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小剂量血浆置换联合双重血浆分子吸附系统/血液灌流治疗慢加急性肝衰竭的效果分析

鲁杰 李顶春 刘叶 袁琳娜 段志文 李武

引用本文:
Citation:

小剂量血浆置换联合双重血浆分子吸附系统/血液灌流治疗慢加急性肝衰竭的效果分析

DOI: 10.3969/j.issn.1001-5256.2022.11.017
基金项目: 

国家自然科学基金 82160801;

云南省“万人计划”名医专项 Yunrenweifa (2020)20, RLMY20200015;

云南省科技厅-应用基础研究联合专项资金项目 2018FE001 (-214)

伦理学声明:本研究方案于2021年2月26日由昆明医科大学伦理委员会审批,批号:2021-206。
利益冲突声明:本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明:鲁杰负责课题设计,资料分析,撰写论文;李顶春、刘叶、袁琳娜参与收集数据;段志文负责修改论文;李武指导撰写论文并最后定稿。
详细信息
    通信作者:

    李武,liwukm@qq.com

Clinical efficacy of low-dose plasma exchange combined with double plasma molecular absorption system/hemoperfusion in treatment of acute-on-chronic liver failure

Research funding: 

National Natural Science Foundation of China 82160801;

Yunnan Province Famous Doctor Project Yunrenweifa (2020)20, RLMY20200015;

Yunnan Provincial Department of Science and Technology -Applied Basic Research Joint Special Fund Project 2018FE001 (-214)

More Information
    Corresponding author: LI Wu, liwukm@qq.com(ORCID: 0000-0002-1222-3629)
  • 摘要:   目的  研究小剂量血浆置换(PE)的组合人工肝治疗慢加急性肝衰竭(ACLF)的临床疗效以及对分层后病死率的影响。  方法  纳入2018年1月—2020年12月于昆明医科大学第一附属医院感染与肝病科收治的ACLF患者共272例,分为小剂量PE联合双重血浆分子吸附系统(DPMAS)/血液灌流(HP)组(n=190)和单纯内科治疗组(n=82)。收集两组患者治疗前、后的实验室指标,比较临床疗效;将两组患者按《肝衰竭诊治指南(2018年版)》分层(前期、早中期、晚期或A、B、C型),随访所有患者出院后12周(短期)、48周(长期)的一般情况及死亡。正态分布的计量资料两组间比较采用独立样本t检验,治疗前后比较采用配对样本t检验;不符合正态分布计量资料两组间比较用Mann-Whitney U检验,治疗前后比较采用Wilcoxon检验。计数资料组间比较采用χ2检验。  结果  小剂量PE联合DPMAS/HP与单纯内科治疗均能降低ACLF患者的ALT、AST、TBil、血氨水平,升高Alb水平,两组治疗前后差异均有统计学意义(P值均<0.05),但是小剂量PE联合DPMAS/HP治疗比单纯内科治疗组能更好地清除ALT、TBil和血氨,改善Alb,各指标治疗前后差值比较均有统计学意义(P值均<0.05)。小剂量PE联合DPMAS/HP治疗后能显著降低胆汁酸、INR、中性粒细胞/淋巴细胞比值、MELD评分,升高血小板与白细胞比率,治疗前后差异均有统计学意义(P值均<0.05),而单纯内科治疗不能改善以上指标,治疗前后差异无统计学意义(P值均>0.05)。与单纯内科治疗组相比,小剂量PE联合DPMAS/HP治疗能降低ACLF患者短期病死率,尤其是能显著降低前期、早中期、A型患者短期病死率,两组间差异均有统计学意义(P值均<0.05)。在小剂量PE联合DPMAS/HP治疗组中,前期患者短期/长期病死率均显著低于晚期,A型患者短期/长期病死率均显著低于C型,差异均有统计学意义(P值均<0.05)。  结论  小剂量PE联合DPMAS/HP治疗具有较好的临床疗效,能有效降低ACLF的短期病死率,尤其能显著降低前期、早中期和A型患者的短期病死率。

     

  • 表  1  两组患者一般资料比较

    Table  1.   Comparison of general data of the two groups of patients

    指标 小剂量PE+DPMAS/HP组(n=190) 单纯内科治疗组(n=82) 统计值 P
    分期(前期/早中期/晚期,例) 73/89/28 36/34/12 χ2=-0.676 0.499
    分型(A型/B型/C型,例) 67/34/89 14/12/56 χ2=-3.409 0.001
    女/男(例) 37/153 17/65 χ2=0.057 0.811
    年龄(岁) 46.8±11.5 52.0±11.5 t=-3.396 0.001
    ACLF病因[例(%)]
      HBV 114(60.0) 26(31.7) χ2=18.356 <0.001
      HCV 4(2.1) 4(4.9) χ2=0.724 0.395
      药物 15(7.9) 19(23.2) χ2=12.221 <0.001
      酒精性肝病 48(25.3) 19(23.2) χ2=0.135 0.713
      自身免疫性肝病 15(7.9) 8(9.8) χ2=0.256 0.613
      其他肝病 8(4.2) 8(9.8) χ2=2.259 0.133
    下载: 导出CSV

    表  2  两组患者治疗前后临床疗效对比

    Table  2.   Comparison of clinical efficacy between the two groups

    指标 组别 治疗前 治疗后 统计值 P
    Alb(g/L) 小剂量PE+DPMAS/HP组 31.3(28.0~35.4) 36.0(34.0~37.3) Z=-7.125 <0.001
    单纯内科治疗组 29.3±6.5 31.7±4.9 t=3.354 0.001
    AST(U/L) 小剂量PE+DPMAS/HP组 178.6(84.7~441.8) 86.1(58.9~159.2) Z=-9.425 <0.001
    单纯内科治疗组 136.5(59.8~298.3) 60.3(34.4~101.5) Z=-6.752 <0.001
    ALT(U/L) 小剂量PE+DPMAS/HP组 149.4(52.3~484.7) 58.0(39.8~114.0) Z=-10.097 <0.001
    单纯内科治疗组 50.5(34.3~203.3) 43.8(24.0~71.0) Z=-4.639 <0.001
    TBil(mg/dL) 小剂量PE+DPMAS/HP组 19.6(12.8~25.2) 8.2(4.9~13.7) Z=-10.184 <0.001
    单纯内科治疗组 12.0(6.7~22.4) 6.7(3.5~12.1) Z=-3.497 <0.001
    血氨(μmol/L) 小剂量PE+DPMAS/HP组 88.0(77.7~105.3) 45.5(26.1~63.0) Z=-11.825 <0.001
    单纯内科治疗组 92.8(74.5~127.5) 68.5(55.0~89.4) Z=-7.427 <0.001
    胆汁酸(μmol/L) 小剂量PE+DPMAS/HP组 223.7(163.4~282.9) 160.0(109.2~221.7) Z=-6.069 <0.001
    单纯内科治疗组 134.7(71.2~222.0) 138.0(79.7~218.0) Z=-0.981 0.327
    INR 小剂量PE+DPMAS/HP组 1.7(1.3~2.3) 1.7(1.4~2.0) Z=-3.500 0.002
    单纯内科治疗组 1.5(1.3~2.2) 1.6(1.4~1.9) Z=-0.890 0.373
    NLR 小剂量PE+DPMAS/HP组 3.8(2.4~5.8) 5.1(2.8~8.8) Z=-3.050 0.002
    单纯内科治疗组 3.6(2.3~6.3) 3.4(1.9~7.8) Z=-0.243 0.808
    PWR 小剂量PE+DPMAS/HP组 14.5(9.8~22.6) 16.2(11.6~24.9) Z=-2.551 0.011
    单纯内科治疗组 16.2(8.3~25.0) 18.4(13.7~23.0) Z=-0.784 0.433
    MELD 小剂量PE+DPMAS/HP组 19.0(14.6~24.4) 17.2(11.9~22.9) Z=-4.796 <0.001
    单纯内科治疗组 16.5(11.2~21.6) 15.4(10.5~20.2) Z=-0.793 0.428
    下载: 导出CSV

    表  3  两组治疗前后差值的比较

    Table  3.   Comparison of the Δvalue between the two groups

    指标 小剂量PE+DPMAS/HP组 单纯内科治疗组 Z P
    ΔAlb(g/L) -3.7(-7.5~0.7) -1.8(-5.5~2.3) -2.797 0.005
    ΔALT(U/L) 74.5(6.8~336.5) 22.2(0.3~172.0) -2.695 0.007
    ΔAST(U/L) 60.7(13.3~278.0) 67.8(-18.3~187.2) -0.180 0.857
    ΔTBil(mg/dL) 10.0(4.6~15.5) 2.9(-0.8~11.8) -4.070 <0.001
    Δ血氨(μmol/L) 38.1(26.1~63.0) 23.1(11.0~43.0) -1.828 0.034
    下载: 导出CSV

    表  4  两组患者分期后病死率比较

    Table  4.   Comparison of mortality after staging between the two groups of patients

    指标 小剂量PE+DPMAS/HP组(n=190) 单纯内科治疗组(n=82) χ2 P
    短期病死率[例(%)]
      前期 16(12.3) 15(41.7) 4.620 0.032
      早中期 29(32.6) 21(61.8) 8.683 0.003
      晚期 15(53.6) 8(66.7) 0.598 0.443
    长期病死率[例(%)]
      前期 38(52.1) 24(66.7) 2.099 0.147
      早中期 69(77.5) 28(82.4) 0.344 0.558
      晚期 22(78.6) 10(83.3) 0.119 0.730
    下载: 导出CSV

    表  5  两组患者分型后病死率比较

    Table  5.   Comparison of mortality after classification between the two groups of patients

    指标 小剂量PE+DPMAS/HP组(n=190) 单纯内科治疗组(n=82) χ2 P
    短期病死率[例(%)]
      A型 10(14.9) 6(42.9) 5.700 0.017
      B型 10(29.4) 6(50.0) 1.657 0.198
      C型 40(44.9) 32(57.1) 2.046 0.153
    长期病死率[例(%)]
      A型 33(49.3) 8(57.1) 0.288 0.591
      B型 25(73.5) 9(75.0) 0.010 0.921
      C型 71(79.8) 45(80.4) 0.007 0.932
    下载: 导出CSV
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