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双重血浆分子吸附系统模式治疗高原慢性肝衰竭患者的效果分析

王博文 彭梦佳 江历恒 方斐 王宇亮 沈元弟

引用本文:
Citation:

双重血浆分子吸附系统模式治疗高原慢性肝衰竭患者的效果分析

DOI: 10.12449/JCH20240119
伦理学声明:本研究经西藏军区总医院伦理委员会审查批准,批号:[2022]02-005。
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:王博文、彭梦佳参与数据的收集分析和论文的撰写;江历恒、方斐参与数据的统计和分析;王宇亮、沈元弟参与研究的设计和论文的修改。
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    通信作者:

    沈元弟, dor_shen226@126.com (ORCID: 0000-0001-8466-4266)

Clinical effect of double plasma molecular adsorption system in treatment of patients with chronic liver failure in high-altitude areas

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  • 摘要:   目的  比较世居高原和移居高原慢性肝衰竭患者接受双重血浆分子吸附系统模式(DPMAS)治疗后的临床特征和病死率。  方法  选取2016年1月—2021年12月于西藏军区总医院重症监护室接受DPMAS治疗的63例慢性肝衰竭患者。根据患者的旅居史将患者分为世居高原组(n=29)和移居高原组(n=34),对比两组患者的基线资料和接受DPMAS治疗前后的临床特征。符合正态分布的计量资料组间比较采用成组t检验;组内治疗前与治疗后比较应采用配对t检验。非正态分布计量资料组间比较采用Mann-Whitney U检验;组内治疗前后比较应采用Wilcoxon秩和检验。计数资料组间比较采用χ2检验。Kaplan-Meier法绘制生存曲线,死亡风险比较采用Log-rank检验。  结果  移居高原组汉族比例明显多于世居高原组(χ2=41.729,P<0.001);世居高原组患者最近一次高原连续居住时间明显长于移居高原组(Z=3.364,P<0.001);MELD评分、肝性脑病、肝肾综合征和消化道出血发生率均较世居高原组明显增高(Z=2.318,χ2值分别为6.903、5.154、6.262,P值均<0.05)。DPMAS治疗前后两组患者的PLT、HGB、ALT、AST、Alb、TBil、DBil、LDH、Cr、INR比较差异均有统计学意义(P值均<0.05)。DPMAS治疗前,移居高原组ALT、AST、TBil、DBil、LDH、Cr、BUN和INR均较世居高原组高(P值均<0.05),HGB较世居高原组低(P<0.05);DPMAS治疗后,移居高原组患者PLT和HGB数量下降较世居高原组更为显著(P值均<0.05),但ALT、AST、TBil、DBil、LDH、BUN和INR均仍较世居高原组高(P值均<0.05)。世居高原组和移居高原组患者接受DPMAS治疗后60天病死率分别为52.5%(95%CI:41.7~63.8)和81.3%(95%CI:77.9~85.6)。相比于世居高原组(HR=0.47,95%CI:0.23~0.95),移居高原组患者60天死亡风险(HR=2.14,95%CI:1.06~4.32)明显增加(P=0.039)。  结论  与世居高原慢性肝衰竭患者相比,移居高原患者的肝功能损伤更重,DPMAS治疗后肝功能改善程度较弱,同时病死率更高。临床医护人员需要加强对移居高原慢性肝衰竭患者的重视,尽可能提高患者生存率。

     

  • 图  1  世居高原组和移居高原组患者接受DPMAS治疗后的生存曲线

    Figure  1.  Survival curves of high altitude native patients and migrated patients after receiving DPMAS treatment

    表  1  世居高原组和移居高原组的基线资料对比

    Table  1.   Comparison of baseline between the high altitude native patients group and migrated patients group

    指标 世居高原组(n=29) 移居高原组(n=34) 统计值 P
    性别[例(%)] χ2=0.169 0.786
    21(72.4) 23(67.6)
    8(27.6) 11(32.4)
    年龄(岁) 48.3±10.4 45.7±8.6 t=1.311 0.153
    民族[例(%)] χ2=41.729 <0.001
    5(17.2) 32(94.2)
    24(82.8) 1(2.9)
    其他 0(0) 1(2.9)
    最近一次高原连续居住时间(周) 149(38~274) 13(6~21) Z=3.364 <0.001
    病因[例(%)] χ2=0.561 0.743
    乙型肝炎 20(69.0) 24(70.6)
    丙型肝炎 3(10.3) 5(14.7)
    其他 6(20.7) 5(14.7)
    发病诱因[例(%)] χ2=0.702 0.873
    感染 15(51.7) 17(50.0)
    出血 5(17.2) 8(23.5)
    药物 2(6.9) 3(8.8)
    其他 7(24.1) 6(17.6)
    治疗[例(%)]
    抗感染治疗 26(89.7) 32(94.1) χ2=0.427 0.654
    止血治疗 11(37.9) 15(44.1) χ2=0.274 0.798
    TIPS 6(20.7) 8(23.5) χ2=0.073 >0.99
    Child-Pugh评分(分) 11.0(10.0~ 12.0) 11.0(10.0~13.0) Z=1.537 0.262
    MELD评分(分) 26.4(22.8~31.5) 29.8(24.1~35.7) Z=2.318 0.017
    腹水[例(%)] 18(62.1) 27(79.4) χ2=2.307 0.166
    肝性脑病[例(%)] 6(20.7) 18(52.9) χ2=6.903 0.010
    肝肾综合征[例(%)] 1(3.4) 8(23.5) χ2=5.154 0.031
    消化道出血[例(%)] 5(17.2) 16(47.1) χ2=6.262 0.016
    门静脉内径(cm) 1.4(1.1~1.8) 1.4(1.1~1.9) Z=0.247 0.814
    门静脉血流速度(cm/s) 14.5(12.8~17.2) 14.3(12.2~17.0) Z=0.481 0.673
    FibroScan肝硬度值(kPa) 18.6(10.2~27.3) 19.1(11.6~29.4) Z=0.476 0.649
    注:MELD,终末期肝病模型;TIPS,经颈静脉肝内门体分流术。
    下载: 导出CSV

    表  2  世居高原组和移居高原组DPMAS治疗前后的临床特征对比

    Table  2.   Comparison of clinical characteristics before and after DPMAS treatment between the high altitude native patients group and migrated patients group

    指标 世居高原组(n=29) 统计值 P 移居高原组(n=34) 统计值 P
    治疗前 治疗后 治疗前 治疗后
    WBC(×109/L) 5.8(4.1~7.9) 6.4(4.9~8.3) Z=0.884 0.375 5.3(3.8~7.7) 5.9(4.0~8.2) Z=0.665 0.504
    PLT(×109/L) 63.4(52.8~77.3) 49.7(34.6~63.9) Z=2.492 0.013 61.6(50.5~72.9) 41.4(30.3~57.6)2) Z=2.611 0.009
    HGB(g/L) 98.3(68.5~134.2) 63.1(45.6~89.7) Z=2.881 0.004 76.3(51.2~100.5)1) 49.9(30.2~71.3)2) Z=2.752 0.006
    ALT(U/L) 276.4±35.4 90.1±22.3 t=3.156 <0.001 348.7±40.61) 99.4±25.72) t=4.376 <0.001
    AST(U/L) 184.9±32.8 81.3±19.6 t=4.187 <0.001 213.5±39.41) 91.6±24.62) t=5.265 <0.001
    Alb(g/L) 26.4(23.5~29.7) 17.1(13.8~19.2) Z=2.235 0.026 24.8(22.1~27.4) 16.5(13.3~18.8) Z=2.163 0.031
    GGT(U/L) 54.7±29.3 48.3±21.7 t=1.872 0.125 59.3±35.0 50.8±28.5 t=1.989 0.096
    TBil(μmol/L) 115.7(69.8~156.2) 86.3(54.5~121.7) Z=2.459 0.014 155.5(111.1~200.5)1) 109.6(71.7~139.2)2) Z=2.812 0.005
    DBil(μmol/L) 59.3(21.6~88.3) 31.2(20.6~49.7) Z=2.063 0.039 72.6(39.3~113.8)1) 44.8(29.4~71.7)2) Z=2.511 0.012
    LDH(U/L) 515.4(246.8~879.9) 292.8(129.4~503.2) Z=2.882 0.004 683.1(298.5~913.5)1) 362.6(133.4~535.8)2) Z=3.087 0.002
    Cr(μmol/L) 72.3(58.9~87.2) 52.4(38.1~73.6) Z=2.172 0.030 89.6(62.4~113.5)1) 61.5(39.6~88.3) Z=2.274 0.023
    BUN(mmol/L) 4.8(3.4~6.5) 4.1(3.0~6.2) Z=1.316 0.187 8.6(6.7~10.8)1) 6.3(4.9~8.0) 2) Z=1.727 0.070
    PT(s) 24.2(20.6~29.5) 26.8(21.3~30.7) Z=1.153 0.247 25.9(21.8~29.7) 27.4(21.9~31.3) Z=1.229 0.221
    Fib(g/L) 1.5(1.3~1.9) 1.8(1.6~2.3) Z=1.657 0.098 1.2(0.8~1.7) 1.7(1.5~2.2) Z=1.852 0.064
    INR 2.65±0.43 1.96±0.39 t=3.546 0.011 2.98±0.571) 2.34±0.41 2) t=3.492 0.028
    注:LDH,乳酸脱氢酶;Fib,纤维蛋白原。与世居高原组治疗前比较,1)P<0.05;与世居高原组治疗后比较,2)P<0.05。
    下载: 导出CSV
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  • 收稿日期:  2023-04-15
  • 录用日期:  2023-05-19
  • 出版日期:  2024-01-23
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