中文English
ISSN 1001-5256
CN 22-1108/R

留言板

尊敬的读者、作者、审稿人, 关于本刊的投稿、审稿、编辑和出版的任何问题, 您可以本页添加留言。我们将尽快给您答复。谢谢您的支持!

姓名
邮箱
手机号码
标题
留言内容
验证码

慢加急性肝衰竭急性静脉曲张出血的危险因素及预后分析

刘婉姝 申力军 翟庆慧 辛绍杰 游绍莉

引用本文:
Citation:

慢加急性肝衰竭急性静脉曲张出血的危险因素及预后分析

DOI: 10.3969/j.issn.1001-5256.2022.11.018
基金项目: 

国家“十三五”科技重大专项 2017ZX10203201-004

伦理学声明:本研究方案经过原解放军第302医院临床研究伦理委员会批准,批号:2013005D、2019085D。
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:刘婉姝、申力军负责课题设计,资料分析,撰写论文;翟庆慧参与收集及分析数据;辛绍杰、游绍莉负责拟定写作思路,指导撰写文章并最后定稿。
详细信息
    通信作者:

    游绍莉,youshaoli1972@163.com

    作者说明:刘婉姝和申力军对本文贡献等同,同为第一作者

Risk factors for acute variceal bleeding in acute-on-chronic liver failure and its influence on prognosis

Research funding: 

The 13th Five-Year National Science and Technology Major Project for Infectious Diseases 2017ZX10203201-004

More Information
  • 摘要:   目的  探讨慢加急性肝衰竭(ACLF)急性静脉曲张出血(AVB)的危险因素及对预后的影响。  方法  对解放军总医院第五医学中心2009年—2015年收治ACLF患者1409例随访6个月,根据是否出现AVB分为AVB组(n=167)和非AVB组(n=1242)。计量资料符合正态分布两组间比较使用Student t检验;不符合正态分布资料两组间比较采用Mann-Whitney U检验。Kaplan-Meier法绘制生存曲线,对随访过程中组间病死率及进展进行Log-rank检验。采用二元Logistic回归分析AVB发生的危险因素。  结果  1409例患者发生AVB 167例,占11.85%。AVB及非AVB患者30 d存活率分别为43.42%、67.79%(χ2=33.558,P<0.001);两组患者180 d存活率分别为18.91%、53.97%(χ2=76.881,P<0.001)。Log-rank检验显示AVB与非AVB患者30 d生存率、180 d生存率差异均有统计学意义(χ2值分别为40.950、89.320,P值均<0.05)。Logistic回归分析AVB发生的危险因素,胸腔积液(OR=1.522,95%CI: 1.071 ~2.162,P=0.019)、急性肾损伤(OR=2.201,95%CI: 1.415~3.426,P<0.001)、ACLF分型(OR=2.491,95%CI: 1.489~4.168,P=0.001)、ACLF分期(OR=2.403,95%CI: 1.687~3.421,P<0.001)及尿素(OR=2.567,95%CI:1.570~4.196,P<0.001)与ACLF患者AVB的发生独立相关。  结论  AVB是影响ACLF近期生存的重要因素,胸腔积液、急性肾损伤、ACLF分型BC型、ACLF晚期以及尿素是AVB发生的独立危险因素。

     

  • 图  1  AVB和预后的关系

    注:a,30 d累积生存率生存曲线;b,180 d累积生存率生存曲线。

    Figure  1.  AVB and prognosis of ACLF

    表  1  1409例ACLF基线特征

    Table  1.   Baseline and clinical characteristics of 1409 cases of ACLF

    指标 AVB组(n=167) 非AVB组(n=1242) 统计值 P
    年龄(岁) 46.48±9.37 46.70±9.97 t=0.079 0.778
    性别[例(%)] χ2=0.721 0.396
      男 145(12.16) 1047(87.84)
      女 22(10.14) 195(89.86)
    ACLF分型[例(%)] χ2=47.069 <0.001
      A型 20(4.17) 460(95.83)
      B型 115(14.71) 667(85.29)
      C型 32(21.77) 115(78.23)
    ACLF分期[例(%)] χ2=47.902 <0.001
      早期 3(8.82) 31(91.18)
      中期 69(7.61) 838(92.39)
      晚期 95(20.30) 373(79.70)
    并发症[例(%)]
      腹水 157(94.01) 1103(88.81) χ2=3.683 0.055
      胸腔积液 77(46.11) 373(30.03) χ2=16.769 <0.001
      肺部感染 70(41.92) 196(15.78) χ2=63.960 <0.001
      SBP 80(47.90) 373(30.03) χ2=20.743 <0.001
      菌血症 24(14.37) 123(9.90) χ2=3.145 0.076
      肝性脑病 124(74.25) 446(35.91) χ2=88.252 <0.001
      AKI 126(75.45) 497(40.02) χ2=73.500 <0.001
    白蛋白(g/L) 28.89±5.73 31.20±4.26 t=6.134 0.013
    TBil(μmol/L) 280.55(172.50~421.78) 284.25(194.93~388.43) Z=0.260 0.795
    PTA(%) 19.01±10.93 25.72±9.77 t=67.070 <0.001
    INR 2.07±0.54 2.07±0.61 t=0.011 0.917
    血清钠(mmol/L) 132.47±5.87 133.29±5.89 t=2.861 0.091
    胆碱酯酶(U/L) 2 583.30±1 420.97 2 770.91±1 404.29 t=2.056 0.040
    纤维蛋白原(g/L) 1.68±0.90 1.74±0.96 t=0.568 0.451
    血肌酐(μmol/L) 95.00(78.75~120.25) 89.00(78.00~105.00) Z=2.740 0.006
    血尿素(mmol/L) 12.65(7.98~21.04) 6.70(4.60~11.30) Z=10.085 <0.001
    血清铁(μmol/L) 22.16±8.63 24.61±7.79 t=13.826 <0.001
    血红蛋白(g/L) 112.20(85.75~137.25) 121.70(104.00~139.00) Z=3.512 <0.001
    血小板计数(×109/L) 80.32±61.09 94.01±55.35 t=8.741 0.003
    MELD评分 25.82±6.69 25.40±5.36 t=0.830 0.363
    MELD-Na评分 31.93±11.21 29.93±9.82 t=5.875 0.015
    30 d存活率(%) 43.42(66/152) 67.79(722/1065) χ2=33.558 <0.001
    180 d存活率(%) 18.91(21/111) 53.97(421/780) χ2=76.881 <0.001
    下载: 导出CSV

    表  2  Logistic回归方程中的变量

    Table  2.   Variables in the equation for the multilevel Logistic regression

    变量 回归系数 标准误 Wald值 自由度 P OR 95%CI
    胸腔积液 0.420 0.179 5.491 1 0.019 1.522 1.071~2.162
    ACLF分型B、C型 0.913 0.263 12.089 1 0.001 2.491 1.489~4.168
    ACLF分期晚期 0.877 0.180 23.644 1 <0.001 2.403 1.687~3.421
    AKI 0.789 0.226 12.235 1 <0.001 2.201 1.415~3.426
    尿素 0.943 0.251 14.122 1 <0.001 2.567 1.570~4.196
    血小板计数 0.370 0.199 3.447 1 0.063 1.448 0.980~2.141
    MELD-Na评分 -0.311 0.184 2.853 1 0.091 0.733 0.511~1.051
    下载: 导出CSV
  • [1] SARIN SK, CHOUDHURY A, SHARMA MK, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update[J]. Hepatol Int, 2019, 13(4): 353-390. DOI: 10.1007/s12072-019-09946-3.
    [2] JOSHI D, O'GRADY J, PATEL A, et al. Cerebral oedema is rare in acute-on-chronic liver failure patients presenting with high-grade hepatic encephalopathy[J]. Liver Int, 2014, 34(3): 362-366. DOI: 10.1111/liv.12257.
    [3] SHIN J, YU JH, JIN YJ, et al. Acute-on-chronic liver failure as a major predictive factor for mortality in patients with variceal bleeding[J]. Clin Mol Hepatol, 2020, 26(4): 540-553. DOI: 10.3350/cmh.2020.0034.
    [4] TREBICKA J, GU W, IBÁÑEZ-SAMANIEGO L, et al. Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS[J]. J Hepatol, 2020, 73(5): 1082-1091. DOI: 10.1016/j.jhep.2020.04.024.
    [5] AL-MAHTAB M, AKBAR SM, GARG H. Influence of variceal bleeding on natural history of ACLF and management options[J]. Hepatol Int, 2016, 10(3): 436-439. DOI: 10.1007/s12072-015-9677-2.
    [6] Liver Failure and Artificial Liver Group, Chinese Society of Infectious Diseases, Chinese Medical Association; Severe Liver Diseases and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association. Diagnostic and treatment guidelines for liver failure (2018 version)[J]. J Chin Hepatol, 2019, 35(1): 38-44. DOI: 10.3969/j.issn.1001-5256.2019.01.007.

    中华医学会感染病学分会肝衰竭与人工肝学组, 中华医学会肝病学分会重型肝病与人工肝学组. 肝衰竭诊治指南(2018年版)[J]. 临床肝胆病杂志, 2019, 35(1): 38-44. DOI: 10.3969/j.issn.1001-5256.2019.01.007.
    [7] MOREAU R, JALAN R, GINES P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis[J]. Gastroenterology, 2013, 144(7): 1426-1437. e1-9. DOI: 10.1053/j.gastro.2013.02.042.
    [8] GARCIA-TSAO G, ABRALDES JG, BERZIGOTTI A, et al. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the study of liver diseases[J]. Hepatology, 2017, 65(1): 310-335. DOI: 10.1002/hep.28906.
    [9] HUANG Y, ZHANG W, XIANG H, et al. Treatment strategies in emergency endoscopy for acute esophageal variceal bleeding (CHESS1905): A Nationwide Cohort Study[J]. Front Med (Lausanne), 2022, 9: 872881. DOI: 10.3389/fmed.2022.872881.
    [10] KAMATH PS, KIM WR, Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD)[J]. Hepatology, 2007, 45(3): 797-805. DOI: 10.1002/hep.21563.
    [11] KIM WR, BIGGINS SW, KREMERS WK, et al. Hyponatremia and mortality among patients on the liver-transplant waiting list[J]. N Engl J Med, 2008, 359(10): 1018-1026. DOI: 10.1056/NEJMoa0801209.
    [12] GARG H, KUMAR A, GARG V, et al. Hepatic and systemic hemodynamic derangements predict early mortality and recovery in patients with acute-on-chronic liver failure[J]. J Gastroenterol Hepatol, 2013, 28(8): 1361-1367. DOI: 10.1111/jgh.12191.
    [13] KAR R, KAR SS, SARIN SK. Hepatic coagulopathy-intricacies and challenges; a cross-sectional descriptive study of 110 patients from a superspecialty institute in North India with review of literature[J]. Blood Coagul Fibrinolysis, 2013, 24(2): 175-180. DOI: 10.1097/MBC.0b013e32835b2483.
    [14] European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis[J]. J Hepatol, 2018, 69(2): 406-460. DOI: 10.1016/j.jhep.2018.03.024.
    [15] AMITRANO L, GUARDASCIONE MA, MARTINO R, et al. Hypoxic hepatitis occurring in cirrhosis after variceal bleeding: still a lethal disease[J]. J Clin Gastroenterol, 2012, 46(7): 608-612. DOI: 10.1097/MCG.0b013e318254e9d4.
    [16] KUMAR A, DAS K, SHARMA P, et al. Hemodynamic studies in acute-on-chronic liver failure[J]. Dig Dis Sci, 2009, 54(4): 869-878. DOI: 10.1007/s10620-008-0421-9.
    [17] MEHTA G, MOOKERJEE RP, SHARMA V, et al. Systemic inflammation is associated with increased intrahepatic resistance and mortality in alcohol-related acute-on-chronic liver failure[J]. Liver Int, 2015, 35(3): 724-734. DOI: 10.1111/liv.12559.
    [18] TREBICKA J, GU W, IBÁÑEZ-SAMANIEGO L, et al. Rebleeding and mortality risk are increased by ACLF but reduced by pre-emptive TIPS[J]. J Hepatol, 2020, 73(5): 1082-1091. DOI: 10.1016/j.jhep.2020.04.024.
    [19] HEO NY. Acute-on-chronic liver failure: A predictor of poor prognosis in patients with variceal bleeding or a risk factor for variceal bleeding?[J]. Clin Mol Hepatol, 2020, 26(4): 487-488. DOI: 10.3350/cmh.2020.0209.
    [20] KUMAR R, KERBERT A, SHEIKH MF, et al. Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding[J]. J Hepatol, 2021, 74(1): 66-79. DOI: 10.1016/j.jhep.2020.06.010.
  • 加载中
图(1) / 表(2)
计量
  • 文章访问数:  67
  • HTML全文浏览量:  20
  • PDF下载量:  19
  • 被引次数: 0
出版历程
  • 收稿日期:  2022-05-05
  • 录用日期:  2022-06-20
  • 出版日期:  2022-11-20
  • 分享
  • 用微信扫码二维码

    分享至好友和朋友圈

目录

    /

    返回文章
    返回