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妊娠期HBV相关慢加急性肝衰竭的临床特征和转归

纪留娟 梅雪 袁伟 邹颖 刘玉 王介非 钱志平

引用本文:
Citation:

妊娠期HBV相关慢加急性肝衰竭的临床特征和转归

DOI: 10.3969/j.issn.1001-5256.2022.04.010
基金项目: 

上海申康中心促进市级医院临床技能与临床创新能力三年行动计划项目 (SHDC2020CR1037B-004);

国家“十三五”科技重大专项 (2018ZX10725506-002);

上海市卫健委课题 (20184Y0058)

伦理学声明:本研究于2020年8月10日经上海市公共卫生临床中心伦理委员会审批,批号为2020-S179-01。
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:纪留娟参与收集、分析数据及论文撰写;梅雪、袁伟、邹颖、刘玉参与修改论文;钱志平、王介非指导撰写论文并最后定稿。
详细信息
    通信作者:

    王介非,wangjiefei@shaphc.org

    钱志平,qianzhiping@shaphc.org

Clinical features and prognosis of HBV-related acute-on-chronic liver failure in pregnancy

Research funding: 

The Shanghai Municipal Education Commission Gaofeng Clinical Medicine Grant Support and Shanghai Hospital Development Center Funding (SHDC2020CR1037B-004);

National Science and Technology Major Project during the 13th Five-Year Plan Period (2018ZX10725506-002);

Project of Shanghai Municipal Health Commission (20184Y0058)

More Information
  • 摘要:   目的  探讨妊娠期HBV相关慢加急性肝衰竭(HBV-ACLF)患者的临床特征和转归。  方法  回顾性分析上海市公共卫生临床中心2008年6月—2020年7月收治的26例妊娠期HBV-ACLF患者的临床资料,包括年龄、发病孕周、产次、首发症状、入院时并发症、实验室指标(WBC、Hb、PLT、ALT、TBil、Alb、SCr、MELD评分、HBsAg、HBV DNA等)、腹部超声、分娩方式、胎儿情况、治疗措施、预后转归等。正态分布的计量资料2组间比较采用t检验;非正态分布的计量资料2组间比较采用Wilcoxon秩和检验;计数资料2组间比较采用χ2检验或Fisher精确检验。  结果  26例患者中8例均在发病后28 d内死亡,病死率达30.8%。经产妇22例,占84.6%,ACLF往往发生在妊娠晚期(20/26,76.9%),平均发病孕周为(30.9±5.8)周。HBV-ACLF临床表现不典型,首发症状常为乏力、纳差(21/26,80.8%)和尿黄(19/26,73.1%)等。死亡组的TBil(Z=-2.056,P=0.041)、凝血酶原时间(Z=-2.362,P=0.016)、国际标准化比值(Z=-2.528,P=0.009)、MELD评分(Z=-2.223,P=0.026)、首发症状至诊断时间(t=-2.468,P=0.021)、HBV DNA水平(χ2=7.571,P=0.021)、肝性脑病严重程度(χ2=24.775,P<0.001)、并发症发生率(χ2=5.951,P=0.042)显著高于存活组,而纤维蛋白原(Z=-2.667,P=0.006)、凝血酶原活动度(Z=-2.365,P=0.016)水平明显低于存活组。  结论  HBV-ACLF是妊娠晚期严重并发症,经产妇多见,短期病死率极高。其早期临床表现隐匿,高MELD评分、高病毒载量和并发症的出现往往提示预后不良。

     

  • 表  1  妊娠期HBV-ACLF存活组和死亡组患者的临床特征比较

    Table  1.   Comparison of clinical characteristics between HBV-ACLF survival group and death group during pregnancy

    临床指标 存活组(n=18) 死亡组(n=8) 统计值 P
    年龄(岁) 28.0±4.0 29.0±3.5 t=-0.886 0.385
    发病孕周(周) 30.2±6.2 32.5±5.0 t=-0.897 0.379
    TBil(μmol/L) 216.1(181.4~262.7) 311.9(221.4~372.4) Z=-2.056 0.041
    Alb(g/L) 28.3±2.6 26.5±3.0 t=1.608 0.121
    SCr(μmol/L) 51.6(37.1~56.8) 49.0(43.0~54.7) Z=-0.222 0.849
    PT(s) 24.3(21.6~30.4) 43.5(25.9~46.9) Z=-2.362 0.016
    PTA(%) 33.5(24.8~40.8) 17.0(15.3~33.0) Z=-2.365 0.016
    INR 2.2(1.9~3.0) 4.6(2.4~5.2) Z=-2.528 0.009
    FIB(g/L) 1.7(1.5~2.1) 0.9(0.6~1.5) Z=-2.667 0.006
    血糖(mmol/L) 4.6±1.4 4.2±1.7 t=0.672 0.508
    WBC(×109/L) 13.8±6.7 16.9±7.9 t=-1.034 0.312
    Hb(g/L) 116.3±20.8 116.4±21.5 t=-0.008 0.993
    PLT(×109/L) 162.3±67.8 164.6±68.5 t=-0.081 0.936
    MELD评分 18.8(15.7~25.5) 28.7(20.6~32.5) Z=-2.223 0.026
    首发症状至诊断时间(d) 6.5±3.5 10.0±3.0 t=-2.468 0.021
    首发症状至抗病毒时间(d) 9.5±4.5 11.5±3.0 t=-0.845 0.408
    下载: 导出CSV

    表  2  妊娠期HBV-ACLF并发症分析

    Table  2.   Analysis of HBV-ACLF complications during pregnancy

    并发症 存活组(n=18) 死亡组(n=8) χ2 P
    感染[例(%)] 10(55.6) 6(75.0) 0.066
    腹水[例(%)] 5(27.8) 4(50.0) 0.382
    急性肾损伤[例(%)] 3(16.7) 3(37.5) 0.330
    产后出血[例(%)] 3(16.7) 2(25.0) 0.628
    肝性脑病[例(%)] 24.775 <0.001
      无 11(61.1) 0
      Ⅰ~Ⅱ期 7(38.9) 0
      Ⅲ~Ⅳ期 0 8(100.0)
    并发症数目[例(%)] 5.951 0.042
      无 4(22.2) 0
      1~2种并发症 10(55.6) 2(25.0)
      ≥3种并发症 4(22.2) 6(75.0)
    下载: 导出CSV

    表  3  妊娠期HBV-ACLF患者的母婴结局

    Table  3.   Maternal and infant outcomes of HBV-ACLF patients during pregnancy

    母婴结局 存活(n=18) 死亡(n=8) χ2 P
    孕妇
      HBV DNA[例(%)] 7.571 0.021
        <105 IU/mL 5(27.8) 1(12.5)
        105~106 IU/mL 10(55.5) 1(12.5)
        >106 IU/mL 3(16.7) 6(75.0)
      HBeAg[例(%)] 0.216
        阳性 10(55.6) 2(25.0)
        阴性 8(44.4) 6(75.0)
      生产方式[例(%)] 0.108
        剖宫产 12(66.7) 5(62.5)
        阴道分娩 6(33.3) 1(12.5)
        未生产 0 2(25.0)
    胎儿[例(%)] 21(80.8) 5(19.2) 10.301 0.002
      足月儿(37~42周) 8(38.1) 0
      早产儿(<37周) 13(61.9) 2(40.0)
      胎死宫内 0 3(60.0)
    下载: 导出CSV
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  • 收稿日期:  2021-09-13
  • 录用日期:  2021-10-18
  • 出版日期:  2022-04-20
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