı, pnömoni varlığı, idrar yolu enfeksiyonu varlığı, serum albümin düzeyinin 2,9 g/dL'nin üzerinde olması, LDH düzeyinin 324 U/L'nin üzerinde olması, MALS varlığı ve serum ferritin düzeyinin 1518'den yüksek olmasının her birinin tek başına 30 günlük mortalite üzerinde istatistiksel anlamlı olduğu görülmüştür. Çoklu lojistik regresyon analizinde, SOFA skorunun 7 puanın üzerinde olması, immünsupresif tedavi almış olma ve ferritin düzeyinin 1518 ng/ml'nin üzerinde olmasının, 30 günlük mortalite ile anlamlı ilişkili olduğu gözlenmiştir (sırasıyla p=0,036, p=0,021 ve p=0,023). Uygulanan ROC eğrisi analizinde mortaliteye göre %73 sensitivite ve %64,83 spesifite ile SOFA skoru değişkeninin kestirim değeri (cut off) 7 (AUC=0,713, p<0,001),%64,95 sensitivite ve %58,27 spesifite ile albümin değişkeninin kestirim değeri (cut off) 2,9 g/dL (AUC=0,632, p=0,001), %50 sensitivite ve %71,58 spesifite ile LDH değişkeninin kestirim değeri (cut off) 324 U/L (AUC=0,593, p=0,035) ,%61,54 sensitivite ve %80,9 spesifite ile ferritin değişken skorunun kestirim değeri (cut off) 1518 ng/ml olarak tespit edilmiştir (AUC=0,732, p<0,001). Sonuç: XDR patojen üremesi olan sepsis hastalarında poliklonal IVIg tedavisi mortalitenin azaltılmasında etkili olabilir. Ferritin >1518 ng/ml olması çok değişkenli regresyon analizinde 30 günlük mortaliteyle ilişkili olarak bulunmuştur.
Introduction: Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. According to the results of large epidemiological studies on sepsis, mortality is approximately %35-40. Many studies have been conducted on additional treatment to reduce mortality in sepsis. Polyclonal IVIg therapy draws attention as one of these additional treatments. In addition to the need for additional treatment, biomarkers are needed to predict the prognosis at an early stage and to select patients to whom these additional treatments can be applied. In this retrospective cohort study, it was aimed to find the parameters associated with mortality in sepsis and to evaluate the efficacy of polyclonal IVIg therapy. Methods: This study was performed by retrospective examination of n=245 patients who were followed up with a diagnosis of sepsis in the intensive care unit of Ege University Faculty of Medicine, Department of Internal Medicine between September 2013 and February 2021. Sepsis diagnoses were established according to Sepsis-3 criteria. Demographic information, vital signs, comorbid conditions, organ failure scores, biochemical and microbiological parameters, whether they received IVIg treatment, 30, 60, 90-day mortality results were recorded. Results: The total number of patients in the study was n=245. In the section of the study where the effect of IVIg treatment on mortality was evaluated, it was seen that 102 patients received IVIg treatment and 143 patients did not. There was no difference in mortality between the group that received and did not receive IVIg treatment. (51% vs 49% p=0.94) When the analysis is restricted to patients who received IVIg therapy on 1st and 2nd days of sepsis, and patients who did not receive IVIg treatment, There is also no mortality differences between groups (%49,7 vs %44,8 p=0,643). In the subgroup analyzes; in patients with XDR pathogen ; It was determined that the group who received IVIg treatment on the 1st and 2nd days of sepsis had a significantly lower 60-day mortality than the group that did not receive IVIg treatment. (95.5% vs 66.7% p=0.33). In univariate cox regression analysis; SOFA score above 7 (OR 4,98 [2,85- 8,70] p <0,001), need for vasopressor treatment at admission (OR 2,14 [1,26- 3,62] p=0,005), use of immunosuppressive therapy (OR 3,37 [1,50- 7,57] p=0,003), presence of neutropenic fever (OR 4,67 [2,38- 9,16] p <0,001), presence of hematological malignancy (OR 4,34 [2,24- 8,42 p<0,001) , presence of pneumonia (OR 2,67 [1,53- 4,64] p<0,001), urinary tract infection (OR 0,38 [0,20- 0,70] p=0,002, serum albumin level above 2.9 g/dL (OR 0,39 [0,23- 0,66] p<0,001), LDH level above 324 U/L (OR 2,52 [1,35- 4,71] p =0,004), presence of MALS (OR 3,04 [1,64- 5,66] p<0,001) and ferritin level higher than 1518 ng/ml (OR 6,78 [2,94- 15,60] p<0,001) were significantly associated with 30-day mortality. İn multivariate cox regression analysis, It was observed that SOFA score above 7 points (OR 9,66 [1,16- 80,82] p=0,036), immunosuppressive treatment (OR 12,41 [1,45- 106,17] p=0,021) and ferritin level above 1518 ng/ml (OR 9,46 [1,36- 65,79] p=0,023) was associated with 30-day mortality. AUC values for ferritin, LDH, albumin and SOFA was 0,732, 0,593, 0,632, 0,713 respectively. Conclusion: Polyclonal IVIg therapy may be effective in reducing mortality in sepsis patients with XDR pathogen. Ferritin value >1518 ng/ml was associated with 30-day mortality in multivariate regression analysis.
Introduction: Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection. According to the results of large epidemiological studies on sepsis, mortality is approximately %35-40. Many studies have been conducted on additional treatment to reduce mortality in sepsis. Polyclonal IVIg therapy draws attention as one of these additional treatments. In addition to the need for additional treatment, biomarkers are needed to predict the prognosis at an early stage and to select patients to whom these additional treatments can be applied. In this retrospective cohort study, it was aimed to find the parameters associated with mortality in sepsis and to evaluate the efficacy of polyclonal IVIg therapy. Methods: This study was performed by retrospective examination of n=245 patients who were followed up with a diagnosis of sepsis in the intensive care unit of Ege University Faculty of Medicine, Department of Internal Medicine between September 2013 and February 2021. Sepsis diagnoses were established according to Sepsis-3 criteria. Demographic information, vital signs, comorbid conditions, organ failure scores, biochemical and microbiological parameters, whether they received IVIg treatment, 30, 60, 90-day mortality results were recorded. Results: The total number of patients in the study was n=245. In the section of the study where the effect of IVIg treatment on mortality was evaluated, it was seen that 102 patients received IVIg treatment and 143 patients did not. There was no difference in mortality between the group that received and did not receive IVIg treatment. (51% vs 49% p=0.94) When the analysis is restricted to patients who received IVIg therapy on 1st and 2nd days of sepsis, and patients who did not receive IVIg treatment, There is also no mortality differences between groups (%49,7 vs %44,8 p=0,643). In the subgroup analyzes; in patients with XDR pathogen ; It was determined that the group who received IVIg treatment on the 1st and 2nd days of sepsis had a significantly lower 60-day mortality than the group that did not receive IVIg treatment. (95.5% vs 66.7% p=0.33). In univariate cox regression analysis; SOFA score above 7 (OR 4,98 [2,85- 8,70] p <0,001), need for vasopressor treatment at admission (OR 2,14 [1,26- 3,62] p=0,005), use of immunosuppressive therapy (OR 3,37 [1,50- 7,57] p=0,003), presence of neutropenic fever (OR 4,67 [2,38- 9,16] p <0,001), presence of hematological malignancy (OR 4,34 [2,24- 8,42 p<0,001) , presence of pneumonia (OR 2,67 [1,53- 4,64] p<0,001), urinary tract infection (OR 0,38 [0,20- 0,70] p=0,002, serum albumin level above 2.9 g/dL (OR 0,39 [0,23- 0,66] p<0,001), LDH level above 324 U/L (OR 2,52 [1,35- 4,71] p =0,004), presence of MALS (OR 3,04 [1,64- 5,66] p<0,001) and ferritin level higher than 1518 ng/ml (OR 6,78 [2,94- 15,60] p<0,001) were significantly associated with 30-day mortality. İn multivariate cox regression analysis, It was observed that SOFA score above 7 points (OR 9,66 [1,16- 80,82] p=0,036), immunosuppressive treatment (OR 12,41 [1,45- 106,17] p=0,021) and ferritin level above 1518 ng/ml (OR 9,46 [1,36- 65,79] p=0,023) was associated with 30-day mortality. AUC values for ferritin, LDH, albumin and SOFA was 0,732, 0,593, 0,632, 0,713 respectively. Conclusion: Polyclonal IVIg therapy may be effective in reducing mortality in sepsis patients with XDR pathogen. Ferritin value >1518 ng/ml was associated with 30-day mortality in multivariate regression analysis.
Açıklama
Anahtar Kelimeler
Sepsis, Mortalite, İntravenöz İmmünoglobulin, Ferritin, Sepsis, Mortality, Intravenous Immunoglobulin, Hyperferritinemia
