The Korean Journal of Medicine

  • 제84권3호
  • /
  • Pages.372-378
  • /
  • 2013
  • /
  • 1738-9364(pISSN)
  • /
  • 2289-0769(eISSN)
대한내과학회 (The Korean Association of Internal Medicine)
권호 표지
DOI QR코드

DOI QR Code

한국인에서 D-Dimer의 위양성과 관련된 인자와 검사의 정확도 향상을 위한 Cut-Off Value

Cut-Off Value and Factors Associated with a False Positive D-Dimer Result for Venous Thromboembolism in Koreans

  • 홍만용 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 이창근 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 유상용 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 신대희 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 정상식 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 권장훈 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 장우성 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 유승진 (울산대학교 의과대학 강릉아산병원 내과) ;
  • 오광훈 (울산대학교 의과대학 강릉아산병원 내과)
  • Hong, Man Yong (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Lee, Changkun (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Yoo, Sang-Yong (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Shin, Dae-Hee (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Cheong, Sang-Sig (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Kwon, Jang Hoon (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Jang, Woo Sung (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Yoo, Seung Jin (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine) ;
  • Oh, Kwang Hoon (Division of Cardiology, Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine)
  • 투고 : 2012.07.30
  • 심사 : 2012.10.11
  • 발행 : 2013.03.01
⟨ 이전 논문 다음 논문 ⟩

초록

목적: 폐동맥 색전증과 심부 정맥 혈전증 이외에 D-dimer 검사의 양성 결과를 나타내는 여러 질환들이 보고되고 있으나, 현재까지 한국인에서 위양성을 유발하는 인자에 대해서는 명백하게 알려진 바가 없다. 따라서 한국인에서 위양성을 초래하는 인자들을 확인하고, 정확도를 향상시키기 위한 새로운 cut-off value를 제시하고자 한다. 방법: 2009년 1월부터 12월까지 본원에 방문한 환자 중 다양한 이유로 D-dimer 검사를 시행 받은 2,047명의 환자를 대상으로 분석하였고, 위양성을 유발하는 인자들을 확인하기 위해 오즈비와 95% 신뢰구간을 로지스틱 회귀분석을 이용하여 분석하였다. 새로운 cut-off value는 ROC curve를 이용하여 구하였다. 결과: 연령의 증가, 외상, 수술의 기왕력, 급성 감염, 결핵, 뇌혈관 질환, 악성종양, 만성 신부전, 급성 관동맥 증후군, 심부전, 호흡기 질환 등이 D-dimer 검사의 위양성을 유발하는 인자로 확인되었다. 또한 민감도와 특이도를 향상시키기 위해 ROC curve를 이용하여 구한 새로운 cut-off value는 0.68 mg/L였다(65세 이하에서는 0.58 mg/L, 65세 이상에서는 0.77 mg/L). 결론: 여러 인자들이 D-dimer 위양성과 관련이 있었으며, 임상에서 D-dimer 검사를 시행하고 임상에 적용할 때에는 이러한 인자들이 결과치에 영향을 줄 수 있음을 충분히 고려하여야겠다.

Background/Aims: The D-dimer value is a simple blood test used to evaluate venous thromboembolism (VTE). However, due to its low specificity, another test is needed for a definite diagnosis, such as a radiographic test. We evaluate the factors associated with a false positive D-dimer test and propose a new cut-off value for detecting VTE more effectively in Koreans. Methods: This was a retrospective, observational study. From January 2009 to December 2009, 2,047 patients (988 men, 63 ${\pm}$ 15 years) had the D-dimer value checked to evaluate VTE. The main outcome of interest was a positive D-dimer test. Odds ratio and 95% confidence intervals were determined using logistic regression analysis. The new D-dimer cut-off was evaluated using receiver operating characteristics (ROC) curves. Results: The result was positive in 1,093 patients (53%), for a false positive percentage for VTE of 95% and a false negative percentage for VTE of 1%. Significant false positive predictors for a positive D-dimer were increasing age, trauma, postoperative, acute infection, tuberculosis, stroke, malignancy, chronic renal failure, acute coronary syndrome, heart failure, and lung disease. The discriminative value of the D-dimer test was assessed using ROC curve analysis. A D-dimer value of 0.68 mg/L on admission was the best cut-off value for predicting the development of VTE with a sensitivity of 95% and specificity of 57%. Conclusions: Many factors affect the D-dimer value and we must consider these factors before using the D-dimer value to evaluate VTE. A D-dimer value of 0.68 mg/L appears to be a good cut-off value for evaluating VTE more effectively in Koreans.

키워드

참고문헌

  1. Kabrhel C, Matts C, McNamara M, Katz J, Ptak T. A highly sensitive ELISA D-dimer increases testing but not diagnosis of pulmonary embolism. Acad Emerg Med 2006;13: 519-524. https://doi.org/10.1111/j.1553-2712.2006.tb01002.x
  2. Stein PD, Hull RD, Patel KC, et al. D-dimer for the exclusion of acute venous thrombosis and pulmonary embolism: a systematic review. Ann Intern Med 2004;140: 589-602. https://doi.org/10.7326/0003-4819-140-8-200404200-00005
  3. Righini M, Nendaz M, Le Gal G, Bounameaux H, Perrier A. Influence of age on the cost-effectiveness of diagnostic strategies for suspected pulmonary embolism. J Thromb Haemost 2007;5:1869-1877. https://doi.org/10.1111/j.1538-7836.2007.02667.x
  4. Righini M, Goehring C, Bounameaux H, Perrier A. Effects of age on the performance of common diagnostic tests for pulmonary embolism. Am J Med 2000;109:357-361. https://doi.org/10.1016/S0002-9343(00)00493-9
  5. Park YS, Ha JW, Kwon KH, et al. Clinical characteristics and predictors of in-hospital mortality for patients with acute major pulmonary embolism. Korean J Med 2000;3: 293-301.
  6. Joo YS, Choi SW, Kim WS, et al. Incidence of pulmonary embolism in Korean patients undergoing hip or knee replacement: value of preoperative and postoperative perfusion and ventilation scintigraphy. Korean J Med 1994;47:101-109.
  7. Righini M, Le Gal G, De Lucia S, et al. Clinical usefulness of D-dimer testing in cancer patients with suspected pulmonary embolism. Thromb Haemost 2006;95:715-719. https://doi.org/10.1160/TH05-12-0791
  8. King V, Vaze AA, Moskowitz CS, Smith LJ, Ginsberg MS. D-dimer assay to exclude pulmonary embolism in high-risk oncologic population: correlation with CT pulmonary angiography in an urgent care setting. Radiology 2008; 247:854-861. https://doi.org/10.1148/radiol.2473070939
  9. Epiney M, Boehlen F, Boulvain M, et al. D-dimer levels during delivery and the postpartum. J Thromb Haemost 2005;3:268-271. https://doi.org/10.1111/j.1538-7836.2004.01108.x
  10. Francalanci I, Comeglio P, Alessandrello Liotta A, et al. D-dimer plasma levels during normal pregnancy measured by specific ELISA. Int J Clin Lab Res 1997;27:65-67. https://doi.org/10.1007/BF02827245
  11. Kline JA, Williams GW, Hernandez-Nino J. D-dimer concentrations in normal pregnancy: new diagnostic thresholds are needed. Clin Chem 2005;51:825-829. https://doi.org/10.1373/clinchem.2004.044883
  12. Choi J, Kwon W, Kim YJ. CT findings of disease with elevated serum D-dimer levels in an emergency room setting. J Korean Soc Radiol 2012;66:93-103. https://doi.org/10.3348/jksr.2012.66.1.93
  13. Castro DJ, Perez-Rodriguez E, Montaner L, Flores J, Nuevo GD. Diagnostic value of D dimer in pulmonary embolism and pneumonia. Respiration 2001;68:371-375. https://doi.org/10.1159/000050529
  14. Lane DA, Preston FE, VanRoss ME, Kakkar VV. Characterization of serum fibrinogen and fibrin fragments produced during disseminated intravascular coagulation. Br J Haematol 1978;40:609-615. https://doi.org/10.1111/j.1365-2141.1978.tb05837.x
  15. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008;6:772-780. https://doi.org/10.1111/j.1538-7836.2008.02944.x
  16. Misaki T, Kitajima I, Kabata T, et al. Changes of the soluble fibrin monomer complex level during the perioperative period of hip replacement surgery. J Orthop Sci 2008;13: 419-424. https://doi.org/10.1007/s00776-008-1266-y
  17. Richman PB, Dominguez S, Kasper D, et al. Interobserver agreement for the diagnosis of venous thromboembolism on computed tomography chest angiography and indirect venography of the lower extremities in emergency department patients. Acad Emerg Med 2006;13:295-301. https://doi.org/10.1111/j.1553-2712.2006.tb01696.x
  18. Engelman DT, Gabram SG, Allen L, Ens GE, Jacobs LM. Hypercoagulability following multiple trauma. World J Surg 1996;20:5-10. https://doi.org/10.1007/s002689900001
  19. Haapaniemi E, Tatlisumak T. Is D-dimer helpful in evaluating stroke patients? a systematic review. Acta Neurol Scand 2009;119:141-150. https://doi.org/10.1111/j.1600-0404.2008.01081.x
  20. Fujii Y, Takeuchi S, Harada A, Abe H, Sasaki O, Tanaka R. Hemostatic activation in spontaneous intracerebral hemorrhage. Stroke 2001;32:883-890. https://doi.org/10.1161/01.STR.32.4.883
  21. Park YW, Koh EJ, Choi HY. Correlation between serum D-dimer level and volume in acute ischemic stroke. J Korean Neurosurg Soc 2011;50:89-94. https://doi.org/10.3340/jkns.2011.50.2.89
  22. Danesh J, Whincup P, Walker M, et al. Fibrin D-dimer and coronary heart disease: prospective study and meta-analysis. Circulation 2001;103:2323-2327. https://doi.org/10.1161/01.CIR.103.19.2323
  23. Lippi G, Filippozzi L, Montagnana M, Salvagno GL, Guidi GC. Diagnostic value of D-dimer measurement in patients referred to the emergency department with suspected myocardial ischemia. J Thromb Thrombolysis 2008;25:247-250. https://doi.org/10.1007/s11239-007-0060-6
  24. Bayes-Genis A, Mateo J, Santalo M, et al. D-dimer is an early diagnostic marker of coronary ischemia in patients with chest pain. Am Heart J 2000;140:379-384. https://doi.org/10.1067/mhj.2000.108823
  25. Dempfle CE, Korte W, Schwab M, et al. Sensitivity and specificity of a quantitative point of care D-dimer assay using heparinized whole blood, in patients with clinically suspected deep vein thrombosis. Thromb Haemost 2006; 96:79-83. https://doi.org/10.1160/TH05-12-0826
  26. Mountain D, Jacobs I, Haig A. The VIDAS D-dimer test for venous thromboembolism: a prospective surveillance study shows maintenance of sensitivity and specificity when used in normal clinical practice. Am J Emerg Med 2007; 25:464-471. https://doi.org/10.1016/j.ajem.2006.09.004

피인용 문헌

  1. Diagnostic Value of Elevated D-Dimer Level in Venous Thromboembolism in Patients With Acute or Subacute Brain Lesions vol.39, pp.6, 2015, https://doi.org/10.5535/arm.2015.39.6.1002
  2. Relationship Between Deep Vein Thrombosis and Lower Limb Swelling in Patients with Brain Lesions vol.10, pp.2, 2013, https://doi.org/10.12786/bn.2017.10.e17