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妊娠期肝衰竭的病因、临床表现及预后分析
Etiology, clinical manifestations, and prognosis of liver failure in pregnancy
文章发布日期:2020年11月13日  来源:  作者:吕苏聪,张宝忠  点击次数:3411次  下载次数:45次

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【摘要】:目的 探讨妊娠期肝衰竭患者的病因、临床表现及TPL预测模型[即结合TBil、PTA(凝血酶原活动度)、LACT(乳酸)三种指标建立的预测模型]对妊娠期肝衰竭预后的评估价值。方法 选取2009年1月1日-2019年12月31日于广州医科大学附属第三医院诊断为肝衰竭的妊娠期患者共69例。根据预后情况分为死亡组(n=22)和生存组(n=47),比较两组患者的病因、临床表现、实验室指标及预后等,运用多因素logistic回归分析妊娠期肝衰竭患者死亡的独立危险因素,并建立TPL预测模型。符合正态分布的计量资料两组间比较采用t检验;非正态分布的计量资料两组间比较采用Wilcoxon符号秩检验;计数资料两组间比较采用χ2检验。绘制受试者工作特征曲线(ROC曲线),以ROC曲线下面积(AUC)衡量TPL模型评估妊娠期肝衰竭患者预后的效能。结果 69例妊娠期肝衰竭患者中,病死率为31.9%。妊娠期急性脂肪肝(AFLP)为妊娠期肝衰竭最常见的病因(37.7%),其次为病毒性肝炎(27.5%),不同病因之间妊娠期肝衰竭患者的病死率,差异无统计学意义(χ2=4.013,P>0.05)。妊娠期肝衰竭最常见的临床表现:黄疸(79.7%)、纳差(63.8%)、双下肢水肿(52.2%),生存组与死亡组患者各临床表现差异均无统计学意义(P值均>0.05)。死亡组患者TBil、LACT、INR均高于生存组,PTA、PLT均低于生存组,差异均有统计学意义(Z=-2.691、Z=-1.998、Z=-2.640、t=-2.545、Z=-2.222,P值均<0.05)。经过logistic多因素回归分析将TBil、PTA、LACT纳入方程并建立TPL模型(P值均<0.05),TPL模型的敏感度、特异度、阳性预测值、阴性预测值分别为90.9%、68.1%、57.1%、94.1%。TPL模型的AUC为:0.833(95%CI:0.771~0.965,P<0.05),高于TBil模型[0.702(95%CI:0.594~0.805,P<0.05]、PTA模型[0.673(95%CI:0.550~0.796,P<0.05]、LACT模型[0.650(95%CI:0.494~0.772,P<0.05]。根据ROC曲线临界值进行分组,结果显示,随着TPL模型评分的升高,患者病死率亦增高(χ2=20.312,P<0.05)。结论 AFLP和病毒性肝炎均为妊娠期肝衰竭的常见病因,妊娠期肝衰竭常见临床表现有黄疸、纳差、双下肢水肿,TPL模型对妊娠期肝衰竭预后预测效能较单一指标具有更高的准确性,因此具有更好的临床指导价值。
【Abstract】:Objective To investigate the etiology and clinical manifestations of liver failure in pregnancy and the value of TPL predictive model based on total bilirubin (TBil), prothrombin activity (PTA), and lactic acid (LACT) in evaluating the prognosis of liver failure in pregnancy. Methods A total number of 69 pregnant patients who were diagnosed with liver failure in The Third Affiliated Hospital of Guangzhou Medical University from January 1, 2009 to December 31, 2019 were enrolled, and according to prognosis, they were divided into death group with 22 patients and survival group with 47 patients. The two groups were compared in terms of etiology, clinical manifestation, laboratory markers, and prognosis. A multivariate logistic regression analysis was used to investigate the independent risk factors for death in patients with liver failure in pregnancy, and a TPL predictive model was established. The t-test was used for comparison of normally distributed continuous data between two groups, and the Wilcoxon signed-rank test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. The receiver operating characteristic (ROC) curve was plotted, and the area under the ROC curve (AUC) was used to analyze the value of TPL model in predicting the prognosis of patients with liver failure in pregnancy. Results Of all 69 patients, 22 died and 47 survived, with a mortality rate of 319%. Acute fatty liver of pregnancy (AFLP) was the most common cause of liver failure in pregnancy (37.7%), followed by viral hepatitis (27.5%). There was no significant difference in mortality rate between the patients with different etiologies (χ2=4.013, P>0.05). Jaundice was the most common clinical manifestation of liver failure in pregnancy (79.7%), followed by poor appetite (63.8%) and edema of both lower limbs (52.2%). There were no significant differences in clinical manifestations between the survival group and the death group (P>0.05). Compared with the survival group, the death group had significantly higher TBil, LACT, and international normalized ratio and significantly lower PTA and platelet count (Z=-2.691, Z=-1.998, Z=-2.640, t=-2.545, Z=-2.222, all P<0.05). The multivariate logistic regression analysis was used to include TBil, PTA, and LACT into an equation and establish the TPL model (all P<0.05), and the TPL model had a sensitivity of 90.9%, a specificity of 68.1%, a positive predictive value of 57.1%, and a negative predictive value of 94.1%. The TPL model had an AUC of 0.833 (95% confidence interval [CI]: 0.771-0.965, P<0.05), and the TPL model had a significantly higher AUC than the TBil model (AUC=0.702, 95% CI: 0.594-0.805, P<0.05), PTA model (AUC=0.673, 95% CI: 0.550-0.796, P<0.05), and LACT model (AUC=0.650, 95% CI: 0.494-0.772, P<0.05). According to the cut-off value of the ROC curve, patients’ mortality rate increased with the increase in the score of the TPL model(χ2=20.312, P<0.05). Conclusion AFLP and viral hepatitis are common causes of liver failure in pregnancy, and jaundice, poor appetite, and edema of both lower limbs are common clinical manifestations of liver failure in pregnancy. The TPL predictive model is more accurate than the single index in predicting the prognosis of liver failure in pregnancy and has a better clinical guiding value.
【关键字】:妊娠并发症; 肝功能衰竭; 体征和症状; 预后
【Key words】:pregnancy complications; liver failure; signs and symptoms; prognosis
【引证本文】:LYU SC, ZHANG BZ. Etiology, clinical manifestations, and prognosis of liver failure in pregnancy[J]. J Clin Hepatol, 2020, 36(12): 2756-2760. (in Chinese)
吕苏聪, 张宝忠. 妊娠期肝衰竭的病因、临床表现及预后分析[J]. 临床肝胆病杂志, 2020, 36(12): 2756-2760.

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