慢加急性肝衰竭患者急性肾损伤的特点及其对预后的影响

摘要/Abstract

摘要： 目的分析慢加急性肝衰竭(ACLF)患者急性肾损伤(AKI)的临床特点及其影响AKI发生的危险因素。方法选取2019年1月至2022年7月无锡市第五人民医院收治的ACLF患者作为研究对象,根据是否发生AKI分为ACLF-非AKI组、ACLF-AKI组。ACLF、AKI诊断符合要求,比较ACLF-非AKI组、ACLF-AKI组临床资料,采用多变量分析影响ACLF患者AKI的危险因素。比较不同结局AKI患者临床资料。结果共纳入ACLF患者117例,其中ACLF-非AKI组73例、ACLF-AKI组44例。ACLF-非AKI组年龄、高血压、消化道出血、细菌感染、WBC、TBil、INR、PT、Scr、血清K+、CTP评分、MELD评分及90 d病死率分别为(49.3±7.9)岁、7例(9.6%)、9例(12.3%)、8例(10.9%)、(7.0±1.4)×10⁹/L、(213.6±69.2)μmol/L、(2.2±0.9)、(33.3±2.9)s、(60.6±18.4)μmol/L、(3.8±0.6)mmol/L、(11.0±1.6)分、(17.9±3.7)分和16例(21.9%);ACLF-AKI组分别为(52.4±8.3)岁、11例(25.0%)、13例(29.5%)、11例(25.0%)、(9.0±1.6)×10⁹/L、(272.1±87.1)μmol/L、(2.4±0.9)、(35.5±3.7)s、(106.8±30.0)μmol/L、(4.0±0.7)mmol/L、(11.5±1.8)分、(22.2±4.3)分和25例(56.8%)(P<0.05);ACLF-非AKI组Alb、eGFR及血清Na+分别为(31.4±5.1)g/L、(137.2±43.2)ml/min/1.73 m²和(134.7±2.8)mmol/L,ACLF-AKI组分别为(27.2±5.0)g/L、(104.4±34.2)ml(min·1.73 m²)和(132.1±2.2)mmol/L(P<0.05)。多变量分析发现年龄、消化道出血、细菌感染、TBil及PT等升高而Alb下降,ACLF患者AKI风险显著增加。44例ACLF合并AKI患者中病情缓解、进展分别为27例、17例。比较不同结局AKI患者临床资料,病情缓解患者TBil、INR、Scr、CTP评分、MELD评分及90 d病死率分别为(250.7±73.3)μmol/L、(2.3±1.0)、(78.2±15.3)μmol/L、(11.5±1.4)分、(25.9±4.5)分及10例(37.0%),病情进展患者分别为(307.2±92.6)μmol/L、(3.0±1.0)、(172.3±24.7)μmol/L、(12.4±1.5)分、(31.4±6.2)分及15例(88.2),(P<0.05);病情缓解、进展患者血清Na+分别为(132.4±2.3)mmol/L、(130.0±2.1)mmol/L,差异有统计学意义(P<0.05);病情缓解患者急性肾小管坏死、肾前性氮质血症及肝肾综合征为2例(7.4%)、19例(70.4%)及6例(22.2%),病情进展患者5例(29.4%)、1例(5.9%)及11例(64.7%),差异有统计学意义(P<0.05)。结论近40%的ACLF患者会发展为AKI,年龄、消化道出血、细菌感染、TBil及PT等升高而Alb下降会导致ACLF患者AKI风险显著增加。ACLF合并AKI患者出现病情进展较为常见,与病情缓解患者相比临床结局更差。

关键词: 慢加急性肝衰竭, 急性肾损伤, 血肌酐, 多变量分析

Abstract: Objective To analyze the clinical features and risk factors of acute kidney injury (AKI) in patients with chronic and acute liver failure (ACLF) and the impact of AKI on the patients' outcomes. Methods A total of 117 ACLF patients admitted to our hospital from January 2019 to July 2022 were selected as the research objects. The patients were divided into ACLF-non-AKI group and ACLF-AKI group according to whether AKI occurred or not. The diagnosis of ACLF and AKI met the diagnostic criteria. The clinical data of ACLF-non-AKI group and ACLF-AKI group were compared, and the risk factors of AKI in ACLF patients were analyzed by multivariate analysis. The patients were followed-up and the clinical outcomes of the ACLF patients with or without AKI were compared. Results A total of 117 patients with ACLF were enrolled, including 73 patients in ACLF-non-AKI group and 44 patients in ACLF-AKI group. Compare the clinical data of the two groups, The age, hypertension, gastrointestinal bleeding, bacterial infection, white blood cells count (WBC), total bilirubin (TBil), international normalized ratio (INR), prothrombin time (PT), serum creatinine (Scr), serum K+, Child-Turcotte-Pugh (CTP) score, Model for End-Stage Liver Disease (MELD) score and 90-day mortality of ACLF-non-AKI group were (49.3±7.9) years, 7 cases (9.6%), 9 cases (12.3%), 8 cases (10.9%), (7.0±1.4) ×10⁹/L, (213.6±69.2) μmol/L, (2.2±0.9), (33.3±2.9) s, (60.6±18.4) μmol/L, (3.8±0.6) mmol/L, (11.0±1.6) points, (17.9±3.7) points and 16 cases (21.9%), respectively, which were significantly lower than those of (52.4±8.3) years,11 cases (25.0%), 13 cases (29.5%), 11 cases (25.0%), (9.0±1.6) ×10⁹/L, (272.1±87.1) μmol/L, (2.4±0.9), (35.5±3.7) points, (106.8±30.0) μmol/l, (4.0±0.7) mmol/l, (11.5±1.8) points, (22.2±4.3) points and 25 cases (55.8%) in the ACLF-AKI group (P<0.05). The albumin (Alb) level, estimated glomerular filtration rate (eGFR) and serum Na+ of ACLF-non-AKI group were (31.4±5.1) g/L, (137.2±43.2) ml/min/1.73 m² and (134.7±2.8) mmol/L, respectively, which were significantly higher than those of (27.2±5.0) g/L, (104.4±34.2) ml/min/1.73 m² and (132.1±2.2) mmol/L in ACLF-AKI group (P<0.05). Multivariate analysis showed that age, gastrointestinal bleeding, bacterial infection, TBil and PT increased whereas Alb decreased were risk factors of AKI in ACLF patients. Among the 44 patients with ACLF complicated with AKI, the remission and progress were 27 and 17 cases, respectively. Comparing the clinical data of AKI patients with different outcomes, TBil, INR, Scr, CTP score, MELD score and 90-day mortality of patients with remission were (250.7±73.3) μmol/L, (2.3±1.0), (78.2±15.3) μmol/L, (11.5±1.4) points, (25.9±4.5) points and 10 cases (37.0%), respectively, which were significantly lower than those of (307.2±92.6) μmol/L, (3.0±1.0), (172.3±24.7) μmol/L, (12.4±1.5) points, (31.4±6.2) points and 15 cases (88.2%) in patients with progressive disease, respectively, P<0.05. The serum Na+ levels of patients in remission and progression were (132.4±2.3) mmol/L and (130.0±2.1) mmol/L, respectively, and the difference was statistically significant (P<0.05). There were 2 cases (7.4%), 19 cases (70.4%) and 6 cases (22.2%) of acute tubular necrosis, pre-renal azotemia and hepatorenal syndrome in remission patients, respectively, and the difference was statistically significant compared with those of 5 cases (29.4%), 1 case (5.9%) and 11 cases (64.7%), in progression patients (P<0.05). Conclusion Nearly 40% of ACLF patients will develop AKI. Factors of age, gastrointestinal bleeding, bacterial infection, TBil and PT increase whereas Alb decreases significantly increase the risk of AKI in ACLF patients. ACLF patients with AKI usually have disease progression, and the clinical outcome is worse than that of patients with remission.

Key words: Acute-on-chronic liver failure, Acute kidney injury, Serum creatinine, Multivariate analysis

李芃芃, 董其刚, 许军. 慢加急性肝衰竭患者急性肾损伤的特点及其对预后的影响[J]. 肝脏, 2023, 28(3): 330-333.

LI Peng-peng, DONG Qi-gang, XU Jun. The characteristics of acute kidney injury in patients with acute-on-chronic liver failure and its impact on prognosis[J]. Chinese Hepatolgy, 2023, 28(3): 330-333.

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