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血浆置换联合持续性肾脏替代治疗对HBV相关慢加急性肝衰竭合并急性肾损伤患者预后的影响
Effect of plasma exchange combined with continuous renal replacement therapy on the prognosis of patients with HBV-related acute-on-chronic liver failure and acute kidney injury
文章发布日期:2019年04月04日  来源:  作者:姚运海,甘建和,赵卫峰  点击次数:385次  下载次数:68次

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【摘要】:目的探索血浆置换(PE)联合持续性肾脏替代治疗(CRRT)对HBV相关慢加急性肝衰竭(ACLF)合并急性肾损伤(AKI)患者预后的影响。方法回顾性分析2013年8月-2017年8月苏州大学附属第一医院收治的198例HBV相关ACLF合并AKI患者临床资料,根据血液净化技术分组,分为单纯药物治疗组(A组,n=68),PE组(B组,n=56),PE联合CRRT组(C组,n=74)。 收集患者入院时的临床资料:性别,年龄,住院期间血液净化治疗前后生化指标:TBil、Alb、SCr、血清钠(Na)、INR、WBC、PLT、红细胞比容等,常见合并症,血液净化治疗方法。治疗前后计算肌酐清除率(Ccr)、肾小球滤过率(eGFR)、MELD-Na评分。正态分布的计量资料3组间比较采用单因素方差分析,组内治疗后比较采用配对t检验,组间比较采用两样本t检验;非正态分布的计量资料3组间比较采用Kruskal-Wallis H检验,组内治疗后比较采用Wilcoxon秩和检验,组间比较采用Mann-Whitney U检验;计数资料3组间比较采用χ2检验。生存时间和生存结局影响因素分析采用Cox比例风险回归模型。结果治疗前3组患者性别、年龄、血生化指标、eGFR、Ccr、合并症、MELD-Na比较差异均无统计学意义(P值均>0.05);B、C组治疗前后eGFR、Ccr水平均明显升高,MELD-Na评分明显下降(B组:Z=-2.81,Z=-3.67,t=6.07,P值均<0.05;C组:Z=-5.81,Z=-4.05,t=-690,P值均<0.05);B、C组治疗后eGFR、Ccr水平及MELD-Na评分比较,差异均无统计学意义(P值均>0.05)。影响ACLF-AKI患者生存指标为血液净化治疗后eGFR、Ccr水平和MELD-Na评分(P值均<0.05)。随着住院时间延长,生存率逐渐下降,死亡风险逐渐增加。结论PE或联合CRRT可短期快速改善ACLF-AKI患者肾功能,但是联合治疗不具优势,血液净化治疗后肾功能改善情况直接影响ACLF-AKI患者预后。
【Abstract】:ObjectiveTo investigate the effect of plasma exchange (PE) combined with continuous renal replacement therapy (CRRT) on the prognosis of patients with HBV-related acute-on-chronic liver failure (ACLF) and acute kidney injury (AKI). MethodsA retrospective analysis was performed for the clinical data of 198 HBV-ACLF-AKI patients who were admitted to The First Affiliated Hospital of Soochow University from August 1, 2013 to August 1, 2017. According to the technique of blood purification, they were divided into pharmacotherapy group (group A with 68 patients), PE group (group B with 56 patients), and PE+CRRT group (group C with 74 patients). Related clinical data on admission were collected, including sex, age, biochemical parameters after blood purification (total bilirubin, albumin, serum sodium, international normalized ratio, white blood cell count, platelet count, and hematocrit), common complications, and blood purification method. Creatinine clearance rate (CCR), estimated glomerular filtration rate (eGFR), and MELD combined with serum sodium concentration (MELD-Na) were calculated before and after treatment. A one-way analysis of variance was used for comparison of normally distributed continuous data between three groups; the paired t-test was used for comparison within one group before and after treatment, and the two samples t-test was used for comparison between groups. The Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data between three groups; the paired samples Wilcoxon signed rank test was used for comparison within one group before and after treatment, and the Mann-Whitney U test was used for comparison between groups. The chi-square test was used for comparison of categorical data between three groups. The Cox proportional-hazards regression model was used to investigate the influencing factors for survival time and outcome. ResultsBefore treatment, there were significant differences between the three groups in sex, age, blood biochemical parameters, eGFR, CCR, complications, and MELD-Na (all P>0.05). Groups B and C had significant increases in eGFR and CCR and a significant reduction in MELD-Na after treatment (group B: Z=-2.81, Z=-3.67, t=6.07, all P<0.05; group C: Z=-5.81, Z=-4.05, t=-6.90, all P<0.05), and there were no significant differences in eGFR, CCR, and MELD-Na between groups B and C after treatment (all P>0.05). The regression analysis showed that eGFR, CCR, and MELD-Na after blood purification were influencing factors for the survival indices of ACLF-AKI patients (all P<0.05). The risk of death and cumulative risk gradually increased over the time of hospitalization. ConclusionPE alone or in combination with CRRT can significantly improve the renal function of ACLF-AKI patients, but the combination treatment has no obvious advantages. The improvement in renal function after blood purification directly affects the prognosis of ACLF-AKI patients, and the risk of death and cumulative risk gradually increase over the time of hospitalization.
【关键字】:肝功能衰竭; 肝炎病毒, 乙型; 肾功能不全; 血浆置换; 肾替代疗法; 预后
【Key words】:liver failure; hepatitis b virus; renal insufficiency; plasma exchange; renal replacement therapy; prognosis
【引证本文】:YAO YH, GAN JH, ZHAO WF. Effect of plasma exchange combined with continuous renal replacement therapy on the prognosis of patients with HBV-related acute-on-chronic liver failure and acute kidney injury[J]. J Clin Hepatol, 2019, 35(5): 1065-1069. (in Chinese)
姚运海, 甘建和, 赵卫峰. 血浆置换联合持续性肾脏替代治疗对HBV相关慢加急性肝衰竭合并急性肾损伤患者预后的影响[J]. 临床肝胆病杂志, 2019, 35(5): 1065-1069.

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