肝硬化急性肾损伤发病风险和治疗应答影响因素的前瞻性研究

摘要/Abstract

摘要： 目的基于肝硬化急性肾损伤新诊断标准前瞻性的观察患者的发病风险和疗效,明确危险因素。方法采用前瞻性、观察性、开放性的方法,对住院的肝硬化(失代偿期)患者进行观察,一旦发生AKI,根据ICA-AKI新指南进行诊断和治疗,收集患者治疗期间的数据,评估治疗应答情况,通过logistic回归分析肝硬化AKI的危险因素以及疗效的影响因素。结果共纳入肝硬化(失代偿期)患者804例,住院期间并发AKI或入院时即存在AKI的患者为213例(26.5%),其中AKI 1期、2期和3期的患者分别占68.1%(145/213)、25.3%(54/213)和6.6%(14/213)。2015年的HRS标准提高了诊断的敏感性,20.9%(14/67)的患者按2007年标准会漏诊。多因素分析显示年龄(P=0.004)、MELD评分(P<0.01)、感染(P<0.01)以及上消化道出血(P<0.01)是肝硬化(失代偿期)患者并发急性肾损伤的主要影响因素。根据AKI分期个体化治疗后,213例肝硬化AKI患者中86.9%(185/213)有应答。多因素分析显示仅有初次AKI分期是肝硬化患者急性肾损伤治疗应答的主要影响因素(P<0.01),随着初次AKI分期的上升,治疗应答的比例下降,AKI1期、2期和3期的治疗应答比例分别为:94.5%(137/145)、70.4%(38/54)和28.6%(4/14)。结论 ICA更新的肝硬化急性肾损伤诊断和管理流程提升了诊断的敏感度和治疗应答的比例,使以往忽略的部分患者得到了及时的处理,按新指南治疗,可以达到较高治疗应答率,但需要在较低的AKI分期就介入干预。

关键词: 急性肾损伤, 肝硬化,治疗应答, 前瞻性研究, 影响因素

Abstract: Objective To prospectively observe the risk of morbidity and the therapeutic effect of acute kidney injury in patients with cirrhosis based on 2015 International Ascites Club (IAC) diagnostic criteria. Methods A prospective, observational and open method was used to observe the hospitalized patients with decompensated cirrhosis. Once acute kidney injury (AKI) occurred, the patients were diagnosed and treated according to the new ICA-AKI guideline. Data were collected during the treatment period to evaluate the therapeutic response. The risk factors for AKI complication and the influencing factors for the treatment were analyzed by logistic regression. Results A total of 804 patients with decompensated cirrhosis were included in the study. 213 patients(26.5%, 213/804) were complicated with AKI during hospitalization or had AKI at admission, of which 68.1%(145/213)、25.3%(54/213)and 6.6%(14/213)were AKI stage 1, 2 and 3, respectively. The 2015 dagnostic criteria of HRS was shown to improve the diagnostic sensitivity. A missed diagnosis rate of 20.9%(14/67)were found in these patients if using the 2007 standard. Multivariate analysis showed that age, MELD score (P=0.004), infection(P=0.000) and upper gastrointestinal bleeding (P=0.000)were the main risk factors of AKI in decompensated cirrhotic patients. After personalized treatment according to AKI stage, 86.9% (185/213) of the patients with AKI were improved. Multivariate analysis showed that only the preliminary stage of AKI was the main factor affecting the prognosis of the AKI patients (P=0.000). If the initial AKI stage increased, the proportion of responsive treatment decreased. The treatment responsive rate in AKI stages 1, 2 and 3 were 94.5% (137/145), 70.4% (38/54) and 28.6% (4/14), respectively. Conclusion The updated diagnostic and management procedure by ICA improves the diagnostic sensitivity and treatment responsive rate of AKI in decompensated cirrhotic patients, This enables some previously neglected patients to be treated timely. By using the new guideline a higher responsive rate can be achieved but the intervention is required to initiate at a lower AKI stage.

Key words: Acute kidney injury, Liver cirrhosis, Treatment response, Prospective study, Influencing factors

尹伟, 李成忠. 肝硬化急性肾损伤发病风险和治疗应答影响因素的前瞻性研究[J]. 肝脏, 2020, 25(8): 791-796.

YIN Wei, LI Cheng-zhong. Prospective study on the risk factors and the treatment response of acute renal injury in liver cirrhotic patients[J]. Chinese Hepatolgy, 2020, 25(8): 791-796.

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