目的:研究儿童急性淋巴细胞白血病(Acute Lymphoblastic Leukemia, ALL)化疗期间营养状况及感染的特点,分析营养状况与感染的关系。方法:选择2020年12月至2021年8月青岛大学附属医院儿童血液肿瘤科44例ALL诊断明确并按CCCG-ALL-2020方案治疗的儿童作为研究对象,搜集他们的临床资料(年龄、性别、危险度、化疗阶段)、营养状况(体重、身高、体质指数BMI及其Z值)以及住院期间感染情况(感染病程、抗生素使用情况、实验室指标、感染部位等),运用秩和检验进行统计学分析。结果:44例ALL儿童,共171个化疗阶段,消瘦/严重消瘦发生率8.77%,肥胖发生率4.10%;感染例次率64.33% (110/171),其中诱导缓解PVDL期、诱导缓解CAT期感染例次率居高,分别为25.15% (43/171)、16.37% (28/171)。感染部位以呼吸道最多见,占40.91%。营养状况、中性粒细胞、血红蛋白、血小板对感染严重程度具有影响,P < 0.05。消瘦/严重消瘦以及肥胖患儿较正常营养状况儿童感染程度重。结论:急性淋巴细胞白细胞儿童化疗期间,中性粒细胞、血红蛋白、血小板、营养状况对感染严重程度具有影响。营养状况越差,感染程度越重。 Objective: To investigate the nutrition and infection characteristics of children with Acute Lymphoblastic Leukemia (ALL) during chemotherapy, and to analyze the relationship between nutrition and infection. Methods: 44 children with ALL were selected as the research object, who were diagnosed and treated according to CCCG-ALL-2020 in the Affiliated Hospital of Qingdao University from December 2020 to August 2021. The clinical data (age, gender, risk level, chemotherapy stage), nutritional status (weight, height, body mass index, BMI and BMI-Z) and infection during hospitalization (course of infection, application of antibiotics, laboratory indicators, sites of infection.) were collected. The rank sum test was used for statistical analysis. Results: There were 44 children with ALL, a total of 171 chemotherapy stages. The incidence of weight loss/severe weight loss was 8.77%, and the incidence of obesity was 4.10%. The incidence of infection was 64.33% (110/171), and the infection rates of PVDL and CAT were high, 25.15% (43/171) and 16.37% (28/171) respectively. Respiratory infection was the most common, accounting for 40.91%. Nutritional status, neutrophils, hemoglobin and platelets had an effect on the severity of infection (P < 0.05). Children with weight loss/severe weight loss and obesity had more severe infection than children with normal nutritional status. Conclusion: Nutritional status, neutrophils, hemoglobin and platelets had an effect on the severity of infection during chemotherapy in children with Acute Lymphoblastic Leukemia. The worse the nutritional status, the more severe the infection.
目的:研究儿童急性淋巴细胞白血病(Acute Lymphoblastic Leukemia, ALL)化疗期间营养状况及感染的特点,分析营养状况与感染的关系。方法:选择2020年12月至2021年8月青岛大学附属医院儿童血液肿瘤科44例ALL诊断明确并按CCCG-ALL-2020方案治疗的儿童作为研究对象,搜集他们的临床资料(年龄、性别、危险度、化疗阶段)、营养状况(体重、身高、体质指数BMI及其Z值)以及住院期间感染情况(感染病程、抗生素使用情况、实验室指标、感染部位等),运用秩和检验进行统计学分析。结果:44例ALL儿童,共171个化疗阶段,消瘦/严重消瘦发生率8.77%,肥胖发生率4.10%;感染例次率64.33% (110/171),其中诱导缓解PVDL期、诱导缓解CAT期感染例次率居高,分别为25.15% (43/171)、16.37% (28/171)。感染部位以呼吸道最多见,占40.91%。营养状况、中性粒细胞、血红蛋白、血小板对感染严重程度具有影响,P < 0.05。消瘦/严重消瘦以及肥胖患儿较正常营养状况儿童感染程度重。结论:急性淋巴细胞白细胞儿童化疗期间,中性粒细胞、血红蛋白、血小板、营养状况对感染严重程度具有影响。营养状况越差,感染程度越重。
儿童,急性淋巴细胞白血病,营养状况,感染
Hu Gong1*, Honglong Liu2, Shixuan Jiang1, Xiaoyu Cheng1, Xuerong Li1#
1The Affiliated Hospital of Qingdao University, Qingdao Shandong
2The University of South China, Hengyang Hunan
Received: Jan. 23rd, 2022; accepted: Feb. 14th, 2022; published: Feb. 25th, 2022
Objective: To investigate the nutrition and infection characteristics of children with Acute Lymphoblastic Leukemia (ALL) during chemotherapy, and to analyze the relationship between nutrition and infection. Methods: 44 children with ALL were selected as the research object, who were diagnosed and treated according to CCCG-ALL-2020 in the Affiliated Hospital of Qingdao University from December 2020 to August 2021. The clinical data (age, gender, risk level, chemotherapy stage), nutritional status (weight, height, body mass index, BMI and BMI-Z) and infection during hospitalization (course of infection, application of antibiotics, laboratory indicators, sites of infection.) were collected. The rank sum test was used for statistical analysis. Results: There were 44 children with ALL, a total of 171 chemotherapy stages. The incidence of weight loss/severe weight loss was 8.77%, and the incidence of obesity was 4.10%. The incidence of infection was 64.33% (110/171), and the infection rates of PVDL and CAT were high, 25.15% (43/171) and 16.37% (28/171) respectively. Respiratory infection was the most common, accounting for 40.91%. Nutritional status, neutrophils, hemoglobin and platelets had an effect on the severity of infection (P < 0.05). Children with weight loss/severe weight loss and obesity had more severe infection than children with normal nutritional status. Conclusion: Nutritional status, neutrophils, hemoglobin and platelets had an effect on the severity of infection during chemotherapy in children with Acute Lymphoblastic Leukemia. The worse the nutritional status, the more severe the infection.
Keywords:Children, Acute Lymphoblastic Leukemia, Nutritional Status, Infection
Copyright © 2022 by author(s) and Hans Publishers Inc.
This work is licensed under the Creative Commons Attribution International License (CC BY 4.0).
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急性淋巴细胞白血病(Acute Lymphoblastic Leukemia, ALL)是儿童最常见的恶性肿瘤 [
选择2020年12月至2021年8月青岛大学附属医院儿童血液肿瘤科ALL诊断明确并按CCCG-ALL-2020方案治疗的患儿作为研究对象,共44例。其中男性27例(61.36%),女性17例(38.64%);初诊年龄1岁4月~15岁10月,平均年龄6岁10月,中位年龄5岁8月;低度危险15例(34.09%),中/高度危险29例(65.91%)。观察时间包括诱导缓解PVDL期(初诊时)、诱导缓解CAT期、早期强化CAT+期、巩固治疗HDMTX1-2期、巩固治疗HDMTX3-4期5个化疗阶段,共171个化疗阶段。
所有研究对象均在入院后登记年龄、性别、体重、身高/身长,通过WHO组织的anthro软件计算体质指数BMI及BMI-Z值,并进行营养状况分组:消瘦/严重消瘦(BMI-Z值 < −2)、正常(−2 ≤ BMI-Z值 ≤ 1)、超重(1 < BMI-Z值 ≤ 3)、肥胖(BMI-Z值 > 3)。对各个化疗阶段合并感染的患儿动态监测体温、血常规、C-反应蛋白、降钙素原、病原学检查,同时记录患儿体重、身高/身长、BMI及BMI-Z值的变化,了解营养状况与感染情况的关系。
数据分析采用SPSS 26.0统计软件。计量数据进行正态性检验,符合正态分布用均数土标准差表示,计数资料用频数或率(%)表示。有序分类变量用秩和检验,用中位数、下四分位数、上四分位数表示,P < 0.05表示差异有统计学意义,再进一步进行两两组间比较。
不同化疗阶段消瘦/严重消瘦发生率:诱导缓解PVDL期(初诊时) 10.53%、诱导缓解CAT期16.22%、早期强化CAT+期0%、巩固治疗HDMTX 1~2期7.89%、巩固治疗HDMTX 3~4期5.26%;超重/肥胖发生率:诱导缓解PVDL期(初诊时) 31.58%、诱导缓解CAT期29.73%、早期强化CAT+期35.00%、巩固治疗HDMTX 1~2期31.58%、巩固治疗HDMTX 3~4期34.21%。见表1。
消瘦/严重消瘦[例(%)] | 正常[例(%)] | 超重[例(%)] | 肥胖[例(%)] | |
---|---|---|---|---|
PVDL (38例) | 4 (10.53) | 22 (57.89) | 10 (26.32) | 2 (5.26) |
CAT+ (20例) | 0 (0.00) | 13 (65.00) | 6 (30.00) | 1 (5.00) |
HDMTX 1~2 (38例) | 3 (7.89) | 23 (60.53) | 10 (26.32) | 2 (5.26) |
HDMTX 3~4 (38例) | 2 (5.26) | 23 (60.53) | 11 (28.95) | 2 (5.26) |
总计(171例) | 15 (8.77) | 101 (59.06) | 48 (28.07) | 7 (4.10) |
表1. 44例ALL儿童不同化疗阶段营养状况
本研究患儿共化疗171疗程,感染110例次,总体感染例次率64.33% (110/171)。其中,诱导缓解PVDL期、诱导缓解CAT期感染例次率居高,分别占25.15% (43/171)、16.37% (28/171)。感染相关手术1例,占0.58% (1/171),无感染相关死亡。有明确感染部位的占83.64%,以呼吸道最多见(40.91%),其次为血流感染(13.64%)、皮肤软组织(13.64%)、消化道(10.91%)、泌尿道(3.64%)、中枢神经系统(0.90%),不明部位感染占16.36%。在HDMTX 1~2期发生感染时以皮肤软组织感染为主,其余化疗阶段均以呼吸道感染为主。以上数据表明,诱导缓解PVDL期、诱导缓解CAT期消瘦/严重消瘦发生率及感染例次率均较其他化疗阶段高。见表2。
中枢神经系统 [例(%)] | 呼吸道 [例(%)] | 消化道 [例(%)] | 泌尿道 [例(%)] | 血流 [例(%)] | 皮肤软组织 [例(%)] | 不明部位 [例(%)] | |
---|---|---|---|---|---|---|---|
PVDL (43例次) | 1 (2.33) | 20 (46.51) | 3 (6.98) | 0 (0.00) | 7 (16.28) | 4 (9.30) | 8 (18.60) |
CAT (28例次) | 0 (0.00) | 9 (32.14) | 4 (14.29) | 1 (3.57) | 5 (17.86) | 2 (7.14) | 7 (25.00) |
CAT+ (12例次) | 0 (0.00) | 5 (41.67) | 2 (16.67) | 2 (16.67) | 1 (8.33) | 1 (8.33) | 1 (8.33) |
HDMTX 1~2 (15例次) | 0 (0.00) | 2 (13.33) | 2 (13.33) | 1 (6.67) | 1 (6.67) | 7 (46.67) | 2 (13.33) |
HDMTX 3~4 (12例次) | 0 (0.00) | 9 (75.01) | 1 (8.33) | 0 (0.00) | 1 (8.33) | 1 (8.33) | 0 (0.00) |
总计(110例次) | 1 (0.90) | 45 (40.91) | 12 (10.91) | 4 (3.64) | 15 (13.64) | 15 (13.64) | 18 (16.36) |
表2. 各化疗阶段感染情况
重症感染是指患者存在感染合并全身炎症反应综合征(SIRS)并且引起器官功能的损伤,其早期缺乏特异性的临床症状及体征,使得严重程度的评估十分困难 [
变量 | 感染严重程度(中位数、下四分位数~上四分位数) | H | P | ||
---|---|---|---|---|---|
轻度(50例) | 中度(36例) | 重度(24例) | |||
BMI-Z值 | 0.575 (−0.805~1.515) | −0.325 (−0.945~0.800) | 0.915 (0.200~1.920) | 6.707 | 0.031 |
白细胞(109/L) | 2.375 (1.338~4.773) | 4.97 (0.728~14.070) | 2.445 (0.998~3.538) | 3.906 | 0.142 |
中性粒细胞(109/L) | 1.03 (0.375~2.475) | 0.925 (0.070~2.008) | 0.575 (0.083~1.125) | 6.639 | 0.036 |
血红蛋白(g/L) | 94 (81.75~109.0) | 75.5 (67.00~92.25) | 78.5 (73.00~85.25) | 18.93 | 0 |
血小板(109/L) | 183 (102.8~295.5) | 57 (24.25~143.0) | 70 (29.00~115.0) | 20.45 | 0 |
表3. 急性淋巴细胞白血病患儿不同程度感染时营养状况、血象的比较
变量 | 两两组间比较(P) | ||
---|---|---|---|
轻度–中度 | 轻度–重度 | 中度–重度 | |
BMI-Z值 | 0.075 | 0.274 | 0.012 |
中性粒细胞 | 0.028 | 0.042 | 0.886 |
血红蛋白 | 0 | 0.001 | 0.981 |
血小板 | 0 | 0.003 | 1 |
表4. 急性淋巴细胞白血病患儿不同程度感染时营养状况、血象的组间两两比较
图1. 感染严重程度6种分类指标层次聚类
图2. 感染严重程度6种分类指标箱形图
图3. 感染严重程度层次1类4种指标对比
图4. 感染严重程度层次2类2种指标对比
图5. 感染严重程度分级后特征分析(Andrews图)
图6. 营养状况与感染严重程度分布范围图
急性淋巴细胞白血病(Acute Lymphoblastic Leukemia, ALL)是儿童及青少年最常见的恶性肿瘤,临床表现主要有发热、贫血、出血及白血病细胞脏器浸润等。由于对疾病的早期发现、化疗方案的不断改进、造血干细胞移植的应用、化疗过程中感染管理及支持治疗的改善,目前儿童ALL的治愈率接近90% [
本研究结果显示,诱导缓解期及早期强化期营养不良发生率及感染发生率均较高,营养状态越差,感染发生率越高,这与我国以往的文献报道结果一致 [
本研究分析了ALL患儿感染的特点,结果显示,ALL儿童总体感染例次率达64.33% (110/171),其中,诱导缓解PVDL期、诱导缓解CAT期感染例次率较其他化疗阶段高。感染部位以呼吸道最多见,这可能是因为细胞毒性药物对呼吸道粘膜的生理屏障产生破坏,而呼吸道与外界环境直接相通,病原微生物易通过空气飞沫传播经上述创面进入体内,增加了患儿的感染机会 [
本研究主要通过测量ALL患儿性别、年龄、身高/身长、体重,依据WHO组织的anthro软件计算体质指数BMI及BMI-Z值,进行营养状况的评估。儿童营养评估的方法较多,但目前针对ALL儿童尚无统一的标准 [
综上所述,ALL儿童营养不良发生率高,关注ALL患儿化疗期间营养状况,并早期、规范地给予ALL儿童营养支持治疗,对减少感染的发生、降低感染严重程度具有重要的意义。
本研究报道已获得病人家属的知情同意。
龚 蝴,刘洪龙,江世璇,程晓玉,李学荣. 儿童急性淋巴细胞白血病营养状况与感染相关性研究A Correlation Study on Nutritional Status and Infection in Children with Acute Lymphoblastic Leukemia[J]. 临床医学进展, 2022, 12(02): 1493-1501. https://doi.org/10.12677/ACM.2022.122216