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普萘洛尔对肝硬化门静脉高压患者血流动力学的影响和疗效观察
Effect of propranolol on hemodynamics and its clinical significance in patients with portal hypertension
文章发布日期:2019年04月04日  来源:  作者:徐慧,张峰,张明,等  点击次数:124次  下载次数:35次

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【摘要】:目的评估短期口服普萘洛尔对肝硬化食管胃底静脉曲张患者是否产生血流动力学应答反应,并进一步探讨其应答状态对预防食管胃静脉曲张破裂出血(EGVB)的临床意义。方法收集自2015年3月-2016年10月南京大学医学院附属鼓楼医院消化科的42例肝硬化食管胃底静脉曲张患者的临床资料。在口服普萘洛尔前和服药7 d后分别测定肝静脉压力梯度(HVPG),并对完成2次HVPG测定的患者进行随访,随访终点为发生食管胃底静脉曲张破裂出血事件。HVPG值下降20%以上或绝对值降至12 mm Hg以下被定义血流动力学应答反应。本研究通过配对样本t检验及χ2检验方法比较服药前后HVPG值改变及应答者和无应答者EGVB的发生率,并通过回归分析探讨EGVB的独立危险因素。结果最终纳入分析的患者共32例,其总体应答率为4375%(应答/无应答:14例/18例),总体HVPG值从(18.3±5.0)mm Hg下降至(15.0±4.9)mm Hg(t=4.640, P<0.001)。应答者和无应答者间的年龄、性别、病因、肝功能分级基础HVPG值均无明显差异(P值均>0.05),应答者的第2次HVPG值明显低于无应答者[(11.5±3.5)mm Hg vs (17.7±5.0)mm Hg,t=5.470, P<0.001]。基于3年随访后,共8例患者出现EGVB;应答者EGVB发生率明显低于无应答者(χ2=8.529, P=0.004)。多因素Cox回归分析显示既往出血史(风险比=12.917, 95%可信区间:1.861~89.648,P=0.010)和第2次HVPG值(风险比=1.481,95%可信区间:1.102~1.990,P=0.009)均是EGVB的独立危险因素。结论肝硬化食管胃底静脉曲张患者短期口服普萘洛尔后的血流动力学应答率是43.75%。应答者发生EGVB的风险明显低于无应答者。既往发生过出血或第2次HVPG较高者发生出血的风险明显升高。
【Abstract】:ObjectiveTo investigate whether short-term oral administration of propranolol can induce hemodynamic response in patients with liver cirrhosis and esophageal and gastric varices, as well as the clinical significance of such response in the prevention of esophagogastric variceal bleeding (EGVB). MethodsA total of 42 cirrhotic patients with esophageal and gastric varices who were treated in Department of Gastroenterology in Affiliated Drum Tower Hospital of Nanjing University Medical School from March 2015 to October 2016 were enrolled. Hepatic venous pressure gradient (HVPG) was measured before and after 7 days of oral administration of propranolol. The patients who completed these two HVPG measurements were followed up until the development of EGVB. Hemodynamic response was defined as a reduction in HVPG by at least 20% or an absolute value of HVPG of ≤12 mm Hg. The paired samples t-test and the chi-square test were used to compare the change in HVPG after propranolol administration and the incidence of EGVB between responders and non-responders. A regression analysis was used to identify the independent risk factors for EGVB. ResultsA total of 32 patients were included in the final analysis, with an overall response rate of 43.75% (14 responders and 18 non-responders), and the overall HVPG value decreased from 18.3±5.0 mm Hg to 15.0±4.9 mm Hg (t=4.640, P<0.001). There were no significant differences in age, sex, etiology, liver function, and baseline HVPG between the responders and the non-responders (all P>0.05), and the responders had a significantly higher HVPG value at the second time of measurement than the non-responders (11.5±3.5 mm Hg vs 17.7±5.0 mm Hg, t=5.470, P<0001). During the 3-year follow-up, 8 patients developed EGVB, and the responders had a significantly lower incidence rate of EGVB than the non-responders (χ2=8.529, P=0.004). The multivariate Cox regression analysis showed that a past history of bleeding (hazard ratio [HR]=12.917, 95% confidence interval [CI]: 1.861-89.648, P=0.010) and HVPG value at the second time of measurement (HR=1.481, 95% CI: 1.102-1.990, P=0.009) were independent risk factors for EGVB. ConclusionThe rate of hemodynamic response in cirrhotic patients with esophageal and gastric varices is 43.75% after short-term oral administration of propranolol. Responders have a significantly lower risk of EGVB than non-responders. Patients with a past history of bleeding or a high HVPG value at the second time of measurement have an increased risk of bleeding.
【关键字】:肝硬化; 高血压, 门静脉; 食管和胃静脉曲张; 普萘洛尔
【Key words】:liver cirrhosis; hypertension, portal; esophageal and gastric varices; propranolol
【引证本文】:XU H, ZHANG F, ZHANG M, et al. Effect of propranolol on hemodynamics and its clinical significance in patients with portal hypertension[J]. J Clin Hepatol, 2019, 35(4): 801-807. (in Chinese)
徐慧, 张峰, 张明, 等. 普萘洛尔对肝硬化门静脉高压患者血流动力学的影响和疗效观察[J]. 临床肝胆病杂志, 2019, 35(4): 801-807.

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