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慢加急性肝衰竭合并细菌感染患者的临床特征及预后影响因素分析

刘晓燕 胡瑾华 李晨 陈婧 童晶晶 关崇丹 彭宇辉 宁鹏 严立龙 苏海滨

刘晓燕,胡瑾华,李晨,等. 慢加急性肝衰竭合并细菌感染患者的临床特征及预后影响因素分析[J]. 临床肝胆病杂志, 2021, 37(9): 2148-2152. DOI: 10.3969/j.issn.1001-5256.2021.09.028
引用本文: 刘晓燕,胡瑾华,李晨,等. 慢加急性肝衰竭合并细菌感染患者的临床特征及预后影响因素分析[J]. 临床肝胆病杂志, 2021, 37(9): 2148-2152. DOI: 10.3969/j.issn.1001-5256.2021.09.028
LIU XY, HU JH, LI C, et al. Clinical features of patients with acute-on-chronic liver failure and bacterial infection and influencing factors for prognosis[J]. J Clin Hepatol, 2021, 37(9): 2148-2152. DOI: 10.3969/j.issn.1001-5256.2021.09.028
Citation: LIU XY, HU JH, LI C, et al. Clinical features of patients with acute-on-chronic liver failure and bacterial infection and influencing factors for prognosis[J]. J Clin Hepatol, 2021, 37(9): 2148-2152. DOI: 10.3969/j.issn.1001-5256.2021.09.028

慢加急性肝衰竭合并细菌感染患者的临床特征及预后影响因素分析

DOI: 10.3969/j.issn.1001-5256.2021.09.028
详细信息
    通讯作者:

    苏海滨,sunhaibin302@163.com

  • 中图分类号: R575.3

Clinical features of patients with acute-on-chronic liver failure and bacterial infection and influencing factors for prognosis

  • 摘要:   目的  研究慢加急性肝衰竭(ACLF)合并细菌感染患者的临床感染特点及90 d生存率的相关影响因素。  方法  选取2014年1月—2015年12月解放军总医院第五医学中心收治的ACLF患者,收集和分析患者的相关临床资料:感染时间及部位、微生物培养情况、生化及炎性指标、合并感染后28 d及90 d预后情况等。计量资料两组间比较采用t检验或Mann-Whitney U检验;计数资料两组间比较采用χ2检验。应用寿命表法绘制生存曲线。将单因素分析中对预后有影响的指标进一步行多因素logistic回归分析。  结果  共收治ACLF患者1074例,其中609例合并细菌感染,感染发生率为56.7%。有16例患者在90 d内行肝移植手术,其余593例均完成了相关数据统计。各部位感染占总感染人数比例分别为:腹腔70.15%、肺部41.15%、败血症11.97%、泌尿系统5.40%、胸腔4.89%,其他部位8.6%。64.76%的患者为单部位感染。微生物培养阳性率分别为:腹水22.70%、痰52.82%、尿40.63%、胸水35.71%。腹水中大肠埃希菌占首位(43.82%);痰液中肺炎克雷伯菌、铜绿假单胞菌和鲍曼不动杆菌分别占22.67%、24.00%、22.67%;血培养中大肠埃希菌和肺炎克雷伯菌分别占33.80%、29.58%,其次为葡萄球菌(15.49%)。ACLF合并细菌感染后90 d生存率为38.11%(226/593),多因素logistic回归分析结果显示年龄(P=0.006)、肝性脑病分期(P<0.001)、肝衰竭分期(P<0.001)和急性肾损伤(P<0.001)是影响ACLF合并细菌感染患者90 d生存的独立危险因素。  结论  ACLF合并细菌感染发生率高,90 d生存率较低,出现急性肾损伤、Ⅲ期以上肝性脑病或肝衰竭晚期时提示预后差。

     

  • 图  1  诊断ACLF合并细菌感染后生存曲线

    表  2  不同部位细菌培养阳性情况

    细菌 腹腔感染(n=89) 肺炎(n=75) 败血症(n=71) 尿路感染(n=13) 胸腔感染(n=9)
    革兰阴性菌[例(%)]
        大肠埃希菌 39(43.82) 4(5.33) 24(33.80) 3(23.08) 2(22.22)
        肺炎克雷伯菌 8(8.99) 17(22.67) 21(29.58) 0 4(44.44)
        铜绿假单胞菌 0 18(24.00) 2(2.82) 0 0
        鲍曼不动杆菌 4(4.49) 17(22.67) 3(4.23) 0 0
        嗜麦芽寡养单胞菌 0 8(10.67) 3(4.23) 0 0
        其他 6(6.74) 0 2(2.82) 2(15.38) 0
    革兰阳性菌[例(%)]
        链球菌 5(5.62) 4(5.33) 3(4.23) 0 1(11.11)
        葡萄球菌 10(11.24) 7(9.33) 11(15.49) 2(15.38) 1(11.11)
        肠球菌 12(13.48) 0 0 6(46.15) 2(22.22)
        其他 5(5.62) 0 2(2.82) 0 0
    下载: 导出CSV

    表  3  生存组和死亡组单因素分析结果

    指标 存活组(n=226) 死亡组(n=367) 统计值 P
    男/女(例) 189/37 295/72 χ2=0.983 0.321
    年龄(岁) 47.38±10.68 51.49±11.89 t=4.248 <0.001
    病因(HBV/酒精/自身免疫性/药物/其他,例) 159/45/10/1/11 229/76/19/13/30 χ2=18.732 0.002
    肝硬化(有/无,例) 199/27 326/41 χ2=0.083 0.774
    感染部位(单/多,例) 178/48 206/161 χ2=593.000 <0.001
    腹水(有/无,例) 223/3 362/5 χ2=0.001 0.970
    肝性脑病(无、Ⅰ/Ⅱ期、Ⅲ/Ⅳ期,例) 167/48/11 138/97/132 χ2=29.907 <0.001
    肺部感染(有/无,例) 57/169 187/180 χ2=38.250 <0.001
    自发性腹膜炎(有/无,例) 169/57 247/120 χ2=3.730 0.050
    上消化道出血(有/无,例) 15/211 68/299 χ2=16.430 <0.001
    败血症(有/无,例) 26/200 45/322 χ2=0.076 0.780
    胸腔感染(有/无,例) 5/221 24/343 χ2=5.130 0.020
    国际标准化比值 1.85±0.44 2.56±1.21 χ2=-8.460 <0.001
    总胆红素(μmol/L) 303.27±137.06 335.81±158.53 t=-2.597 0.010
    血肌酐(μmol/L) 106.70±67.63 152.48±125.37 t=-6.165 <0.001
    白细胞(×109/L) 7.00(4.75~9.68) 8.34(5.43~13.07) Z=-3.883 <0.001
    中性粒细胞(×109/L) 4.87(3.01~7.41) 6.18(3.78~10.48) Z=-4.645 <0.001
    降钙素原(ng/ml) 0.70(0.39~1.45) 0.79(0.42~1.91) Z=-1.955 0.050
    C反应蛋白(g/L) 16.78(9.28~36.30) 17.60(9.64~36.11) Z=-0.937 0.349
    乳酸(mmol/L) 1.56(1.25~2.01) 1.69(1.28~2.73) Z=-1.837 0.066
    肝衰竭分期(早期/中期/晚期,例) 195/25/6 73/170/124 χ2=59.300 <0.001
    MELD评分 22.71±6.18 27.99±8.29 t=-7.971 <0.001
    下载: 导出CSV

    表  4  影响ACLF合并感染患者90 d生存的多因素logistic回归分析

    指标 B SE Wald Exp(B) 95%CI P
    年龄 -0.038 0.014 7.442 0.963 0.937~0.989 0.006
    自发性腹膜炎 -0.214 0.440 0.236 0.807 0.341~1.913 0.627
    肝性脑病分期 23.332 <0.001
        Ⅰ/Ⅱ期vs无 2.409 0.508 22.523 11.128 4.114~30.099 <0.001
        Ⅲ/Ⅳ期vs无 1.860 0.546 11.603 6.427 2.203~18.747 0.001
    急性肾损伤 -1.288 0.315 16.744 0.276 0.149~0.511 <0.001
    白细胞 -0.014 0.024 0.366 0.986 0.941~1.032 0.545
    总胆红素 -0.001 0.001 1.183 0.999 0.997~1.001 0.277
    血肌酐 0.000 0.002 0.017 1.000 0.996~1.003 0.896
    肝衰竭分期 19.104 <0.001
        中期vs早期 1.954 0.449 18.933 7.057 2.927~17.017 <0.001
        晚期vs早期 1.463 0.466 9.838 4.318 1.731~10.772 0.002
    降钙素原 -0.101 0.063 2.633 0.903 0.799~1.021 0.105
    常量 -1.153 1.023 1.270 0.316 0.260
    下载: 导出CSV
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  • 收稿日期:  2021-01-17
  • 修回日期:  2021-02-03
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