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HBV相关慢加急性肝衰竭患者短期预后的影响因素分析

刘晨瑞 李亚萍 罗森 冯丹丹 吴凤萍 翟嵩 党双锁

刘晨瑞, 李亚萍, 罗森, 等. HBV相关慢加急性肝衰竭患者短期预后的影响因素分析[J]. 临床肝胆病杂志, 2021, 37(1): 56-62. DOI: 10.3969/j.issn.1001-5256.2021.01.012
引用本文: 刘晨瑞, 李亚萍, 罗森, 等. HBV相关慢加急性肝衰竭患者短期预后的影响因素分析[J]. 临床肝胆病杂志, 2021, 37(1): 56-62. DOI: 10.3969/j.issn.1001-5256.2021.01.012
LIU CR, LI YP, LUO S, et al. Influencing factors for the short-term prognosis of patients with HBV-related acute-on-chronic liver failure[J]. J Clin Hepatol, 2021, 37(1): 56-62. DOI: 10.3969/j.issn.1001-5256.2021.01.012
Citation: LIU CR, LI YP, LUO S, et al. Influencing factors for the short-term prognosis of patients with HBV-related acute-on-chronic liver failure[J]. J Clin Hepatol, 2021, 37(1): 56-62. DOI: 10.3969/j.issn.1001-5256.2021.01.012

HBV相关慢加急性肝衰竭患者短期预后的影响因素分析

DOI: 10.3969/j.issn.1001-5256.2021.01.012
基金项目: 

2018陕西省科技项目 2018SF-269

详细信息
    作者简介:

    刘晨瑞(1997—),男,主要从事肝脏疾病基础与临床研究

    通讯作者:

    李亚萍,liyaping8605@126.com

    党双锁,dang212@126.com

  • 利益冲突声明:本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突,特此声明。
  • 作者贡献声明:刘晨瑞、李亚萍负责课题设计,资料分析,撰写论文;罗森、冯丹丹、吴凤萍参与收集数据,修改论文;翟嵩、党双锁负责拟定写作思路,指导撰写文章并最后定稿。
  • 中图分类号: R512.62;R575.3

Influencing factors for the short-term prognosis of patients with HBV-related acute-on-chronic liver failure

  • 摘要:   目的  分析探究影响HBV相关慢加急性肝衰竭(HBV-ACLF)短期预后的危险因素。  方法  收集2009年1月—2019年12月西安交通大学第二附属医院收治的240例非肝移植HBV-ACLF患者的临床资料,按照入院后28 d和90 d存活情况进行分组(28 d:生存组164例,死亡组76例;90 d:生存组140例,死亡组100例)。收集患者发病诱因、肝功能指标、MELD评分、MELD-Na评分和出现的并发症等资料。计量资料用2组间比较采用Mann-Whithey U检验,计数资料2组间比较采用χ2检验。根据ROC曲线,计算ROC曲线下面积(AUC),采用约登指数确定临界值,HBV-ACLF短期预后的危险因素分析采用logistic多因素回归分析。  结果  HBV-ACLF患者的诱因主要包括HBV自发激活(55.6%)、核苷类似物停药或耐药引起HBV激活(25.2%)等。依28 d存活情况分组,基线资料中年龄、PTA、NLR、血钠、MELD评分、MELD-Na评分、TBil水平2组间比较差异均有统计学意义(Z值分别为-2.400、-6.015、-5.070、-5.103、-5.044、-7.430、-6.637,P值均<0.05);依90 d生存情况分组,基线资料中年龄、PTA、NLR、血钠、MELD评分、MELD-Na评分、TBil、胆固醇水平2组间比较差异均有统计学意义(Z值分别为-2.205、-7.728、-3.335、-4.015、-6.053、-7.908、-6.655、-3.607,P值均<0.05)。logistic多因素回归分析显示,TBil>260.20 mmol/L、PTA<24.8%、NLR>5.63、血钠<130.8 mmol/L、MELD>17.84分、MELD-Na>25.1分是影响患者28 d生存的独立危险因素[OR(95%CI)分别为4.572 (1.321~15.823)、8.934(3.026~26.374)、2.632(1.126~6.152)、27.467(6.113~123.423)、4.303(1.048~17.663)、3.453(1.614~7.387),P值均<0.05];TBil>260.20 mmol/L、PTA<25.5%、血钠<135.3 mmol/L、MELD>17.84分、MELD-Na>25.1分是影响患者90 d生存的独立危险因素[OR(95%CI)分别为5.148(1.918~13.822)、15.718(5.161~47.866)、10.080(3.244~31.323)、11.157(2.580~48.254)、4.391(2.057~9.372),P值均<0.05]。240例患者中160例(66.7%)90 d内发生感染,其中细菌感染140例、病毒感染12例,真菌感染8例。160例出现感染的患者其90 d病死率显著高于无感染的患者(46.3% vs 32.5%, χ2=6.720,P=0.010)。240例患者中176例28 d内出现腹水,44例出现胸腔积液,36例发生急性肾损伤,60例发生肝性脑病,12例发生消化道出血, 2组间急性肾损伤、Ⅲ~Ⅳ度肝性脑病、消化道出血所占比例比较差异均有统计学意义(χ2值分别为64.088、29.811、7.797, P值均<0.05)。  结论  HBV-ACLF患者基线TBil、PTA、血钠、MELD评分、MELD-Na评分是影响患者28 d和90 d预后的独立危险因素。HBV激活引起的肝脏炎症坏死是ACLF的始动因素,而感染、急性肾损伤、肝性脑病和消化道出血是影响患者预后的主要的并发症。
  • 表  1  2组患者基线数据的比较(依28 d生存情况分组)

    项目 生存组(n=164) 死亡组(n=76) 统计值 P
    年龄(岁) 49.00(32.00~54.00) 51.50(46.25~58.50) Z=-2.400 0.016
    男/女(例) 120/44 60/16 χ2=0.924 0.336
    PTA (%) 37.05(29.50~39.70) 21.90(18.53~32.10) Z=-6.015 <0.001
    NLR 2.55(1.79~4.15) 5.42(3.02~8.09) Z=-5.070 <0.001
    血钠(mmol/L) 137.20(134.40~139.10) 133.35(128.93~137.65) Z=-5.103 <0.001
    MELD评分 18.14(15.25~22.00) 23.13(18.95~26.15) Z=-5.044 <0.001
    MELD-Na评分 20.37(15.56~22.53) 27.62(23.14~33.42) Z=-7.430 <0.001
    TBil (mmol/L) 242.25(228.50~311.90) 372.25(297.90~463.77) Z=-6.637 <0.001
    血小板计数(109/L) 97.50(52.00~158.00) 100.00(55.75~139.25) Z=-0.464 0.643
    SCr(μmol/L) 57.87(46.36~69.61) 59.05(48.23~71.59) Z=-0.464 0.643
    胆固醇(mmol/L) 2.28(1.43~2.78) 1.94(1.46~2.29) Z=-1.232 0.218
    AFP(ng/ml) 16.36(5.33~104.10) 30.06(5.44~571.23) Z=-1.645 0.100
    下载: 导出CSV

    表  2  2组患者基线数据的比较(依90 d生存情况分组)

    项目 生存组(n=140) 死亡组(n=100) 统计值 P
    年龄(岁) 49.00(33.00~54.00) 51.00(43.00~57.00) Z=-2.205 0.027
    男/女(例) 100/40 80/20 χ2=2.286 0.131
    PTA(%) 38.20(33.50~39.80) 23.50(19.20~31.50) Z=-7.728 <0.001
    NLR 2.64(1.87~4.94) 3.69(2.48~7.63) Z=-3.335 <0.001
    血钠(mmol/L) 137.00(134.70~139.00) 133.40(130.20~139.50) Z=-4.015 <0.001
    MELD评分 17.60(14.22~21.25) 22.00(20.15~26.01) Z=-6.053 <0.001
    MELD-Na评分 18.56(15.25~22.40) 27.26(21.32~32.85) Z=-7.908 <0.001
    TBil (mmol/L) 234.20(224.40~309.70) 343.06(277.92~442.55) Z=-6.655 <0.001
    血小板计数(109/L) 102.00(57.00~151.00) 93.00(52.00~140.00) Z=-0.423 0.673
    SCr(μmol/L) 58.33(48.24~69.61) 54.50(47.41~68.03) Z=-0.619 0.536
    胆固醇(mmol/L) 2.33(1.53~2.91) 1.93(1.36~2.28) Z=-3.607 <0.001
    AFP(ng/ml) 14.98(5.22~90.70) 41.52(7.12~248.70) Z=-1.881 0.060
    下载: 导出CSV

    表  3  各指标的AUC和临界值(基于28 d、90 d生存情况)

    指标 28 d 90 d
    AUC(95%CI) 临界值 P AUC(95%CI) 临界值 P
    TBil(mmol/L) 0.769(0.704~0.834) 260.2 <0.001 0.761(0.698~0.824) 260.2 <0.001
    PTA(%) 0.732(0.661~0.803) 24.8 <0.001 0.781(0.720~0.842) 25.5 <0.001
    NLR 0.705(0.633~0.777) 5.63 <0.001 0.611(0.536~0.686) 3.55 0.004
    血钠(mmol/L) 0.720(0.646~0.795) 130.8 <0.001 0.660(0.582~0.738) 135.3 <0.001
    MELD评分 0.705(0.636~0.774) 17.84 <0.001 0.735(0.671~0.799) 17.84 <0.001
    MELD-Na评分 0.802(0.744~0.860) 25.1 <0.001 0.807(0.752~0.861) 25.1 <0.001
    下载: 导出CSV

    表  4  HBV-ACLF患者基线数据与28 d预后的多因素分析

    指标 OR(95%CI) P 校正OR(95%CI) 校正P
    TBil>260.2 mmol/L 10.861(4.905~24.048) <0.001 4.572(1.321~15.823) 0.016
    PTA<24.8% 10.278(5.183~20.382) <0.001 8.934(3.026~26.374) <0.001
    NLR>5.63 4.146(2.259~7.611) <0.001 2.632(1.126~6.152) 0.026
    血钠<130.8 mmol/L 14.182(6.099~32.978) <0.001 27.467(6.113~123.423) <0.001
    MELD评分>17.84 14.087(4.915~40.377) <0.001 4.303(1.048~17.663) 0.043
    MELD-Na评分>25.1 6.717(3.683~12.248) <0.001 3.453(1.614~7.387) <0.001
    下载: 导出CSV

    表  5  HBV-ACLF患者基线数据与90 d预后的多因素分析

    指标 OR(95%CI) P 校正OR(95%CI) 校正P
    TBil>260.2 mmol/L 12.410(6.201~24.836) <0.001 5.148(1.918~13.822) 0.001
    PTA<25.5% 21.000(9.290~47.471) <0.001 15.718(5.161~47.866) <0.001
    NLR>3.55 3.182(1.856~5.454) <0.001 1.066(0.443~2.563) 0.887
    血钠<135.3 mmol/L 3.879(2.255~6.671) <0.001 10.080(3.244~31.323) <0.001
    MELD评分>17.84 25.412(8.860~72.885) <0.001 11.157(2.580~48.254) 0.001
    MELD-Na评分>25.1 7.111(3.975~12.721) <0.001 4.391(2.057~9.372) <0.001
    下载: 导出CSV

    表  6  HBV-ACLF患者并发症与28 d预后的关系

    并发症 生存组(n=164) 死亡组(n=76) χ2 P
    腹水[例(%)] 116(71) 60(79) 1.793 0.181
    胸腔积液[例(%)] 28(17) 16(21) 0.549 0.459
    急性肾损伤[例(%)] 4(2) 32(42) 64.088 <0.001
    Ⅲ~Ⅳ度肝性脑病[例(%)] 8(5) 24(32) 29.811 <0.001
    消化道出血[例(%)] 4(2) 8(11) 7.797 <0.001
    下载: 导出CSV
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  • 收稿日期:  2020-05-24
  • 修回日期:  2020-09-24
  • 刊出日期:  2021-01-18
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