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不同肝病基础的重症酒精性肝炎患者短期预后评估及其影响因素

朱萍 赵和平 韩涛 叶青 李庭红 向慧玲

朱萍, 赵和平, 韩涛, 等. 不同肝病基础的重症酒精性肝炎患者短期预后评估及其影响因素[J]. 临床肝胆病杂志, 2021, 37(2): 370-374. DOI: 10.3969/j.issn.1001-5256.2021.02.024
引用本文: 朱萍, 赵和平, 韩涛, 等. 不同肝病基础的重症酒精性肝炎患者短期预后评估及其影响因素[J]. 临床肝胆病杂志, 2021, 37(2): 370-374. DOI: 10.3969/j.issn.1001-5256.2021.02.024
ZHU P, ZHAO HP, HAN T, et al. Evaluation and influencing factors of the short-term prognosis of severe alcoholic hepatitis with different underlying liver diseases[J]. J Clin Hepatol, 2021, 37(2): 370-374. DOI: 10.3969/j.issn.1001-5256.2021.02.024
Citation: ZHU P, ZHAO HP, HAN T, et al. Evaluation and influencing factors of the short-term prognosis of severe alcoholic hepatitis with different underlying liver diseases[J]. J Clin Hepatol, 2021, 37(2): 370-374. DOI: 10.3969/j.issn.1001-5256.2021.02.024

不同肝病基础的重症酒精性肝炎患者短期预后评估及其影响因素

DOI: 10.3969/j.issn.1001-5256.2021.02.024
基金项目: 

国家科技重大专项 2017ZX10203201-007

国家自然科学基金面上项目 81870429

详细信息
    作者简介:

    朱萍(1981—),女,主治医生,博士,主要从事肝脏疾病的临床与基础研究

    通讯作者:

    韩涛,hantaomd@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:朱萍、赵和平、韩涛负责课题设计,资料分析,撰写论文;李庭红、叶青、向慧玲参与收集数据,修改论文;韩涛负责拟定写作思路,指导撰写文章并最后定稿。
  • 中图分类号: R575.1

Evaluation and influencing factors of the short-term prognosis of severe alcoholic hepatitis with different underlying liver diseases

  • 摘要:   目的  探讨不同肝病基础的重症酒精性肝炎(AH)患者临床特征及其短期预后的评估和影响因素。  方法  回顾性分析天津市第三中心医院2004年8月—2018年8月收治的170例重症AH患者临床资料,按不同肝病基础分为A型(无肝硬化,n=27)、B型(代偿期肝硬化,n=52)和C型(失代偿期肝硬化,n=91)。计算Maddrey判别函数(MDF)评分、慢性肝衰竭序贯性器官衰竭评估(CLIF-SOFA)评分、终末期肝病模型(MELD)评分、ABIC评分(年龄、胆红素、国际标准化比值、肌酐)以及Glasgow酒精性肝炎评分(GAHS)。计量资料多组间比较采用方差分析或Kruskal-Wallis H检验;计数资料多组间比较采用χ2检验。采用单因素和多因素Cox回归分析筛选影响重症AH患者短期预后的独立危险因素。应用Kaplan-Meier法绘制生存曲线,生存差异组间比较采用log-rank检验。受试者工作特征曲线计算各预测模型的曲线下面积(AUC)及95%CI、敏感度、特异度,并应用DeLong法进行比较。  结果  A、B、C型患者28 d生存率分别为88.9%、80.8%和51.6%,3组比较差异有统计学意义(χ2=19.83,P < 0.001)。MELD评分、MDF评分、GAHS评分、ABIC评分和CLIF-SOFA评分预测28 d病死率的AUC(95%CI)分别为0.584(0.493~0.676)、0.696(0.605~0.786)、0.644(0.554~0.735)、0.745(0.662~0.827)和0.795(0.726~0.863);CLIF-SOFA评分与MDF评分、MELD评分、GAHS评分相比,差异均有统计学意义(P值均 < 0.05);CLIF-SOFA评分预测28 d病死率的最佳阈值为8.50分,敏感度为79.0%,特异度为67.9%。发病时不同肝病基础(HR=2.296,95% CI:1.356~3.887,P=0.002)以及合并肝性脑病(HR=1.911,95% CI:1.059~3.449,P=0.031)是28 d预后的危险因素。  结论  不同肝病基础的重症AH患者具有不同的临床特征和短期预后,发病时不同肝病基础及合并肝性脑病与重症AH患者28 d预后密切相关。CLIF-SOFA评分能够较好地预测重症AH患者28 d预后。
  • 图  1  不同肝病基础的重症AH患者28 d生存率比较

    表  1  不同肝病基础重症AH患者的临床特征比较

    临床特征 A型(n=27) B型(n=52) C型(n=91) 统计值 P
    性别[例(%)] χ2=4.26 0.119
      男 25(92.6) 52(100.0) 89(97.8)
      女 2(7.4) 0 2(2.2)
    年龄(岁) 44.26±9.18 48.56±8.53 50.79±9.11 F=5.67 0.004
    WBC(×109/L) 11.81(6.92~16.55) 8.10(5.46~10.23) 8.54(5.73~13.30) χ2=7.23 0.027
    NEU(×109/L) 10.52(5.08~15.05) 5.81(3.90~8.95) 7.04(4.08~11.26) χ2=6.88 0.032
    LYM(×109/L) 1.05(0.75~1.33) 0.76(0.54~1.05) 0.77(0.43~1.05) χ2=9.60 0.008
    PLT(×109/L) 182.00(100.00~199.000) 71.00(45.75~97.00) 50.00(46.00~68.50) χ2=22.22 < 0.001
    Alb(g/L) 29.10(25.80~31.00) 26.15(26.15~28.05) 26.35(23.35~28.63) χ2=0.85 0.011
    ALT(U/L) 51.00 (46.00~72.00) 59.50(46.00~75.00) 50.00(46.00~68.50) χ2=0.50 0.780
    AST(U/L) 87.00(75.50~136.00) 96.50(74.75~125.00) 87.00(76.00~128.00) χ2=0.23 0.891
    GGT(U/L) 214.00(152.50~366.50) 196.50(95.50~332.50) 76.00(34.50~172.50) χ2=25.42 < 0.001
    TBil(μmol/L) 284.40(207.70~353.90) 235.80(135.15~346.86) 190.80(130.50~277.55) χ2=6.41 0.041
    BUN(mmol/L) 5.72(4.70~8.54) 6.55(4.51~9.68) 7.92(5.03~15.91) χ2=6.12 0.047
    Cr(μmol/L) 58.00(48.50~75.50) 71.00(50.00~96.85) 78.00(53.50~124.50) χ2=5.10 0.078
    Na+(mmol/L) 133.30(131.40~136.90) 132.00(125.70~135.90) 131.80(127.75~135.15) χ2=2.38 0.305
    K+(mmol/L) 3.53(3.25~3.95) 3.63(3.11~4.27) 3.88(3.20~4.69) χ2=2.46 0.293
    INR 1.79(1.63~2.19) 2.14(1.79~2.40) 2.36(1.90~3.05) χ2=14.87 0.001
    PT(s) 20.50(19.20~24.15) 23.30(20.68~25.73) 25.70(21.56~32.30) χ2=15.01 0.001
    MDF评分(分) 60.24(37.82~61.24) 49.24(38.54~65.12) 60.24(37.82~86.06) χ2=5.37 0.068
    感染[例(%)] 7(25.9) 22(42.3) 52(57.1) χ2=8.99 0.011
    消化道出血[例(%)] 4(14.8) 13(25.0) 26(28.6) χ2=0.38 0.352
    腹水[例(%)] 11(40.7) 35(67.3) 62(68.1) χ2=7.20 0.027
    肝性脑病[例(%)] 1(3.7) 13(25.0) 23(25.3) χ2=6.15 0.046
    肝肾综合征[例(%)] 4(14.8) 11(21.2) 28(30.8) χ2=3.48 0.175
    28 d病死率[例(%)] 3(11.1) 10(19.2) 44(48.4) χ2=19.83 < 0.001
    下载: 导出CSV

    表  2  不同评分模型的ROC曲线分析

    评分模型 AUC(95% CI) 最佳阈值(分) 特异度 敏感度
    MELD评分 0.584(0.493~0.676) 30.74 0.708 0.456
    MDF评分 0.696(0.605~0.786) 64.66 0.805 0.632
    GAHS评分 0.644(0.554~0.735) 10.50 0.858 0.421
    ABIC评分 0.745(0.662~0.827) 8.92 0.903 0.526
    CLIF-SOFA评分 0.795(0.726~0.863) 8.50 0.679 0.790
    下载: 导出CSV

    表  3  单因素Cox回归分析结果

    变量 单因素分析
    HR(95% CI) P
    基础肝病 2.644(1.625~4.304) < 0.001
    性别 1.391(0.193~10.052) 0.743
    年龄(岁) 1.042(1.012~1.072) 0.005
    WBC(×109/L) 1.076(1.041~1.113) < 0.001
    NEU(×109/L) 1.085(1.045~1.127) < 0.001
    LYM(×109/L) 0.886(0.543~1.444) 0.626
    PLT(×109/L) 0.996(0.991~1.001) 0.086
    Alb(g/L) 0.939(0.882~0.999) 0.046
    ALT(U/L) 1.004(0.998~1.011) 0.216
    AST(U/L) 1.003(0.999~1.007) 0.100
    GGT(U/L) 0.997(0.995~0.999) 0.003
    TBil(μmol/L) 1.001(0.999~1.003) 0.390
    BUN(mmol/L) 1.059(1.034~1.084) < 0.001
    Cr(μmol/L) 1.003(1.002~1.005) < 0.001
    Na+(mmol/L) 0.989(0.955~1.023) 0.519
    K+(mmol/L) 1.256(0.945~1.669) 0.116
    INR 1.474(1.291~1.684) < 0.001
    PT(s) 1.057(1.037~1.077) < 0.001
    消化道出血 0.871(0.469~1.618) 0.663
    感染 3.127(1.770~5.521) < 0.001
    腹水 1.156(0.666~2.005) 0.606
    肝性脑病 3.028(1.773~5.171) < 0.001
    肝肾综合征 3.758(2.226~6.344) < 0.001
    下载: 导出CSV
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  • 收稿日期:  2020-07-13
  • 修回日期:  2020-10-13
  • 刊出日期:  2021-02-20
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