手足口病患儿血清FGF-21与GDF-15水平检测的临床诊疗应用研究.pdf

180现代检验医学杂志第 38 卷第 5 期2023 年 9 月J Mod Lab Med,Vol.38,No.5,Spet.2023手足口病患儿血清 FGF-21 与 GDF-15 水平检测的 临床诊疗应用研究朱磊a，徐妍妍a，盛利平a，温娜娜a，胡爽爽a，钱同b（徐州医科大学附属徐州儿童医院 a.重症医学科；b.检验科，江苏徐州 221006）摘要：目的探讨手足口病（hand,foot and mouth disease，HFMD）患儿血清成纤维细胞生长因子 21（fibroblast growth factor 21，FGF-21）和生长分化因子 15（growth differentiation factor 15，GDF-15）表达水平及临床价值。方法选取 2018 年 5 月 2022 年 5 月徐州医科大学附属徐州儿童医院诊治的 HFMD 患儿 80 例为研究对象，分为普通型组和重症组，每组 40 例；以同期因腹股沟斜疝诊治且无基础疾病的 30 例患儿作为对照组。应用酶联免疫吸附试验（enzyme linked immunosorbent assay，ELISA）检测血清 FGF-21 和 GDF-15 水平。受试者工作特征（ROC）曲线分析两指标单独及联合检测对重症 HFMD 的诊断价值。结果重症组血清 FGF-21，GDF-15，IL-6 水平分别为101.9625.15 pg/ml，702.95123.38pg/ml 和 176.7374.01pg/ml，高于普通型组（84.1018.85pg/ml，515.78115.96 pg/ml，105.8035.33pg/ml）和对照组（77.5117.12 pg/ml，337.33121.07pg/ml，81.4316.53pg/ml），差异均有统计学意义（t=3.595，6.991，5.469；4.585，12.368，7.855，均 P 0.001）。与对照组相比，普通型组血清 GDF-15 水平升高，差异有统计学意义（t=6.252，P 0.001）。治疗 7 天后，重症组和普通型组血清 FGF-21，GDF-15 水和 IL-6平均低于治疗前，差异均有统计学意义（t=5.599，6.741，6.537；2.741，6.711，7.266，均 P 0.05）。ROC 分析显示，血清 FGF-21，GDF-15 诊断重症 HFMD 的曲线下面积（AUC）分别为 0.723（95%CI：0.611 0.835），0.868（95%CI：0.792 0.944），敏感度分别为 92.50%，87.50%，特异度分别为 52.50%，72.50%；两者联合串联检测诊断重症 HFMD的 AUC 为 0.875（95%CI：0.791 0.959），其敏感度和特异度分别为 80.00%，82.50%。结论重症 HFMD 患儿血清FGF-21，GDF-15 水平升高，检测其表达水平对重症 HFMD 的诊断具有重要参考价值。关键词：成纤维细胞生长因子 21；生长分化因子 15；手足口病中图分类号：R512.5；R392.11文献标识码：A文章编号：1671-7414（2023）05-180-05doi:10.3969/j.issn.1671-7414.2023.05.034Research on the Application of Serum FGF-21 and GDF-15 in Clinical Diagnosis and Treatment of Children with Hand,Foot and Mouth DiseaseZHU Leia,XU Yanyana,SHENG Lipinga,WEN Nanaa,HU Shuangshaunga,QIAN Tongb（a.Department of Intensive Care Unit；b.Department of Clinical Laboratory,Xuzhou Childrens Hospital of Xuzhou Medical University，Jiangsu Xuzhou 221006，China）Abstract:ObjectiveTo investigate the serum levels of fibroblast growth factor 21(FGF-21)and growth differentiation factor 15(GDF-15)in children with hand,foot and mouth disease(HFMD)and their clinical significance.Methods80 children with HFMD diagnosed and treated in Xuzhou Childrens Hospital of Xuzhou Medical University from May 2018 to May 2022 were selected and classified into severe group and common group,with 40 cases in each group.30 children with oblique inguinal hernia but no underlying disease during the same period were selected as control group.Serum FGF-21 and GDF-15 levels in each group were detected by enzyme-linked immunosorbent assay(ELISA).Receiver operating characteristic(ROC)curve was used to evaluate the diagnostic value of serum FGF-21,GDF-15 and combined detection for severe HFMD.ResultsSerum FGF-21,GDF-15 and IL-6 levels in the severe HFMD group were 101.9625.15 pg/ml，702.95123.38pg/ml and 176.73 74.01pg/ml,respectively，higher than those in common group（84.1018.85pg/ml，515.78115.96 pg/ml,105.8035.33pg/ml）and control group（77.5117.12 pg/ml，337.33121.07pg/ml,81.4316.53pg/ml），and the differences were statistically significant(t=3.595,6.991,5.469;4.585,12.368,7.855,all P 0.001).Compared with the control group，the serum GDF-15 基金项目：徐州市卫生健康委科技项目（XWKYHT20200006）：BNIP3 介导的自噬通路在重症手足口病脑损伤中作用的临床研究；彭城英才-医学青年后备人才项目（XWRCHT20220021）：BNIP3 介导的线粒体自噬在创伤性脑损伤中的作用及机制研究。作者简介：朱磊（1985-），男，硕士，副主任医师，副教授，研究方向：儿科感染性疾病，E-mail：。通讯作者：钱同（1980-），男，硕士，副主任技师，研究方向：临床检验，E-mail：。181现代检验医学杂志第 38 卷第 5 期2023 年 9 月J Mod Lab Med,Vol.38,No.5,Sept.2023level in the common group was increased，and the difference was statistically significant（t=6.252，P 0.001）.After 7 days of treatment,serum FGF-21,GDF-15 and IL-6 in severe and common groups were decreased,and the differences were statistically significant(t=5.599,6.741,6.537;2.741,6.711,7.266,all P0.05）。普通型组有 8 例患儿提前出院，未复查血清指标。本研究经医院医学伦理委员会批准（2021-05-08-H08）。1.2仪器与试剂TDL-400C 低速离心机（山东百欧医疗科技有限公司），F50 多功能酶标仪（瑞士Tecan）；FGF-21，GDF-15和白介素-6（interleukin-6，IL-6）试剂盒（武汉云克隆科技股份有限公司）。1.3方法HFMD 患儿治疗前及治疗 7 天后，所有研究对象均空腹采集静脉血 3 ml，室温放置 30min，3 000r/min 离心 15min，收集上层血清-80保存待检。采用酶联免疫吸附试验测定血清FGF-21，GDF-15 及 IL-6 水平，具体操作严格按照试剂说明书进行。1.4统计学分析采用 SPSS19.0 软件进行分析，计量资料用均数 标准差（xs）表示，多组间差异用方差分析，两组间比较用 t 检验，治疗前后比较用配对 t 检验，计数资料组间比较用 2检验。符合正态分布的资料采用 Pearson 相关分析，非正态分布的资料采用 Spearman 相关分析。受试者工作特征（ROC）曲线分析 FGF-21 和 GDF-15 表达水平对 HFMD 的诊断价值。P0.05 为差异有统计学意义。2结果2.1三组患儿血清 FGF-21，GDF-15，IL-6 水平的比较见表 1。对照组、普通型 HFMD 组和重症HFMD 组患儿血清 FGF-21，GDF-15 和 IL-6 水平依次升高，差异有统计学意义（F=13.244,80.266,35.378,均 P0.01），治疗前，重症组血清 FGF-21，GDF-15，IL-6 水平高于普通型组和对照组，差异有统计学意义（均 P0.05）。普通型组 HFMD 组患儿血清 FGF-21 与对照组比较，差异无统计学意义（P=0.137）。GDF-15,IL-6 比较，差异有统计学意义（均 P0.05）。HFMD 患儿经治疗后，血清 GDF-15，FGF-21 和 IL-6 水平均降低，重症组（t=6.741，5.599，6.537）、普通型组（t=6.711，2.741，7.266），差异均有统计学意义（P0.05）。治疗后，重症 HFMD 患儿血清 GDF-15，FGF-21 和 IL-6 水平仍高于普通型和对照组，差异具有统计学意义（均P0.05），而血清 GDF-15 仍高于正常水平（P0.05）。2.2HFMD 患 儿 血 清 FGF-21，GDF-15 水 平 与IL-6 水平的相关性分析HFMD 患儿血清 FGF-21，GDF-15 水平与 IL-6 水平呈正相关(r=0.428，0.779，均 P 0.01)。2.3血清 FGF-21，GDF-15 对 HFMD 的诊断价值见图 1。ROC 曲线分析显示，血清 FGF-21，GDF-182现代检验医学杂志第 38 卷第 5 期2023 年 9 月J Mod Lab Med,Vol.38,No.5,Spet.202315 诊断 HFMD 的曲线下面积分别为 0.607（95%CI：0.473 0.742），0.856（95%CI：0.769 0.943），最 佳 截 断 值 分 别 为 79.65pg/ml，394.5pg/ml，敏感度分别为 62.50%，87.50%，特异度分别为60.00%，70.00%。表 1 各组血清 FGF-21，GDF-15，IL-6 水平（xs，pg/ml）项 目重症组普通型组对照组重症组 vs 普通型组重症组 vs 对照组普通型组 vs 对照组tPtPtP治疗前 FGF-21101.9625.1584.1018.8577.5117.123.5950.0004.5850.011.5040.137 GDF-15702.95123.38515.78115.96337.33121.076.9910.00012.3680.016.2520.01 IL-6176.7374.01105.8035.3381.4316.535.4690.0007.8550.014.3970.01治疗后 FGF-2190.7218.4578.4316.20-2.9610.0043.0550.05 GDF-15564.00152.43416.81131.99-4.3180.0006.7080.012.4660.05 IL-6142.4357.7292.2827.51-4.5160.0006.3450.05图 1 血清 FGF-21，GDF-15 诊断 HFMD 的 ROC 曲线2.4 血 清 FGF-21，GDF-15 对 诊 断 重 症 HFMD的诊断价值见图 2。ROC 曲线分析显示，血清FGF-21，GDF-15 诊断重症 HFMD 的曲线下面积分别为0.723（95%CI：0.6110.835），0.868（95%CI：0.792 0.944），最佳截断值分别为 81.60pg/ml，562.00pg/ml，敏感度分别为 92.50%，87.50%，特异度分别为 52.50%，72.50%。图 2 血清 FGF-21，GDF-15 诊断重症 HFMD 的 ROC 曲线2.5 血 清 FGF-21 和 GDF-15 联 合 检 测 对 重 症HFMD 的诊断价值见表 2。根据血清 FGF-21，GDF-15 的最佳截断值，计算其对重症 HFMD 的诊断价值，发现两项指标串联（AUC:0.875,95%CI:0.7910.959)使用价值最高。表 2 血清 FGF-21，GDF-15 单独和联合检测对重症 HFMD 的诊断价值（%）类 别敏感度特异度阳性预测值阴性预测值准确度FGF-21（81.60pg/ml）92.5052.5066.0787.5072.50GDF-15（562.00pg/ml）87.5072.5076.0985.2980.00两项联合（串联）80.0082.5082.0580.4981.25两项联合（并联）100.0042.5063.49100.0071.253讨论HFMD 是儿科常见的传染性疾病，普通型患儿可仅表现为手、足及口腔等部位皮疹，预后良好；重症患儿并发中枢神经系统受损，表现为发热、精神差、嗜睡、易惊等，部分病例因神经系统受累导致血管舒缩功能紊乱和炎症介质大量释放引起心肺功能衰竭，严重威胁患儿的生命健康1。早期识别重症病例是改善 HFMD 患儿预后的关键环节，也是临床诊疗中关注的焦点。目前仍缺乏特异的生物学指标，寻找能及时准确地诊断重症 HFMD 的标志物具有重要的临床意义。FGF-21 是一种主要由肝脏、血管内皮细胞分泌的代谢性因子，属于成纤维细胞生长因子家族中的一员8。GDF-15 是转化生长因子 超家族成员之一，既往多用于心血管疾病的诊断及预后评估9。近期的研究提示，FGF-21 和 GDF-15 是由线粒体应激诱导产生的10，是诊断线粒体功能障碍的可靠标志物4-5,11，且在调节炎症反应、细胞凋亡等过程中发挥重要作用12-14。IL-6 属于多效性炎症因子，是衡量机体炎症反应水平的可靠标志物15-16，与重症 HFMD 的病理进程密切相关，是临床诊断重症 HFMD 的有效标志物17-18。KANG 等12研究提示，FGF-21 可抑制衰老和糖尿病小鼠大脑中核因子-B 和 IL-6 的表达，减轻神经炎症反应。183现代检验医学杂志第 38 卷第 5 期2023 年 9 月J Mod Lab Med,Vol.38,No.5,Sept.2023TAVENIER 等19研究提示，老年患者血清 GDF-15水平升高和 IL-6 高水平表达密切相关，是疾病预后不良的危险因素之一。目前 FGF-21，GDF-15 作为诊断标志物已广泛应用于多种疾病4,20，然而其在HFMD 中的临床价值尚不清楚。诸多研究证实，线粒体功能障碍、炎症反应参与了重症 HFMD 的病理进程2-3,21，推测血清 FGF-21，GDF-15 是诊断重症 HFMD 的潜在标志物。本研究发现，重症 HFMD 组血清 FGF-21，GDF-15 水平高于普通型组和对照组，而且治疗后重症和普通型 HFMD 患儿血清 FGF-21，GDF-15水平均降低，提示 FGF-21，GDF-15 水平与 HFMD病情轻重及预后有关。相关性分析发现，HFMD 患儿血清FGF-21，GDF-15水平与IL-6水平呈正相关，进一步说明 FGF-21，GDF-15 在 HFMD 的病情进展中发挥着重要作用。应用 ROC 曲线分析发现，血清 FGF-21 79.65pg/ml 时诊断普通型 HFMD 的特异度、敏感度均偏低，临床应用价值不高；而GDF-15 394.5pg/ml 时诊断普通型 HFMD 具有较高的特异度及敏感度，具有一定的临床价值。然而由于普通型 HFMD 根据病史和症状、体征即可作出临床诊断，且不需特殊治疗，预后良好，其相关诊断标志物的临床应用价值不高。如何早期识别重症 HFMD 才是临床诊疗中关注的重点。ROC 曲线分析发现，血清 FGF-21 81.60pg/ml 时诊断重症HFMD 敏感度高，但特异度较低，容易误诊；血清GDF-15 562.00pg/ml 时诊疗重症 HFMD 敏感度和特异度均较高，而两项指标串联使用进一步提高了准确度，且敏感度和特异度也较高，具有较好的临床应用价值。综上所述，重症 HFMD 患儿血清 FGF-21 和GDF-15 水平升高，可能与线粒体功能障碍、炎症反应相关；检测 FGF-21 和 GDF-15 水平有助于重症 HFMD 的诊断及预后评估，两者串联检测准确度更高。然而，由于本研究纳入受试对象有限，有待多中心的临床试验进一步研究两者的临床价值。参考文献：1 LI Xingwang,NI Xin,QIAN Suyun,et al.Chinese guidelines for the diagnosis and treatment of hand,foot and mouth disease(2018 edition)J.World Journal of Pediatrics,2018,14(5):437-447.2 YANG Yang,CONG Haolong,DU Ning,et al.Mitochondria redistribution in enterovirus A71 infected cells and its effect on virus replicationJ.Virologica Sinica,2019,34(4):397-411.3 YANG Xiaoxia,SHUI Xiaochuan,DAI Xiaoqing,et al.PLAC8 promotes EV71 infected inflammatory lesion by disturbing Th-cell-related cytokines release in neonatal mouse J.Virology,2021,564:39-45.4 LI Yi,LI Shengrui,QIU Yinfeng,et al.Circulating FGF21 and GDF15 as biomarkers for screening,diagnosis,and severity assessment of primary mitochondrial disorders in childrenJ.Front Pediatr,2022,10:851534.5 LEHTONEN J M,AURANEN M,DARIN N,et al.Diagnostic value of serum biomarkers FGF21 and GDF15 compared to muscle sample in mitochondrial disease J.Journal of Inherited Metabolic Disease,2021,44(2):469-480.6 KAUR N,GARE S R,RUIZ-VELASCO A,et al.FGF21/FGFR1-KL cascade in cardiomyocytes modulates angiogenesis and inflammation under metabolic stressJ.Heliyon,2023,9(4):e14952.7 KATO E T,MORROW D A,GUO Jianping,et al.Growth differentiation factor 15 and cardiovascular risk:individual patient meta-analysisJ.European Heart Journal,2023,44(4):293-300.8 李玄丹,李材忠,唐永婕,等老年 ARDS 患者血清FGF-21,GDF-15 及 PTX-3 表达水平及其与病情评估和预后的相关性研究 J.现代检验医学杂志,2022,37(4):188-192.LI Xuandan,LI Caizhong,TANG Yongjie,et al.Expression levels of serum FGF-21,GDF-15 and PTX-3 in elderly patients with ARDS and their correlation with disease evaluation and prognosis J.Journal of Modern Laboratory Medicine,2022,37(4):188-192.9 YIN Dan,YAN Xiaofang,BAI Xueke,et al.Prognostic value of growth differentiation factors 15 in acute heart failure patients with preserved ejection fractionJ.ESC Heart Failure,2023,10(2):1025-1034.10 DAVIS R L,LIANG C,SUE C M.A comparison of current serum biomarkers as diagnostic indicators of mitochondrial diseasesJ.Neurology,2016,86(21):2010-2015.11 RILEY L G,NAFISINIA M,MENEZES M J,et al.FGF21 outperforms GDF15 as a diagnostic biomarker of mitochondrial disease in childrenJ.Molecular Genetics and Metabolism,2022,135(1):63-71.12 KANG Kai,XU Pengfei,WANG Mengxia,et al.FGF21 attenuates neurodegeneration through modulating neuroinflammation and oxidant-stress J.Biomed Pharmacother,2020,129:110439.13 LENG Yan,WANG Junyu,WANG Zhifei,et al.Valproic acid and other HDAC inhibitors upregulate fgf21 gene expression and promote process elongation in glia by inhibiting HDAC2 and 3 J.Int J Neuropsychoph,2016,19(8):pyw035.14 LUAN H H,WANG A,HILLIARD B K,et al.GDF15 is an Inflammation-Induced central mediator of tissue toleranceJ.Cell,2019,178(5):1231-1244.e11.15 RHLE A,WIEDENMANN N,FENNELL J T,et al.Interleukin-6 as surrogate marker for imaging-based hypoxia dynamics in patients with head-and-neck cancers undergoing definitive chemoradiation-results from a prospective pilot trialJ.European Journal of Nuclear Medicine and Molecular Imaging,2022,49(5):1650-1660.16 王秋云,严敏,程珍,等肿瘤及血液病患者血清sTRAIL 表达及与 IL-6 和 Hepcidin 水平的相关性研究 J.现代检验医学杂志,2021,36(1):58-60,64.WANG Qiuyun,YAN Min,CHENG Zhen,et al.184现代检验医学杂志第 38 卷第 5 期2023 年 9 月J Mod Lab Med,Vol.38,No.5,Spet.2023Study of the expression of the serum sTRAIL,and its correlation with levels of serum IL-6 and hepcidin in the patients with the tumor and hematological diseasesJ.Journal of Modern Laboratory Medicine,2021,36(1):58-60,64.17 ZHU Lei,YIN Hong,QIAN Tong,et al.Distinct expression and clinical value of aquaporin 4 in children with hand,foot and mouth disease caused by enterovirus 71J.Journal of Medical Virology,2022,94(2):587-593.18 LEE J Y,SON M,KANG Jinhan,et al.Serum interleukin-6 levels as an indicator of aseptic meningitis among children with enterovirus 71-induced hand,foot and mouth diseaseJ.Postgraduate Medicine,2018,130(2):258-263.19 TAVENIER J,RASMUSSEN L J H,ANDERSEN A L,et al.Association of GDF15 with inflammation and physical function during aging and recovery after acute hospitalization:a longitudinal study of older patients and Age-Matched controlsJ.The Journals of Gerontology.Series A,Biological Sciences and Medical Sciences,2021,76(6):964-974.20 YANG Pinni,ZHU Zhengbao,SHI Mengyao,et al.Association of serum growth differentiation factor-15 levels with the risks of death and vascular events in patients with ischemic stroke:The role of diabetesJ.Nutrition Metabolism and Cardiovascular Diseases,2022,32(3):616-623.21 WANG Bei,ZHANG Chongyang,YU Congci,et al.Enterovirus 71 induces INF2 cleavage via activated caspase-2 in infected RD cells J.Front Microbiol,2021,12:684953.收稿日期：2022-09-13修回日期：2023-05-15（上接第137页）9 TAO Yachao,WANG Menglan,LIAO Juan,et al.Dynamics of serum pregenome RNA in chronic hepatitis B patients receiving 96-month nucleos(t)ide analog therapyJ.Frontiers in Medicine,2022,9:787770.10 MARCHETTI A L,GUO H.New insights on molecular mechanism of hepatitis B virus covalently closed circular DNA formationJ.Cells,2020,9(11):2430.11 XIE Yiran,ZHU Haoxiang,GUO Yifei,et al.Reduction of hepatitis B surface antigen may be more significant in PEGylated interferon-alpha therapy combined with nucleotide analogues than combined with nucleoside analogues in chronic hepatitis B patients:a propensity score matching studyJ.Canadian Journal of Gastroenterology Hepatology,2022,2022:4325352.12 王雷婕,顾智强,许梓萌,等.核苷(酸）类药物经治慢性乙型肝炎患者低病毒血症发生的可能机制J.中华肝脏病杂志,2021,29(12):1151-1155.WANG Leijie,GU Zhiqiang,XU Zimeng,et al.A possible mechanism for low-level viremia occurrence in nucleos(t)ide analog-treated chronic hepatitis B patientsJ.Chinese Journal of Hepatology,2021,29(12):1151-1155.13 HIGASHI-KUWATA N,HAYASHI S,KUMAMOTO H,et al.Identification of a novel long-acting 4-modified nucleoside reverse transcriptase inhibitor against HBVJ.Journal of Hepatology,2021,74(5):1075-1086.14 宣碧碧,徐永红,杜忠彩,等慢性乙型肝炎和乙型肝炎肝硬化患者发生低病毒血症的影响因素及其与肝脏炎症、肝纤维化进展的关系 J.临床肝胆病杂志,2022,38(10):2252-2259 XUAN Bibi,XU Yonghong,DU Zhongcai,et al.Influencing factors for low-level viremia in patients with chronic hepatitis B or hepatitis B liver cirrhosis and its as-sociation with the progression of liver inflammation and liver fibrosisJ.Journal of Clinical Hepatology,2022,38(10):2252-2259.15 SATO K,INOUE J,AKAHANE T,et al.Switching to tenofovir alafenamide fumarate in chronic hepatitis B patients who had detectable HBV DNA during treatment with entecavirJ.Tohoku Journal of Experimental Medicine,2022,258(4):277-285.16 HUANG Zehong,LU Guiyang,QIU Lingxian,et al.Risk of hepatocellular carcinoma in antiviral treatment-nave chronic hepatitis B patients treated with entecavir or tenofovir disoproxil fumarate:a network meta-analysisJ.BMC Cancer,2022,22(1):287.17 JIANG Bei,DAI Qinghai,LIU Yamin,et al.Levels of HBV RNA in chronic HBV infected patients during first-line nucleos(t)ide analogues therapyJ.Infectious Agents and Cancer,2022,17(1):61.18 张媛媛.血清 HBV pgRNA 的特征及临床价值 J.临床与病理杂志,2020,40(4):1018-1022.ZHANG Yuanyuan.Characteristics and clinical value of serum HBV pgRNA J.Journal of Clinical and Pathological Research,2020,40(4):1018-1022.19 YAN Haozhen,HUANG Zhihao,GUO Xuguang,et al.A study on pregenomic RNA and factors related to hepatitis B virus infection based on real worldJ.Frontiers in Public Health,2022,10:856103.20 PAN Jiali,TIAN Yu,XU Jinghang,et al.Dynamics of hepatitis B virus pregenomic RNA in chronic hepatitis B pa