在肝硬化患者感染与全身炎症以及肝性脑病之间的因果关系已经被提出。但是肝硬化合并感染的患者，其临床与亚临床认知功能改变及其可逆性的完整模式，还没有专业研究。我们的调查旨在描述在住院的肝硬化患者的认知功能障碍的特点，并与无肝脏疾病的患者做对比，有或没有感染做对比。150例肝硬化患者进行预先登记。 81例无肝脏疾病构成对照组。一开始即对所有患者积极寻找细菌感染和败血症临床证据。在入院时以及获得院内感染时对所有患者进行神经心理评估。在患者感染时及3个月后的对他们的辨别能力进行重新评估。在肝硬化无感染的患者中有42%患者有认知功能障碍（临床或亚临床型），在感染组有79％的患者有认知功能障碍，但不是SIRS和90%不是脓毒症。在对照组认知功能障碍只表现为亚临床型，且只发生在有败血症的患者（42%）。选择多因素分析，在肝硬化患者感染是认知功能障碍的唯一的独立预测因素（OR值为9.5%，95%可信区间为3.5-26.2；p=0.00001）。亚临床认知功能障碍是通过心理测试获得，也证实与感染期及感染控制后认知功能可恢复有密切关系。与无肝脏疾病患者相比，肝硬化患者合并感染与更坏的认知功能障碍有关。在肝硬化患者寻找及治疗感染对改善临床及亚临床认知功能障碍是非常关键的。
BACKGROUND & AIMS:
A causal relationship between infection, systemic inflammation, and hepatic encephalopathy (HE) has been suggested in cirrhosis. No study, however, has specifically examined, in cirrhotic patients with infection, the complete pattern of clinical and subclinical cognitivealterations and its reversibility after resolution. Our investigation was aimed at describing the characteristics of cognitive impairment in hospitalizedcirrhotic patients, in comparison with patients without liver disease, with and without infection.
METHODS:
One hundred and fifty cirrhotic patients were prospectively enrolled. Eighty-one patients without liver disease constituted the control group. Bacterial infections and sepsis were actively searched in all patients independently of their clinical evidence at entry. Neurological and psychometric assessment was performed at admission and in case of nosocomial infection. The patients were re-evaluated after the resolution of the infection and 3months later.
RESULTS:
Cognitive impairment (overt or subclinical) was recorded in 42% of cirrhotics without infection, in 79% with infection without SIRS and in 90% with sepsis. The impairment was only subclinical in controls and occurred only in patients with sepsis (42%). Multivariate analysis selected infection as the only independent predictor of cognitive impairment (OR 9.5; 95% CI 3.5-26.2; p=0.00001) in cirrhosis. The subclinical alterations detected by psychometric tests were also strongly related to the infectious episode and reversible after its resolution.
CONCLUSIONS:
Infections are associated with a worse cognitive impairment in cirrhotics compared to patients without liver disease. The search and treatment of infections are crucial to ameliorate both clinical and subclinical cognitive impairment of cirrhotic patients.
吉林大学第一医院肝病科 刘素英 摘译
本文首次发表于[J Hepatol. 2013 Aug;59(2):243-50]
本文首次发表于[J Hepatol. 2013 Aug;59(2):243-50]
Increased risk of cognitive impairment in cirrhotic patients with bacterial infections.
AbstractBACKGROUND & AIMS:
A causal relationship between infection, systemic inflammation, and hepatic encephalopathy (HE) has been suggested in cirrhosis. No study, however, has specifically examined, in cirrhotic patients with infection, the complete pattern of clinical and subclinical cognitivealterations and its reversibility after resolution. Our investigation was aimed at describing the characteristics of cognitive impairment in hospitalizedcirrhotic patients, in comparison with patients without liver disease, with and without infection.
METHODS:
One hundred and fifty cirrhotic patients were prospectively enrolled. Eighty-one patients without liver disease constituted the control group. Bacterial infections and sepsis were actively searched in all patients independently of their clinical evidence at entry. Neurological and psychometric assessment was performed at admission and in case of nosocomial infection. The patients were re-evaluated after the resolution of the infection and 3months later.
RESULTS:
Cognitive impairment (overt or subclinical) was recorded in 42% of cirrhotics without infection, in 79% with infection without SIRS and in 90% with sepsis. The impairment was only subclinical in controls and occurred only in patients with sepsis (42%). Multivariate analysis selected infection as the only independent predictor of cognitive impairment (OR 9.5; 95% CI 3.5-26.2; p=0.00001) in cirrhosis. The subclinical alterations detected by psychometric tests were also strongly related to the infectious episode and reversible after its resolution.
CONCLUSIONS:
Infections are associated with a worse cognitive impairment in cirrhotics compared to patients without liver disease. The search and treatment of infections are crucial to ameliorate both clinical and subclinical cognitive impairment of cirrhotic patients.
