肝硬化失代偿期合并急性肾损伤的预后:基于ICA-AKI标准的前瞻性研究

摘要/Abstract

摘要： 目的探讨肝硬化失代偿期合并急性肾损伤(AKI)的发生率、影响因素及预后,使用ICA-AKI标准对肝硬化合并AKI的临床影响进行前瞻性评估,以指导治疗策略并改善患者预后。方法纳入2016年1月—2020年12月于常熟市第一人民医院就诊的217例肝硬化失代偿期患者。使用ICA-AKI标准,将患者分为AKI组(53例)和非AKI组(164例)。对患者进行至少一年的随访,评估其肾功能损害的严重程度以及与年龄和Child-Pugh分级的关系。生存率通过Kaplan-Meier法计算,并使用Log-rank检验对生存时间进行比较。使用Cox回归模型探究死亡风险的影响因素。结果本研究发现,在4年追踪期内,AKI组和非AKI组患者的住院次数均呈上升趋势,AKI组患者的平均住院费用明显高于非AKI组,并显示出下降趋势。从时间趋势来看,AKI组的住院死亡率自2018年的36.5%减少至2021年的12.1%,下降幅度显著;非AKI肝硬化患者的死亡率降幅较小,从6.3%减少至3.8%。年龄与AKI发生率正相关,20至40岁组、41至60岁组以及超过60岁组的发病率分别为7.8%、25.4%和44.4%,统计学分析显示差异显著(χ²=9.42,P<0.05)。此外,AKI组的Child-Pugh评分平均值(12.8)显著高于非AKI组(10.4),P值<0.001,暗示肝脏功能衰竭更为严重。在最长达49个月的随访中,AKI组的死亡率为18.9%,非AKI组的死亡率为5.5%,生存分析显示AKI组的中位总体生存时间较短(χ²=9.344,P<0.05)。肝硬化并发症(如自发性细菌性腹膜炎、肝性脑病、静脉曲张出血和腹水)患者若并发AKI,其死亡风险显著提高,调整后比值比(aOR)分别为5.77、5.49、7.95、5.62。特别地,在静脉曲张出血患者中,伴随AKI的死亡风险是未合并AKI的患者的7倍以上(aOR 7.89;95%CI 7.68~8.33)。结论肝硬化失代偿期患者并发AKI与年龄增长和肝功能进一步衰竭密切相关,且这些患者的生存时间较短,治疗成本较高。尽管AKI患者的死亡率有所降低,但并发症如自发性细菌性腹膜炎和静脉曲张出血等可显著增加死亡风险。

关键词: 肝硬化, 急性肾损伤, ICA-AKI标准, 预后, 生存分析

Abstract: Objective To assess the clinical utility of ICA-AKI diagnostic criteria in cirrhotic patients with acute kidney injury (AKI). Methods A cohort of 217 decompensated cirrhotic patients treated at the First People's Hospital of Changshu City from January 2018 to December 2021 was stratified into an AKI group (n=53) and a non-AKI group (n=164) based on ICA-AKI criteria. Renal injury was staged as 1, 2, and 3 with 32, 16, and 5 cases, respectively. The study compared renal insufficiency across various ages and Child-Pugh scores, with follow-up conducted through outpatient clinics and phone calls until December 2021. Survival rates were computed using the Kaplan-Meier method, with survival analysis performed via Log-rank test and Cox regression analysis employed to investigate mortality determinants in cirrhotic patients with AKI. Results Over four years, hospital admissions rose in both cohorts. The AKI group faced significantly greater average hospitalization expenses compared to the non-AKI group, with a declining trend in the costs of the AKI group over the same period. In contrast to rising morbidity, the hospital mortality rate in the AKI group decreased markedly from 36.5% in 2018 to 12.1% in 2021, whereas the mortality rate in cirrhotic patients without AKI experienced a minor decrease from 6.3% to 3.8%. The incidence of AKI among cirrhotic patients varied significantly with age (7.8% in the 20-40 age group, 25.4% in the 41-60 age group, and 44.4% in those over 60), with a significant statistical difference (χ²=9.42, P<0.05). The Child-Pugh score was notably higher in the AKI group (P<0.001). After the longest follow-up of 49 months, mortality was 18.9% in the AKI group compared to 5.5% in the non-AKI group. Median overall survival was significantly reduced in the AKI group. Notably, common complications such as spontaneous bacterial peritonitis (SBP), hepatic encephalopathy (HE), variceal hemorrhage (VH), ascites in cirrhosis substantially heightened the mortality risk when coinciding with AKI status,(adjusted odds ratios [aOR] of 5.77, 5.49, 7.95, 5.62, respectively). Specifically, the risk of death in VH patients with AKI was more than seven times higher than those without AKI after adjusting for age (aOR 7.89; 95% CI 7.68-8.33). Conclusion The incidence of AKI in hospitalized cirrhotic patients is notably high, and AKI significantly escalates both hospitalization costs and mortality. The implementation of ICA-AKI criteria for assessing renal injury in cirrhosis patients is of vital clinical significance.

Key words: Cirrhosis, Acute Kidney Injury, ICA-AKI Criteria, Prognosis, Survival Analysis

陈健, 王甘红, 周静洁, 刘罗杰, 徐晓丹. 肝硬化失代偿期合并急性肾损伤的预后:基于ICA-AKI标准的前瞻性研究[J]. 肝脏, 2025, 30(4): 500-504.

CHEN Jian, WANG Gan-Hong, ZHOU Jing-Jie, LIU Luo-Jie, XU Xiao-Dan. The prognosis of decompensated cirrhosis complicated by acute kidney injury: a prospective study based on the ICA-AKI criteria[J]. Chinese Hepatolgy, 2025, 30(4): 500-504.

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