失代偿期肝硬化并发细菌感染的危险因素及炎症指标的早期诊断价值

摘要/Abstract

摘要： 目的探讨失代偿期肝硬化患者并发细菌感染的危险因素及炎症指标的早期诊断价值。方法选择2022年1月至2023年12月我院收治的失代偿期肝硬化患者278例并进行回顾性分析,根据患者是否伴有细菌感染分为感染组102例(n=102)、非感染组176例(n=176),分析感染的临床特点,并采用多因素logistic回归模型分析失代偿期肝硬化患者并发细菌感染的危险因素,采用受试者工作特征(ROC)曲线,计算白细胞计数(WBC)、中性粒细胞与淋巴细胞计数比值(NLR)、C反应蛋白(CRP)及降钙素原(PCT)对失代偿期肝硬化并发细菌感染的早期诊断价值。结果失代偿期肝硬化易并发呼吸道感染及自发性腹膜炎, 102例感染的患者中,病原菌以大肠埃希菌(36.8%)、肺炎克雷伯菌(22.8%)为主。多因素分析提示,合并糖尿病、合并上消化道出血、Child-Pugh分级C级是肝硬化患者并发细菌感染的危险因素。经ROC曲线计算出诊断失代偿期肝硬化并发细菌感染的临床参考值:WBC的临床参考值为6.25×10⁹/L(AUC=0.787,P＜0.05,95%CI为0.720～0.855)、NLR的临床参考值为3.17(AUC=0.706,P＜0.05,95%CI为0.631～0.781)、CRP的临床参考值为15.19mg/L(AUC=0.621,P＜0.05,95%CI为0.536～0.707)、降钙素原的临床参考值为0.335 ng/mL(AUC=0.835,P＜0.05,95%CI为0.774～0.895),四者联合诊断的灵敏度为90.6%、特异度为64.3%。结论失代偿期肝硬化易并发呼吸道感染及自发性腹膜炎,病原菌以大肠埃希菌、肺炎克雷伯菌为主,合并糖尿病、并发上消化道出血及Child-Pugh分级为C级的肝硬化患者易发生细菌感染。在临床诊疗过程中对有上述危险因素的失代偿期肝硬化患者应动态监测其WBC、NLR、CRP、PCT等炎症指标,以早期发现潜在的感染,尽早治疗,改善预后。

关键词: 肝硬化, 细菌感染, 危险因素, 炎症指标

Abstract: Objective To investigate the risk factors of bacterial infection in patients with decompensated cirrhosis and the value of early diagnosis by inflammation index. Methods A retrospective analysis was performed on 278 patients with decompensated cirrhosis admitted to our hospital from January 2022 to December 2023. According to whether the patients were accompanied by bacterial infection, they were divided into an infected group (102 cases) and a non-infected group (176 cases). The clinical characteristics of infection were analyzed. Multiple logistic regression was used to analyze the risk factors of decompensated cirrhosis complicated with bacterial infection. The value of white blood cell count (WBC), neutrophil to lymphocyte count ratio (NLR), C-reactive protein (CRP) and procalcitonin (PCT) in early diagnosis of decompensated cirrhosis complicated with bacterial infection was calculated by receiver operating characteristic curve (ROC). Results Decompensated cirrhosis is prone to complications of respiratory tract infection and spontaneous peritonitis, and the pathogenic bacteria are mainly Escherichia coli (36.8%) and Klebsiella pneumoniae (22.8%). Multivariate analysis suggests that diabetes mellitus, upper gastrointestinal hemorrhage, and Child-Pugh grade C are the risk factors of bacterial infection in cirrhosis patients. The clinical reference value for the diagnosis of decompensated cirrhosis complicated with bacterial infection was calculated by ROC curve: the clinical reference value of WBC was 6.25×10⁹/L (AUC=0.787, P<0.05, 95%CI 0.720~0.855), and the clinical reference value of NLR was 3.17 (AUC=0.706, P<0.05, 95%CI 0.631~0.781), the clinical reference value of CRP was 15.19 mg/L (AUC=0.621, P<0.05, 95%CI 0.536~0.707), and the clinical reference value of procalcitonin was 0.335ng/mL (AUC=0.835, P<0.05, 95%CI 0.774~0.895), the sensitivity and specificity of the combined diagnosis were 90.6% and 64.3%, respectively. Conclusion Patients with decompensated cirrhosis are prone to complicated with respiratory tract infection and spontaneous peritonitis, mainly caused by Escherichia coli and Klebsiella pneumoniae. Patients with cirrhosis combined with diabetes, upper gastrointestinal hemorrhage and Child-Pugh grade C are prone to bacterial infection. During clinical diagnosis and treatment, the WBC count, NLR, C-reactive protein, procalcitonin and other inflammatory indicators should be dynamically monitored for patients with decompensated cirrhosis with the abovel risk factors, so as to early detect and promptly treat potential infection and improve prognosis.

Key words: Liver cirrhosis, Infection, Risk factors, Inflammatory index

余斌斌, 吴俊, 陆逸君, 向谦. 失代偿期肝硬化并发细菌感染的危险因素及炎症指标的早期诊断价值[J]. 肝脏, 2025, 30(8): 1066-1070.

YU Bin-bin, WU Jun, LU Yi-jun, XIANG Qian. Risk factors of bacterial infection in patients with decompensated cirrhosis and the value of early diagnosis by inflammatory indicators[J]. Chinese Hepatolgy, 2025, 30(8): 1066-1070.

/ 推荐

参考文献

[1] Maurice J, Pinzani M. The stratification of cirrhosis[J]. Hepatol Res, 2020,50(5):535-541.
[2] Trebicka J, Fernandez J, Papp M, et al. PREDICT STUDY group of the EASL-CLIF Consortium. The PREDICT study uncovers three clinical courses of acutely decompensated cirrhosis that have distinct pathophysiology[J]. J Hepatol, 2020,73(4):842-854.
[3] Schaapman J J, Amoros À, van der Reijden J J, et al. Genetic variants of innate immunity receptors are associated with mortality in cirrhotic patients with bacterial infection[J]. Liver Int, 2020,40(3):646-653.
[4] Labenz C, Kostev K, Galle P R, et al. Proton pump inhibitor use is associated with a variety of infections in patients with liver cirrhosis[J]. Medicine (Baltimore), 2020,99(50):e23436.
[5] 黄浩. C反应蛋白和降钙素原在肝硬化腹水自发性细菌性腹膜炎中的诊断价值[J]. 现代消化及介入诊疗,2019,24(1):65-68.
[6] Magalhães R S, Magalhães J, Sousa-Pinto B, et al. Neutrophil-to-lymphocyte ratio: an accurate method for diagnosing infection in cirrhosis[J]. Postgrad Med, 2021,133(6):613-618.
[7] 中华医学会肝病学分会. 肝硬化诊治指南[J]. 中华肝脏病杂志,2019,27(11):846-865.
[8] 中华医学会肝病学分会. 肝硬化腹水诊疗指南[J]. 中华肝脏病杂志,2023,31(8):813-826.
[9] 中华医学会, 中华医学会杂志社, 中华医学会全科医学分会, 等. 成人社区获得性肺炎基层诊疗指南(2018年)[J]. 中华全科医师杂志,2019,18(2):117-126.
[10] 中华医学会外科学分会胆道外科学组. 急性胆道系统感染的诊断和治疗指南(2021版)[J]. 中华外科杂志,2021,59(6):422-429.
[11] Piano S, Singh V, Caraceni P, et al. International Club of Ascites Global Study Group. Epidemiology and effects of bacterial infections in patients with cirrhosis worldwide[J]. Gastroenterology, 2019,156(5):1368-1380.e10.
[12] Bajaj J S, Kamath P S, Reddy K R. The evolving challenge of infections in cirrhosis[J]. N Engl J Med, 2021,384(24):2317-2330.
[13] Premkumar M, Devurgowda D, Dudha S, et al. A/H1N1/09 influenza is associated with high mortality in liver cirrhosis[J]. J Clin Exp Hepatol, 2019,9(2):162-170.
[14] 周晓颖, 王琳, 崔祖丽. 乙型肝炎肝硬化伴上消化道出血患者发生医院感染的相关因素多元回归分析[J]. 大连医科大学学报,2019,41(1):47-50.
[15] Ruf A, Dirchwolf M, Freeman R B. From Child-Pugh to MELD score and beyond: taking a walk down memory lane[J]. Ann Hepatol, 2022,27(1):100535.
[16] Bernsmeier C, Cavazza A, Fatourou E M, et al. Leucocyte ratios are biomarkers of mortality in patients with acute decompensation of cirrhosis and acute-on-chronic liver failure[J]. Aliment Pharmacol Ther,2020,52(5):855-865.
[17] 苏娟, 石岳飞, 张惠林. 肝硬化并肺部感染患者血清PCT、CRP、WBC的表达水平及临床意义[J]. 贵州医药,2022,46(1):29-30.
[18] Sato S, Sato S, Tsuzura H, et al. Elevated serum procalcitonin levels and their association with the prognosis of patients with liver cirrhosis[J]. Eur J Gastroenterol Hepatol,2020,32(9):1222-1228.