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人工肝支持系统治疗慢加急性肝衰竭效果的网状Meta分析

甘亮亮 张金周 王贤东 傅彩虹 苏佳 汤雪梅

引用本文:
Citation:

人工肝支持系统治疗慢加急性肝衰竭效果的网状Meta分析

DOI: 10.3969/j.issn.1001-5256.2022.01.021
基金项目: 

甘肃省人民医院院内基金 (18GSSY6-5)

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:甘亮亮、张金周负责课题设计,资料分析,撰写论文;汤雪梅、傅彩虹、苏佳参与文献筛选,收集数据,修改论文;王贤东负责拟定写作思路,指导撰写文章并最后定稿。
详细信息
    通信作者:

    汤雪梅,18205512@qq.com

Efficacy of artificial liver support system in treatment of acute-on-chronic liver failure: A network Meta-analysis

Research funding: 

Hospital Fund of Gansu Provincial Hospital (18GSSY6-5)

  • 摘要:   目的  采用网状Meta分析系统评价不同人工肝支持系统治疗慢加急性肝衰竭(ACLF)的疗效。  方法  计算机检索PubMed、EMBASE、Cochrane library、Clinical Trial、CNKI、SinoMed和万方数据库中关于不同形式人工肝治疗ACLF患者的随机对照试验。根据纳入排除标准进行文献筛选、资料提取及方法学质量评价,采用Stata15.1及R4.1.0软件进行网状Meta分析。  结果  共纳入14篇文献,共计1141例患者。网状Meta分析结果显示:不同干预方式交叉对比降低病死率差异均无统计学意义(P值均>0.05),排序概率图显示降低30 d病死率血浆置换(PE)最优,其他依次为体外细胞疗法(ELAD)、分级血浆分离吸附(Prometheus)、分子吸附再循环系统(MARS)、Biologic-DT肝脏透析设备、PE+MARS。降低90 d病死率PE最优,其他依次为Prometheus、ELAD、MARS。改善肝性脑病方面,Biologic-DT最优,其他依次为MARS、PE+MARS、ELAD。出血风险最低者为ELAD,与标准医学治疗(SMT)相比Biologic-DT可能增加出血风险(RR=1.9×108,95%CI: 4.6~6.2×1027)。  结论  PE可能是降低ACLF患者30 d及90 d病死率的最优选择。Biologic-DT可能在改善肝性脑病方面效果较好,但有可能增加出血风险。

     

  • 图  1  文献筛选流程图及结果

    图  2  偏移风险评估图

    图  3  病死率网状关系图

    注:a, 30 d;b, 90 d。

    图  4  30 d及90 d病死率网状Meta分析联赛图(95%CI)

    注:绿色表示30 d病死率,橙色表示90 d病死率。若95%CI包含1, 则比较无统计学意义; 95%CI不包含1, 则比较有统计学意义。NA, 未比较。

    图  5  网状Meta分析排序概率图

    注:a, 30 d病死率; b, 90 d病死率;c, 肝性脑病改善;d, 出血。

    图  6  病死率漏斗图

    注:a, 30 d; b, 90 d。

    表  1  纳入研究的基本特质

    研究 年份 国家 人群 病因 MELD
    Bañares R[13] 2013 欧洲 急性失代偿肝硬化 酒精、病毒、自身免疫、药物等 24.9
    Duan Z[14] 2018 中国 慢性重型肝炎 HBV、酒精、自身免疫、药物等 29.4
    Hassanein TI[15] 2007 美国 肝硬化失代偿并肝性脑病 酒精、病毒、自身免疫、药物等 30.5
    Heemann U[16] 2002 德国 急性失代偿肝硬化 酒精、病毒、自身免疫、中毒 -
    Hillebrand DJ[17] 2010 美国 急性失代偿肝硬化 - 37.6
    Huang YK[18] 2012 中国 慢性重型乙型肝炎合并肝性脑病 HBV -
    Kramer L[19] 2001 奥地利 肝硬化并肝性脑病 酒精、病毒、自身免疫、隐源性 -
    Kribben A[20] 2012 欧洲 急性失代偿慢性肝病 酒精、病毒、其他 27.5
    Laleman W[21] 2006 比利时 酒精性肝硬化并酒精性肝炎 酒精 25.6
    Mitzner SR[22] 2000 德国 急性失代偿肝硬化 酒精、病毒、自身免疫、布加病 -
    Qin G[23] 2014 中国 慢性重型乙型肝炎急性加重 HBV 29.1
    Sen S[24] 2004 英国 急性失代偿酒精性肝病 酒精 18
    Thompson J[25] 2018 美国、英国 重症酒精性肝炎 酒精 27.4
    周锐[12] 2012 中国 慢性重型乙型肝炎 HBV 30.8
    研究 例数 平均年龄(岁) 男性(%) 干预方式 干预情况 随访时间
    Bañares R[13] 179 50.9 68.7 MARS vs SMT 6.8 h,6.5次 91 d
    Duan Z[14] 49 39.4 93.9 ELAD vs SMT 持续68.1 h 5年
    Hassanein TI[15] 70 52.5 51.4 MARS vs SMT 4 h,2.7次 180 d
    Heemann U[16] 24 52.5 45.8 ELAD vs SMT 6 h,3~10次 6个月
    Hillebrand DJ[17] 18 - - ELAD vs SMT 持续122.8 h 90 d
    Huang YK[18] 120 42.5 76.7 MARS vs PE+MARS MARS 2.1次 30 d
    Kramer L[19] 20 55.5 65 Biologic-DT vs SMT 6 h 30 d
    Kribben A[20] 145 50.5 63.4 Prometheus vs SMT 5.7 h,8.1次 90 d
    Laleman W[21] 18 51.2 66.7 MARS vs Prometheus vs SMT 6 h,3次 7 d
    Mitzner SR[22] 13 46.7 38.5 MARS vs SMT 6~8 h,5.25次 30 d
    Qin G[23] 234 46.4 76.9 PE vs SMT 2.1 h,2次 5~10年
    Sen S[24] 18 44.5 72.2 MARS vs SMT 8 h,4次 90 d
    Thompson J[25] 203 45.7 47.8 ELAD vs SMT 持续0~120 h 91 d
    周锐[12] 30 40.5 76.7 PE vs SMT 2.5~4 h,2~7次 6~24个月
    注:MARS,分子吸附在循环系统;ELAD,体外细胞疗法;Prometheus,分级血浆分离吸附;PE,血浆置换。
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  • 收稿日期:  2021-07-30
  • 录用日期:  2021-08-31
  • 出版日期:  2022-01-20
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