重症加强治疗病房肝衰竭患者的临床特征及生存分析

摘要/Abstract

摘要： 目的分析重症加强治疗病房肝衰竭患者的病因、临床特征、人工肝治疗和预后相关影响因素。方法采用回顾性研究将2019年1月—2021年12月陕西省人民医院重症医学科收治的140例接受人工肝治疗的肝衰竭患者作为研究对象, 对其病因、实验室检查、主要并发症/合并症、人工肝治疗的模式、时机及预后相关影响因素进行分析。结果接受人工肝治疗的肝衰竭患者共140例,随访60 d生存组73例(52.1%),死亡组67例(47.9%)。2组患者年龄(t=-2.325,P=0.022)、住院时间(t=-3.439,P=0.001)、病因(χ²=50.239,P<0.001)、肝衰竭分类(χ²=12.779,P=0.002)差异有统计学意义;生存组患者的APACHE Ⅱ评分(t=-6.792,P<0.001)、终末期肝病模型(MELD)(t=-4.079,P<0.001)、总胆红素(TBil)(t=-3.115,P=0.002)、国际标准化比值(INR)(t=-3.839,P<0.001)、血肌酐(SCr)(t=-2.408,P=0.018)、尿素(UREA)(t=-2.042,P=0.043)、白细胞计数(WBC)(t=-4.853,P<0.001)、降钙素原(PCT)(Z=-3.110,P=0.002)均显著低于死亡组,凝血酶原活动度(PTA)(t=3.443,P=0.001)显著高于死亡组(P<0.05);生存组患者急性肾损伤的发生率(χ²=7.312,P=0.007)显著低于死亡组;肝性脑病和电解质紊乱的发生率两组之间差异无统计学意义(P>0.05);两组患者分别行胆红素吸附(PBA)、血浆置换(PE)、双重血浆分子吸附(DPMAS)及双重血浆分子吸附联合血浆置换(DPMAS+PE)4种不同模式人工肝治疗,其人工肝治疗模式差异无统计学意义(P>0.05),但两组患者接受人工肝治疗时期的差异有统计学意义(χ²=10.419,P=0.005);经多因素COX回归模型分析发现,年龄(HR=1.04,95%CI 1.017~1.065,P=0.001)、肝衰竭晚期(HR=4.889,95%CI 1.103-21.676,P=0.037)、APACHE Ⅱ评分(HR=1.085,95%CI 1.032-1.141,P=0.001)、INR(HR=3.089,95%CI 1.178-8.097,P=0.022)、TBil(HR=1.006,95%CI 1.002~1.01,P=0.006)、SCr(HR=1.011,95%CI 1.001~1.021,P=0.032)、PCT(HR=1.023,95%CI 1.006-1.04,P=0.009)是影响患者预后的独立危险因素。结论不同人工肝治疗模式对重症加强治疗病房肝衰竭患者的生存状况无显著影响,但与患者接受人工肝治疗的时机有关。年龄、肝衰竭晚期、APACHE Ⅱ评分、INR、TBil、SCr、PCT是影响患者预后的独立危险因素。

关键词: 肝衰竭, 人工肝, 生存分析

Abstract: Objective To investigate etiology, clinical characteristics, artificial liver treatment and prognosis-related influencing factors of patients with liver failure in intensive care unit (ICU). Methods A retrospective study was used to analyze the etiology, laboratory tests, major complications/comorbidities, mode and timing of artificial liver therapy and prognosis-related influencing factors in 140 patients with liver failure who received artificial liver therapy in our hospital. Results A total of 140 patients with liver failure who received artificial liver support system were followed up for 60 days, 73 patients (52.1%) in the survival group and 67 patients (47.9%) in the death group. There were statistically significant differences in age (t=-2.325, P=0.022), length of stay (t=-3.439, P=0.001), etiology (χ²=50.239, P<0.001) and classification of liver failure (χ²=12.779, P=0.002) between the two groups (P<0.05). APACHE Ⅱ score (t=-6.792, P<0.001), end-stage liver disease model (MELD) (t=-4.079, P<0.001), total bilirubin (TBil) (t=-3.115, P=0.002), international standardized ratio (INR) (t=-3.839, P<0.001), serum creatinine (SCr) (t=-2.408, P=0.018), urea nitrogen (UREA) (t=-2.042, P=0.043), white blood cell (WBC) (t=-4.853, P<0.001) and procalcitonin (PCT) (Z=-3.11, P=0.002)in survival group were significantly lower than those in death group. Prothrombin activity (PTA) (t=3.443, P=0.001) was significantly higher than that in death group (P<0.05). The incidence of acute kidney injury (χ²=7.312, P=0.007) in survival group was significantly lower than that in death group (P<0.05). There was no significant difference in the incidence of hepatic encephalopathy and electrolyte disorder between the 2 groups (P>0.05). Patients in the 2 groups underwent bilirubin adsorption (PBA), plasma exchange (PE), dual plasma molecular adsorption (DPMAS) and dual plasma molecular adsorption combined with plasma exchange (DPMAS+PE) in four different modes of artificial liver treatment, and the difference in their artificial liver treatment modes was not statistically significant (P>0.05), but there was statistical significance in the period of artificial liver therapy (χ²=10.419, P=0.005) between 2 groups (P<0.05). Multivariate COX regression model showed that age (HR=1.04, 95%CI 1.017-1.065, P=0.001), advanced liver failure (HR=4.889, 95%CI 1.103-21.676, P=0.037), APACHE Ⅱ score (HR=1.085, 95%CI 1.032-1.141, P=0.001), INR (HR=3.089, 95%CI 1.178-8.097, P=0.022), TBil (HR=1.006, 95%CI 1.002-1.01, P=0.006), SCr (HR=1.011, 95%CI 1.001-1.021, P=0.032) and PCT (HR=1.023, 95%CI 1.006-1.04, P=0.009) were independent risk factors for prognosis. Conclusion Different modes of artificial liver support system have no significant effect on the survival of patients with liver failure in ICU, but are associated with the timing of patients receiving artificial liver treatment. Age, advanced liver failure, APACHE Ⅱ score, INR, TBIL, SCr and PCT are independent risk factors for prognosis.

Key words: Liver failure, Artificial liver support system, Survival analysis

牛丹, 张倩楠, 白惠惠. 重症加强治疗病房肝衰竭患者的临床特征及生存分析[J]. 肝脏, 2023, 28(4): 410-415.

NIU Dan, ZHANG Qian-nan, BAI Hui-hui. Clinical features and survival analysis of patients with liver failure in intensive care unit[J]. Chinese Hepatolgy, 2023, 28(4): 410-415.

参考文献

[1] 中华医学会重症医学分会. 《中国重症加强治疗病房(ICU)建设与管理指南》(2006) . 中国危重病急救医学,2006,18(07):387-388.
[2] 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). 中华肝脏病杂志,2019,27(1):18-26.
[3] 中华医学会感染病学分会肝衰竭与人工肝学组. 非生物型人工肝治疗肝衰竭指南(2016年版). 中华临床感染病杂志,2016,9(2):97-103.
[4] Cecconi M, De Backer D, Antonelli M, et al. Consensus on circulatory shock and hemodynamic monitoring. Task force of the European Society of Intensive Care Medicine. Intensive Care Med,2014,40(12):1795-1815.
[5] Markwart R, Saito H, Harder T, et al. Epidemiology and burden of sepsis acquired in hospitals and intensive care units: a systematic review and meta-analysis. Intensive Care Med,2020,46(8):1536-1551.
[6] 李敏, 苏健婷, 武珊珊, 等. 乙型肝炎肝硬化患者年龄和性别与肝病相关死亡风险的关系. 中华肝脏病杂志,2021,29(05):403-408.
[7] Maeso-Díaz R, Gracia-Sancho J. Aging and Chronic Liver Disease. Semin Liver Dis, 2020,40(4):373-384.
[8] Grek A, Arasi L. Acute Liver Failure. AACN Adv Crit Care,2016,27(4):420-429.
[9] Bajaj JS, O'Leary JG, Lai JC, et al. Acute-on-Chronic Liver Failure Clinical Guidelines. Am J Gastroenterol,2022,117(2):225-252.
[10] 赵洁, 李力, 李秀惠, 等. 乙型肝炎病毒相关慢加急性肝衰竭患者短期预后模型的建立及预测价值研究. 中华危重病急救医学,2020,32(08):988-993.
[11] 袁受涛. ICU中的APACHE Ⅱ危重病评分系统分析. 中国临床实用医学,2010,4(12):198-199.
[12] Godinjak A, Iglica A, Rama A, et al. Predictive value of SAPS II and APACHE II scoring systems for patient outcome in a medical intensive care unit. Acta Med Acad,2016,45(2):97-103.
[13] Flamm SL, Yang YX, Singh S, et al. American Gastroenterological Association Institute Guidelines for the Diagnosis and Management of Acute Liver Failure. Gastroenterology,2017,152(3):644-647.
[14] 庄焱,谢青. 肝衰竭并发急性肾损伤热点研究新进展. 临床肝胆病杂志,2018,34(9):1836-1841.
[15] 郑义彬, 王爱国, 陈冲, 等. 乙型肝炎病毒相关慢加急性肝衰竭患者血清PCT与肝功能参数的相关性分析. 中西医结合肝病杂志,2021,31(12):1130-1133.
[16] 中华医学会肝病学分会重型肝病与人工肝学组. 人工肝血液净化技术临床应用专家共识(2022年版). 临床肝胆病杂志,2022,38(4):767-775.