重組人促紅細(xì)胞生成素對(duì)早產(chǎn)兒腦損傷保護(hù)作用的分析

董海鵬，宋燕燕，譚美珍，都　萍，劉倩筠，郭樂(lè)琴，陳蓁蓁

(廣東省廣州市婦女兒童醫(yī)療中心，廣東 廣州 510180)

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重組人促紅細(xì)胞生成素對(duì)早產(chǎn)兒腦損傷保護(hù)作用的分析

董海鵬，宋燕燕，譚美珍，都萍，劉倩筠，郭樂(lè)琴，陳蓁蓁

(廣東省廣州市婦女兒童醫(yī)療中心，廣東 廣州 510180)

[摘要]目的探討重組人促紅細(xì)胞生成素(rhEPO)對(duì)早產(chǎn)兒腦組織的保護(hù)作用及其對(duì)早產(chǎn)兒糾正年齡1歲內(nèi)智能發(fā)育的影響。方法選擇2013年12月至2014年12月廣州市婦女兒童醫(yī)療中心珠江新城院區(qū)新生兒病房收治的出生胎齡<34周早產(chǎn)兒為研究對(duì)象。其中，經(jīng)患兒家屬知情同意后于住院期間使用rhEPO治療(生后7天開(kāi)始，250 IU/kg，皮下注射，每周3次)的治愈出院早產(chǎn)兒101例為促紅細(xì)胞生成素(EPO)組；患兒家屬不同意住院期間使用rhEPO治療的治愈出院早產(chǎn)兒93例為對(duì)照組。比較兩組患兒42天時(shí)的腦干誘發(fā)電位(BAEP)及糾正年齡3～6月齡、9～12月齡時(shí)的智能發(fā)育情況。結(jié)果①EPO組42例和對(duì)照組37例患兒BAEP檢查報(bào)告進(jìn)行分析：對(duì)照組左耳Ⅲ波、Ⅴ波波峰潛伏期(PL)均明顯長(zhǎng)于EPO組(t值分別為-2.350、-2.357，均P<0.05)；對(duì)照組右耳Ⅰ波、Ⅲ波、Ⅴ波PL均明顯長(zhǎng)于EPO組(t值分別為-8.494、-2.063、-2.179，均P<0.05)；對(duì)照組左耳Ⅰ～Ⅲ波、Ⅰ～Ⅴ波波峰間潛伏期(IPL)均明顯長(zhǎng)于EPO組(t值分別為-2.851、-2.634，均P<0.05)；②對(duì)早產(chǎn)兒糾正年齡3～6月齡時(shí)進(jìn)行Gesell測(cè)試：EPO組80例，對(duì)照組71例，EPO組大運(yùn)動(dòng)、精細(xì)運(yùn)動(dòng)、語(yǔ)言、個(gè)人社交發(fā)育商均高于對(duì)照組，差異均具有統(tǒng)計(jì)學(xué)意義(t值分別為-2.658、-5.292、-2.311、-4.169，均P<0.05)；早產(chǎn)兒糾正年齡9～12個(gè)月時(shí)參加Gesell測(cè)試的早產(chǎn)兒為：EPO組72例，對(duì)照組59例，EPO組大運(yùn)動(dòng)、語(yǔ)言、適應(yīng)性、個(gè)人社交發(fā)育商均高于對(duì)照組，差異均具有統(tǒng)計(jì)學(xué)意義(t值分別為-2.082、-2.355、-2.065、-2.385，均P<0.05)；③EPO組支氣管肺發(fā)育不良、顱內(nèi)出血、BAEP異常發(fā)生率明顯低于對(duì)照組，差異均具有統(tǒng)計(jì)學(xué)意義(χ2值分別為6.686、4.628、4.366，均P<0.05)。結(jié)論出生胎齡<34周早產(chǎn)兒生后7天開(kāi)始使用rhEPO治療可以降低住院期間支氣管肺發(fā)育不良、顱內(nèi)出血及腦干聽(tīng)覺(jué)誘發(fā)電位異常的發(fā)生率，有利于促進(jìn)早產(chǎn)兒糾正胎齡1歲內(nèi)的智能發(fā)育。

[關(guān)鍵詞]重組人促紅細(xì)胞生成素；腦損傷；早產(chǎn)兒；腦干聽(tīng)覺(jué)誘發(fā)電位；智能發(fā)育

隨著圍產(chǎn)醫(yī)學(xué)的發(fā)展，更多的低胎齡、低體重新生兒得以救治[1]。然而早產(chǎn)兒由于神經(jīng)、呼吸、消化等各系統(tǒng)發(fā)育均不夠成熟，發(fā)生腦損傷的可能性較足月兒明顯增加。促紅細(xì)胞生成素(Erythropoietin，EPO)是一種由腎臟和肝臟分泌的激素樣物質(zhì)。近年研究發(fā)現(xiàn)，EPO不僅可促進(jìn)造血，而且具有神經(jīng)系統(tǒng)保護(hù)功能[2]。本研究旨在觀察外源重組人促紅細(xì)胞生成素(rhEPO)對(duì)缺氧缺血性腦損傷(hypoxic-ischemic brain damage，HIBD)早產(chǎn)兒腦干聽(tīng)覺(jué)誘發(fā)電位(brainstem auditory evoked potentials, BAEP)、智力發(fā)育的影響，從而進(jìn)一步探索rhEPO對(duì)腦組織的保護(hù)作用及其具體機(jī)制。

1資料與方法

1.1研究對(duì)象

選取2013年12月至2014年12月珠江新城院區(qū)新生兒病房收治的胎齡<34周早產(chǎn)兒，且出生體重<2 500g者為研究對(duì)象，共194例。將其中患兒家屬同意住院期間使用rhEPO治療的且治愈出院早產(chǎn)兒為EPO組，共101例；選擇同期在本院珠江新城院區(qū)出生的胎齡<34周早產(chǎn)兒中患兒家屬不同意住院期間使用rhEPO治療的治愈出院早產(chǎn)兒為對(duì)照組，共93例。排除標(biāo)準(zhǔn)：有凝血功能障礙、紅細(xì)胞增多癥、溶血及先天發(fā)育異常和嚴(yán)重感染的早產(chǎn)兒。本研究經(jīng)過(guò)醫(yī)院倫理委員會(huì)的批準(zhǔn)并均獲得研究對(duì)象家屬的知情同意，在本院高危兒門(mén)診建立隨訪檔案并留存。

1.2治療方法

兩組患兒均置于新生兒暖箱，行心電監(jiān)護(hù)，維持內(nèi)環(huán)境穩(wěn)定、防治感染、加強(qiáng)呼吸管理，必要時(shí)予以呼吸機(jī)輔助通氣等治療。EPO治療組在常規(guī)治療基礎(chǔ)上予以rhEPO(國(guó)藥準(zhǔn)字S20000007)治療，生后7天開(kāi)始，250IU/kg，皮下注射，每周3次，共3～4周。

1.3觀測(cè)指標(biāo)

①患兒42天時(shí)的BAEP檢查結(jié)果，BAEP的兩大主要觀測(cè)指標(biāo)為波峰潛伏期(peaklatency，PL)和波峰間潛伏期(inter peaklatency，IPL)；②糾正年齡3～6月齡、9～12月齡的神經(jīng)發(fā)育情況。采用Gesell發(fā)育量表，包含適應(yīng)性、大運(yùn)動(dòng)、精細(xì)運(yùn)動(dòng)、語(yǔ)言、個(gè)人-社交5個(gè)領(lǐng)域。測(cè)得發(fā)育商數(shù)(developmental quotient，DQ)，DQ(測(cè)試項(xiàng)目之一或多項(xiàng))≤75分者診斷為發(fā)育遲緩，DQ(測(cè)試項(xiàng)目之一或多項(xiàng))75～85分為邊緣水平，DQ(所有測(cè)試項(xiàng)目)>85分為正常；③并發(fā)癥發(fā)生率：包括紅細(xì)胞增多癥、嗜中性粒細(xì)胞減少、血小板增加、高血壓、支氣管肺發(fā)育不良(BPD)、新生兒壞死性小腸結(jié)腸炎(NEC)、新生兒敗血癥、顱內(nèi)出血、早產(chǎn)兒腦室周?chē)踪|(zhì)軟化(PVL)、動(dòng)脈導(dǎo)管未閉(PDA)BAEP異常、早產(chǎn)兒視網(wǎng)膜病變(ROP)。

1.4統(tǒng)計(jì)學(xué)方法

2結(jié)果

2.1一般資料比較

兩組患兒出生胎齡、出生體重、性別構(gòu)成、分娩方式、Apgar評(píng)分、胎膜早破、妊娠期高血壓綜合癥、妊娠期糖尿病、母孕期感染、產(chǎn)前激素使用情況差異均無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，兩組患兒具有可比性，見(jiàn)表1。

注：-為采用Fisher確切概率法，無(wú)統(tǒng)計(jì)值。

2.2兩組患兒住院期間腦干誘發(fā)電位結(jié)果比較

比較兩組患兒生后42天BAEP檢查結(jié)果，其中EPO組有42例早產(chǎn)兒存在有效資料，對(duì)照組有37例。對(duì)照組左耳Ⅲ波、Ⅴ波PL明顯長(zhǎng)于EPO組左耳對(duì)應(yīng)波PL(P<0.05)；對(duì)照組右耳Ⅰ波、Ⅲ波、Ⅴ波PL明顯長(zhǎng)于EPO組右耳對(duì)應(yīng)波PL(P<0.05)，見(jiàn)表2。

對(duì)照組左耳Ⅰ～Ⅲ波、Ⅰ～Ⅴ波IPL明顯長(zhǎng)于EPO組左耳對(duì)應(yīng)波IPL(P<0.05)；兩組患兒右耳Ⅰ～Ⅲ波、Ⅲ～Ⅴ波、Ⅰ～Ⅴ波IPL比較無(wú)明顯差異(P>0.05)，見(jiàn)表3。

2.3 Gesell發(fā)育量表結(jié)果

因廣州流動(dòng)人口較多，隨訪率隨患兒年齡增加逐漸降低，糾正年齡3～6月齡時(shí)參加隨訪的早產(chǎn)兒為：EPO組89例，對(duì)照組75例；糾正年齡9～12月齡時(shí)參加隨訪的早產(chǎn)兒為：EPO組78例，對(duì)照組68例。

糾正年齡3～6月齡時(shí)EPO組大運(yùn)動(dòng)、精細(xì)運(yùn)動(dòng)、語(yǔ)言、個(gè)人社交發(fā)育商均高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，兩組適應(yīng)性發(fā)育商差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見(jiàn)表4。糾正年齡9～12月時(shí)EPO組大運(yùn)動(dòng)、語(yǔ)言、適應(yīng)性、個(gè)人社交發(fā)育商均高于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，兩組精細(xì)運(yùn)動(dòng)發(fā)育商差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)，見(jiàn)表5。

2.4住院期間并發(fā)癥發(fā)生情況

兩組患兒住院期間均無(wú)1例出現(xiàn)紅細(xì)胞增多癥、嗜中性粒細(xì)胞減少、血小板增加、高血壓等rhEPO可能導(dǎo)致的副作用。兩組患兒NEC、新生兒敗血癥、PVL、PDA、ROP發(fā)生率差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。EPO組BPD、顱內(nèi)出血、BAEP異常發(fā)生率明顯低于對(duì)照組，差異均具有統(tǒng)計(jì)學(xué)意義(P<0.05)，見(jiàn)表6。

表6 兩組患兒并發(fā)癥比較[n(%)]

Table 6Comparison of complications between

注：-為采用Fisher確切概率法，無(wú)統(tǒng)計(jì)值。

3討論

3.1促紅細(xì)胞生成素的中樞神經(jīng)系統(tǒng)保護(hù)作用機(jī)制

早產(chǎn)兒因其獨(dú)特的腦部解剖結(jié)構(gòu)和各系統(tǒng)不成熟等生理特點(diǎn)，更容易發(fā)生腦損傷[3]，PVL是其最嚴(yán)重的結(jié)局。由于損傷側(cè)的腦組織結(jié)構(gòu)萎縮、腦細(xì)胞死亡，神經(jīng)系統(tǒng)完整性遭到破壞，將對(duì)腦功能造成不良影響，可導(dǎo)致運(yùn)動(dòng)、智能、視聽(tīng)、心理等功能障礙[4]。rhEPO最早作為一種促紅細(xì)胞生成藥物被普遍應(yīng)用于臨床治療貧血，研究發(fā)現(xiàn)EPO不但影響紅細(xì)胞系，而且是一種對(duì)維持整個(gè)生物體自身穩(wěn)態(tài)發(fā)揮重要作用的多功能營(yíng)養(yǎng)因子[5]。正常情況下在中樞神經(jīng)系統(tǒng)中即存在EPO及EPO受體(EPOR)，EPO及EPOR的合成以及釋放受多種因素的影響，EPO及EPOR在早產(chǎn)兒中樞神經(jīng)系統(tǒng)內(nèi)神經(jīng)元和膠質(zhì)細(xì)胞均呈低水平表達(dá)，當(dāng)腦組織受到缺氧缺血刺激時(shí)會(huì)促進(jìn)EPO及EPOR表達(dá)。動(dòng)物實(shí)驗(yàn)以及臨床研究均證實(shí)EPO具有一定的神經(jīng)保護(hù)作用。EPO對(duì)神經(jīng)系統(tǒng)保護(hù)作用的具體機(jī)制尚不明確，可能為：①抗炎癥；②減少NO生成；③促進(jìn)血管生成；④抗氧化；⑤抑制凋亡；⑥促進(jìn)神經(jīng)細(xì)胞生成；⑦降低興奮性氨基酸毒性。EPO可能通過(guò)以上機(jī)制來(lái)對(duì)神經(jīng)元細(xì)胞起到保護(hù)作用，減少神經(jīng)元細(xì)胞的破壞[6-7]。早產(chǎn)兒由于血腦屏障發(fā)育不完善，尤其腦損傷時(shí)血腦屏障會(huì)遭受破壞，這更加提高了rhEPO通過(guò)血腦屏障的機(jī)率。腦細(xì)胞內(nèi)EPOR會(huì)隨著EPO濃度的提高而上調(diào)，兩者共同作用下發(fā)揮神經(jīng)保護(hù)作用[8]。

3.2本研究結(jié)果及不足之處

3.2.1促紅細(xì)胞生成素與腦干聽(tīng)覺(jué)誘發(fā)電位、發(fā)育商改變

BAEP應(yīng)用于臨床聽(tīng)覺(jué)神經(jīng)傳導(dǎo)通路以及中樞神經(jīng)系統(tǒng)功能的評(píng)價(jià)[9]。PL和IPL是BAEP檢查中應(yīng)該予以重點(diǎn)觀察且特異性很高的兩個(gè)指標(biāo)，其中PL主要反映的是外周傳導(dǎo)所

需要的時(shí)間；IPL主要反映中樞聽(tīng)覺(jué)神經(jīng)系統(tǒng)傳導(dǎo)需要的時(shí)間。當(dāng)腦損傷時(shí)由于聽(tīng)覺(jué)神經(jīng)系統(tǒng)通路的破壞可以導(dǎo)致PL和IPL的延長(zhǎng)，BAEP中各波PL和IPL也會(huì)因?yàn)槟X損傷程度的加重而愈加延長(zhǎng)。因此可以通過(guò)對(duì)BAEP中各波PL和IPL的測(cè)量進(jìn)一步判斷腦損傷對(duì)聽(tīng)覺(jué)神經(jīng)系統(tǒng)傳導(dǎo)通路及腦功能的影響。rhEPO可以減輕缺氧缺血所致的腦損傷，有助于腦功能尤其聽(tīng)覺(jué)神經(jīng)傳導(dǎo)系統(tǒng)的改善。予以外源性rhEPO輸注后，rhEPO即可在短時(shí)間內(nèi)到達(dá)中樞神經(jīng)系統(tǒng)起到抗炎、抗氧化、促進(jìn)神經(jīng)生長(zhǎng)等有關(guān)，從而具有一定的預(yù)防腦損傷的作用。本研究顯示，EPO組患兒PL短于對(duì)照組，EPO組左耳IPL短于對(duì)照組，EPO組患兒BAEP異常的發(fā)生率低于對(duì)照組，說(shuō)明rhEPO對(duì)早產(chǎn)兒腦組織具有一定的保護(hù)作用。

Gesell發(fā)育量表在量表測(cè)試中占有很高的地位，經(jīng)常被用作其它發(fā)育測(cè)試量表的校標(biāo)，是評(píng)估兒童發(fā)育水平、制訂干預(yù)方案及評(píng)價(jià)干預(yù)效果的理想量表。本研究發(fā)現(xiàn)，早產(chǎn)兒糾正胎齡3～6月、9～12月時(shí)EPO組患兒適應(yīng)性、大運(yùn)動(dòng)、精細(xì)運(yùn)動(dòng)、語(yǔ)言、個(gè)人-社交各個(gè)方面得分均高于對(duì)照組，說(shuō)明rhEPO對(duì)腦組織具有一定的保護(hù)作用，可以促進(jìn)早產(chǎn)兒糾正年齡1歲內(nèi)的智能發(fā)育。

3.2.2本研究不足之處

本研究只是對(duì)rhEPO治療和早產(chǎn)兒住院期間并發(fā)癥以及患兒糾正年齡1歲內(nèi)的智能發(fā)育關(guān)系進(jìn)行了相關(guān)研究，未研究rhEPO治療與患兒長(zhǎng)期智能發(fā)育的關(guān)系。rhEPO治療與患兒長(zhǎng)期智能發(fā)育的關(guān)系仍需對(duì)住院期間予以rhEPO治療的早產(chǎn)兒進(jìn)行長(zhǎng)期隨訪以及開(kāi)展大規(guī)模、多中心的臨床研究來(lái)證實(shí)。

[參考文獻(xiàn)]

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[專業(yè)責(zé)任編輯：周煕慧]

Protective effects of recombinant human erythropoietin on brain injury in preterm infants

DONG Hai-peng, SONG Yan-yan, TAN Mei-zhen, DU Ping, LIU Qian-jun, GUO Le-qin, CHEN Zhen-zhen

(Guangdong Women and Children’s Medical Center, Guangdong Guangzhou 510180, China)

[Key words]recombinant human erythropoietin (rhEPO); brain injury; preterm infants; brainstem auditory evoked potentials (BAEP); intelligence development

[Abstract]Objective To explore the protective effect of recombinant human erythropoietin (rhEPO) on the brain tissue and its effects on improving the intelligence development of preterm infants under corrected age of 1 year. Methods Preterm infants whose gestational ages were less than 34 weeks were selected as research objects. All these infants were hospitalized in Zhujiang New Town Branch of Guangdong Women and Children’s Medical Center during the period of December 2013 to December 2014. With informed consent from family members, 101 cases of recovered preterm infants treated with rhEPO during their hospital stays were included in EPO group. The treatment started at the 7th day after birth (250 IU/kg through subcutaneous injection; three times a week).As for another 93 cases of recovered infants, whose patients disapproved of using rhEPO during their hospital stays were chosen in control group. Infants’ brainstem auditory evoked potentials (BAEP) at the 42nd day after birth and their state of intelligence development at 3-6 months or 9-12 months corrected age were compared between two groups. Results BAEP examination reports of 42 infants in EPO group and 37 cases in the control group were analyzed. Peak latency (PL) of wave Ⅲ and Ⅴof the left ear in the control group was longer than that in EPO group (tvalue was -2.350 and -2.357, respectively, bothP<0.05). The PL of waveⅠ, Ⅲ and Ⅴ of the right ear in the control group was significantly longer than that in EPO group (tvalue was -8.494, -2.063, and -2.179, respectively, allP<0.05). The inter peak latency (IPL) of waveⅠ-Ⅲ and waveⅠ-Ⅴof the left ear in the control group was significantly longer than that in EPO group (tvalue was -2.851 and -2.634, respectively, bothP<0.05). In total, 80 cases of preterm infants from EPO group and 71 cases from the control group underwent Gesell test at the corrected age of 3-6 months. Infants from EPO group exceeded the control group in gross motor, fine motor, language, adaptability, and individual’s developmental quotient. The preceding differences were of statistical significance (tvalue was -2.658, -5.292, -2.311 and -4.169, respectively, allP<0.05). Besides, 72 cases of preterm infants from EPO group and 59 cases from the control group underwent Gesell test at the corrected age of 9-12 months. Infants from EPO group had higher scores in gross motor, language, adaptability, and individual’s developmental quotient than those in the control group, and the differences were of statistical significance (tvalue was-2.082, -2.355, -2.065 and -2.385, respectively, allP<0.05). The incidence rate of bronchopulmonary dysplasia, intracranial hemorrhage and abnormal BAEP was significantly lower in EPO group than in the control group with significant difference (χ2value was 6.686, 4.628 and 4.366, respectively, allP<0.05).Conclusion The incidence rate of bronchopulmonary dysplasia, intracranial hemorrhage and abnormal BAEP can be lowered if preterm infants at the gestational age of less than 34 weeks begin to take rhEPO 7 days after birth. Besides, rhEPO is beneficial to the intelligence development of preterm infants at the corrected gestational age of less than 1 year.

[收稿時(shí)間]2016-03-25

[作者簡(jiǎn)介]董海鵬(1976-)，男，主治醫(yī)師，主要從事兒童保健工作。

[通訊作者]宋燕燕，主任醫(yī)師。

doi:10.3969/j.issn.1673-5293.2016.05.006

[中圖分類號(hào)]R722

[文獻(xiàn)標(biāo)識(shí)碼]A

[文章編號(hào)]1673-5293(2016)05-0568-03