重症酒精性肝炎患者临床特征及预后评估

摘要/Abstract

摘要： 目的回顾重症酒精性肝炎(SAH)患者临床资料,比较非SAH-慢加急性肝衰竭(ACLF)、SAH-ACLF患者临床特征、预后评分及短期预后,为SAH病情管理、预后评价及治疗策略制定提供依据。方法收集2009年1月至2021年10月SAH患者112例(男105例,女7例),年龄(49.6±9.4)岁。根据SAH患者是否存在慢加急性肝衰竭(ACLF)分为非SAH-ACLF、SAH-ACLF。比较非SAH-ACLF、SAH-ACLF患者临床特征、预后评分及28天、90天生存率。对偏态分布的计量资料以[M(P₂₅,P₇₅)]表示,采用Mann-Whitney U检验;对正态分布的计量资料以(±s)表示,采用独立t检验;计数资料以绝对数表示,采用卡方检验比较;生存率比较采用Log-Rank检验。结果非SAH-ACLF、SAH-ACLF患者分别为82例、30例。比较临床特征可知,非SAH-ACLF患者消化道出血、肝性脑病、感染及腹水为9例(11.0%)、8例(9.7%)、19例(23.2%)及27例(32.9%),与SAH-ACLF[8例(26.7%)、16例(53.3%)、17例(56.7%)及20例(66.7%)]比,差异具有统计学意义(χ²=-4.200,-24.733,-11.299,-10.267,P<0.05);非SAH-ACLF患者白细胞(WBC)、总胆红素(TBil)、直接胆红素(DBil)、尿素氮(BUN)及肌酐(Scr)为7.0(4.6,10.8)×10⁹/L、140.6(98.4,302.8)μmol/L、82.0(44.4,172.5)μmol/L、4.8(3.1,6.5)mmol/L及58.4(52.0,76.5)μmol/L,与SAH-ACLF[9.4(6.5,14.5)×10⁹/L、242.8(186.0,412.6)μmol/L、162.5(90.2,231.8)μmol/L、9.2(4.0,15.4)mmol/L及91.4(65.4,220.6)μmol/L]比,差异具有统计学意义(Z=-3.914,-10.126,-11.020,-10.104,-8.002,P<0.05);非SAH-ACLF患者凝血酶原时间(PT)、国际标准化比值(INR)为20.2(19.0,23.6)s、1.6(1.5,2.0),与SAH-ACLF[26.5(21.5,32.2)s、2.2(1.8,2.8)]比,差异具有统计学意义(Z=-3.802,-3.914,P<0.05)。非SAH-ACLF患者MDF评分、MELD评分、ABIC评分、CLIF-SOFA评分、CLIF-C OFs及CLIF-C ACLF评分为52.0(41.5,68.4)分、11.2(9.0,14.2)分、7.4(6.0,9.0)分、4.0(3.0,5.0)分、8.0(7.0,9.0)分及35.4(30.2,42.5)分,与SAH-ACLF[82.0(56.2,108.0)分、20.8(15.5,25.4)分、8.8(7.5,10.6)分、6.0(5.0,8.0)分、10.0(9.0,11.0)分及48.0(40.0,52.1)分]比,差异具有统计学意义(Z=2.664,6.508,2.251,2.610,2.412,5.268,P<0.05)。非SAH-ACLF、SAH-ACLF患者28天生存率为95.1%(78/82)、70.0%(21/30),差异具有统计学意义(χ²=11.511,P<0.05);非SAH-ACLF、SAH-ACLF患者90天生存率为84.1%(69/82)、46.7%(14/30),差异具有统计学意义(χ²=16.079,P<0.05)。结论与未并发ACLF的SAH患者相比较,并发ACLF后无论是并发症、血生化指标,还是各项预后评分均显著差于前者,同时短期预后也明显不理想,需要在临床实践中着重关注。

关键词: 重症酒精性肝炎, 慢加急性肝衰竭, Maddrey判别函数评分, 慢性肝衰竭-序贯器官衰竭评分

Abstract: Objective To review the clinical data of severe alcoholic hepatitis (SAH) patients, and compare the clinical features, prognosis scores and short-term prognosis of non-SAH- acute-on-chronic liver failure (ACLF) and SAH-ACLF patients, so as to provide basis for SAH disease management, prognosis evaluation and treatment strategy formulation. Methods From January 2009 to October 2021, 112 patients with SAH [105 males and 7 females, aged (49.6±9.4) years] were collected. Patients with SAH were divided into non-SAH-ACLF group and SAH-ACLF group according to whether there was ACLF. We compared the clinical features, prognosis scores and 28-day and 90-day survival rates between patients in two groups. The measurement data of skewness distribution was expressed as [M (P₂₅, P₇₅)], and Mann-Whitney U test was adopted. The measurement data of normal distribution was expressed as (±s), and independent t test was adopted. Counting data were expressed as absolute numbers, which were compared by Chi-square test. The survival rate was compared by Log-Rank test. Results There were 82 and 30 patients without SAH-ACLF and with SAH-ACLF, respectively. According to the clinical characteristics, 9 cases (11.0%), 8 cases (9.7%), 19 cases (23.2%) and 27 cases (32.9%) of gastrointestinal bleeding, hepatic encephalopathy, infection and ascites in non-SAH-ACLF group, which were compared with SAH-ACLF group [8 cases (26.7%), 16 cases (53.3%), 17 cases (56.7%) and 20 cases (66.7%)], with statistical significance (χ²=-4.200, -24.733, -11.299, -10.267, P<0.05). White blood cells (WBC), total bilirubin (TBil), direct bilirubin (DBil), urea nitrogen (BUN) and creatinine (Scr) in patients without SAH-ACLF were 7.0 (4.6, 10.8) × 10⁹/L, 140.6 (98.4, 302.8) μmol/L, 82.0 (44.4, 172.5) μmol/L, 4.8 (3.1, 6.5) mmol/L and 58.4 (52.0, 76.5) μmol/L, compared with those in SAH-ACLF group [9.4 (6.5, 14.5) × 10⁹/L, 242.8 (186.0, 412.6) μmol/L, 162.5 (92.5, 231.8) μmol/L, 9.2 (4.0, 15.4) mmol/L and 91.4 (65.4, 220.6) μmol/L, with statistical significance (Z=-3.914, -10.126, -11.020, -10.104, -8.002, P<0.05). The prothrombin time (PT) and international normalized ratio (INR) of non-SAH-ACLF group were 20.2 (19.0, 23.6) s and 1.6 (1.5, 2.0), which were significantly higher than those of SAH-ACLF group [26.5 (21.5, 32.2) s and 2.2 (1.8, 2.0), Z=-3.802, -3.914, P<0.05]. The Maddrey discriminant function (MDF) score, model for end-stage liver disease (MELD) score, Age-bilirubin-INR-creatinine (ABIC) score, chronic liver failure-sequential organ failure (CLIF-SOFA) score, chronic liver failure-Consortium Organ Failure score (CLIF-C OFs) and CLIF-C ACLF score of non-SAH-ACLF patients were 52.0 (41.5, 68.4) points, 11.2 (9.0, 14.2) points, 7.4 (6.0, 9.0) points, (7.4. 9.0) points, 4.0 (3.0, 5.0) points, 8.0 (7.0, 9.0) points and 35.4 (30.2, 42.5) points, compared with those in SAH-ACLF group [82.0 (56.2, 108.0) points, 20.8 (15.5, 25.4) points, 8.8 (7.5, 10.6) points, 6.0 (5.0, 8.0) points, 10.0 (9.0, 11.0) points and 48.0 (40.0, 52.1) points], with statistical significance (Z=2.664, 6.508, 2.251, 2.610, 2.412, 5.268, P<0.05). The 28-day survival rates of non-SAH-ACLF and SAH-ACLF patients were 95.1% (78/82) and 70.0% (21/30), with statistical significance (χ²=11.511, P<0.05). The 90-day survival rates of non-SAH-ACLF and SAH-ACLF patients were 84.1% (69/82) and 46.7% (14/30), with statistical significance (χ²=16.079, P<0.05). Conclusion Compared with SAH patients without ACLF, complications, blood biochemical indexes and prognosis scores after ACLF are significantly worse than the former, and the short-term prognosis is obviously unsatisfactory, which needs to be paid attention to in clinical practice.

Key words: Severe alcoholic hepatitis, Acute-on-chronic liver failure, Maddrey discriminant function score, Chronic liver failure-sequential organ failure score

李向阳, 唐泉淼, 王雷. 重症酒精性肝炎患者临床特征及预后评估[J]. 肝脏, 2022, 27(5): 584-587.

LI Xiang-yang, TANG Quan-miao, WANG Lei. Clinical characteristics and prognosis of patients with severe alcoholic hepatitis[J]. Chinese Hepatolgy, 2022, 27(5): 584-587.

参考文献

[1] Dasarathy S. Nutrition and alcoholic liver disease: effects of alcoholism on nutrition, effects of nutrition on alcoholic liver disease, and nutritional therapies for alcoholic liver disease. Clin Liver Dis, 2016, 20(3):535-550.
[2] Kovalic AJ, Cholankeril G, Satapathy SK. Nonalcoholic fatty liver disease and alcoholic liver disease: metabolic diseases with systemic manifestations. Transl Gastroenterol Hepatol, 2019, 4:65.
[3] Matsuoka L, Izzy M, Feurer ID, et al. Sex and gender disparities in pretransplant characteristics and relationships with postoperative outcomes in liver transplant recipients with alcoholic liver disease. Exp Clin Transplant, 2020, 18(6):701-706.
[4] Mou HY, Nie HM, Hu XY. Gutuo Jiejiu decoction improves survival of patients with severe alcoholic hepatitis: A retrospective cohort study. World J Gastroenterol, 2017, 23(16):2957-2963.
[5] Chen H, Shen F, Sherban A, et al. DEP domain-containing mTOR-interacting protein suppresses lipogenesis and ameliorates hepatic steatosis and acute-on-chronic liver injury in alcoholic liver disease. Hepatology, 2018, 68(2):496-514.
[6] Gholam PM. Prognosis and prognostic scoring models for alcoholic liver disease and acute alcoholic hepatitis. Clin Liver Dis, 2016, 20(3):491-497.
[7] Louvet A, Thursz MR, Kim DJ, et al. Corticosteroids reduce risk of death within 28 days for patients with severe alcoholic hepatitis, compared with pentoxifylline or placebo-a meta-analysis of individual data from controlled trials. Gastroenterology, 2018, 155(2):458-468.e8.
[8] Sersté T, Cornillie A, Njimi H, et al. The prognostic value of acute-onchronic liver failure during the course of severe alcoholic hepatitis. J Hepatol, 2018, 69(2):318-324.
[9] Maras JS, Das S, Bhat A, et al. Dysregulated lipid transport proteins correlate with pathogenesis and outcome in severe alcoholic hepatitis. Hepatol Commun, 2019, 3(12):1598-1625.
[10] Louvet A, Labreuche J, Artru F, et al. Main drivers of outcome differ between short term and long term in severe alcoholic hepatitis: a prospective study. Hepatology, 2017, 66:1464-1473.
[11] 中华医学会肝病学分会脂肪肝和酒精性肝病学组, 中国医师协会脂肪性肝病专家委员会. 酒精性肝病防治指南(2018更新版), 2018, 26(3): 188-194.
[12] 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). 实用肝脏病杂志, 2019, 22(2): 164-171.
[13] Vergis N, Atkinson SR, Knapp S, et al. In patients with severe alcoholic hepatitis, prednisolone increases susceptibility to infection and infectionRelated mortality, and is associated with high circulating levels of bacterial DNA. Gastroenterology, 2017, 152:1068-1077.
[14] Sundaram V, Jalan R, Wu T, et al. Factors associated with survival of patients with severe acute-on-chronic liver failure before and after liver transplantation. Gastroenterology, 2019, 156(5):1381-1391. e3.
[15] Artru F, Louvet A, Ruiz I, et al. Liver transplantation in the most severely ill cirrhotic patients: A multicenter study in acute-on-chronic liver failure grade 3. J Hepatol, 2017, 67(4):708-715.
[16] Zhang QK, Wang ML. Value of model for end stage liver disease-serum odium scores in predicting complication severity grades after liver transplantation for acute-on-chronic liver failure. Transplant Proc, 2019, 51(3):833-841.
[17] Shalimar, Kedia S, Mahapatra SJ, et al. Severity and outcome of acuteon-chronic liver failure is dependent on the etiology of acute hepatic insults: analysis of 368 patients. J Clin Gastroenterol, 2017,51(8):734-741.
[18] Sonika U, Jadaun S, Ranjan G, et al. Alcohol-related acute-on-chronic liver failure-comparison of various prognostic scores in predicting outcome. Indian J Gastroenterol, 2018, 37(1):50-57.