Establishment and evaluation of a predictive model for short-time prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure
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摘要: 目的探讨HBV相关慢加急性肝衰竭(HBV-ACLF)患者短期(12周)生存预后的预测因素,建立新型预测模型。方法收集2015年4月-2018年8月在安徽医科大学附属省立医院确诊HBV-ACLF的67例患者的临床资料,根据确诊后12周随访生存情况分为生存组(n=28)和死亡组(n=39)。收集患者临床资料,包括性别、年龄、TBil、国际标准化比值(INR)、肌酐(Cr)、血清钠、PLT、ALT、AST、Alb、血清胱抑素C(CysC),是否有急性肾损伤(AKI)。正态分布的计量资料2组间比较采用t检验,偏态分布的计量资料2组间比较采用Wilcoxon秩和检验;计数资料组间比较采用χ2检验;影响HBV-ACLF患者预后因素采用多因素logistic回归法并建立预测模型;采用受试者工作特征曲线(ROC曲线)评价预测模型,ROC曲线下面积(AUC)的比较采用DeLong法。结果死亡组患者的年龄、TBil、INR、CysC、MELD评分均高于生存组,合并AKI患者的近期生存率明显低于无AKI者(P值均<0. 05)。TBil[比值比(OR)=1. 013,95%可信区间(95%CI):1....Abstract: Objective To investigate the predictive factors for short-term(12-week) survival and prognosis of patients with hepatitis B virus(HBV)-related acute-on-chronic liver failure(HBV-ACLF),and to establish a new predictive model. Methods Related clinical data were collected from 67 patients who were diagnosed with HBV-ACLF in The Affiliated Provincial Hospital of Anhui Medical University from April 2015 to August 2018,and according to their survival at 12-week follow-up after diagnosis,they were divided into survival group with 28 patients and death group with 39 patients. Their clinical data were collected,including sex,age,total bilirubin(TBil),international normalized ratio(INR),creatinine(Cr),serum sodium,platelet count(PLT),alanine aminotransferase(ALT),aspartate aminotransferase(AST),albumin(Alb),serum cystatin C(CysC),and presence or absence of acute kidney injury(AKI). The t-test was used for comparison of normally distributed continuous data between two groups,and the Wilcoxon rank-sum test was used for comparison of continuous data with skewed distribution between two groups; the chi-square test was used for comparison of categorical data between groups; logistic regression was used to perform the factorial analysis and establish a predictive model; the receiver operator characteristic(ROC) curve was used to evaluate the predictive model,and the method by DeLong et al. was used to compare the area under the ROC curve(AUC). Results The death group had significantly higher age,TBil,INR,CysC,and Model for End-Stage Liver Disease(MELD) score than the survival group,and the patients with AKI had a significantly lower short-term survival rate than those without AKI(all P < 0. 05). TBil(odds ratio [OR]= 1. 013,95% confidence interval [CI]: 1. 003-1. 024,P = 0. 014),INR(OR = 6. 857,95%CI: 1. 449-32. 449,P = 0. 015),CysC(OR = 2. 826,95% CI: 1. 001-7. 983,P = 0. 050),and PLT(OR = 0. 982,95% CI: 0. 964-1. 000,P = 0. 048) were independent predictive factors for patient survival. A TICP model was established with the combination of TBil,INR,CysC,and PLT,and there was a significant difference in AUC between the TICP model and MELD score[0. 879(95% CI: 0. 776-0. 946) vs 0. 760(95% CI: 0. 644-0. 859),Z = 2. 708,P = 0. 007]. Compared with MELD score,the TICP model had significantly better accuracy(87. 05% vs 67. 16%),sensitivity(84. 62% vs 56. 41%),and Youden index(0. 70 vs 0. 42). Conclusion TBil,INR,CysC,and PLT are independent influencing factors for short-term prognosis of HBV-ACLF patients,and the TICP predictive model with the combination of these four indices has a good value in predicting the short-term survival and prognosis of HBV-ACLF patients.
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Key words:
- acute-on-chronic liver failure /
- hepatitis B virus /
- acute kidney injury /
- prognosis
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门静脉高压是失代偿期肝硬化患者的主要临床表现之一,其导致的食管胃静脉曲张破裂出血、肝性脑病、顽固性腹水等并发症是患者死亡的重要原因[1]。大量研究表明肝静脉压力梯度(hepatic venous pressure gradient, HVPG)可反映门静脉高压的严重程度。2021年Baveno Ⅶ国际共识[2]推荐,对于病毒性肝炎相关肝硬化和酒精性肝硬化患者,HVPG值为诊断门静脉高压的金标准。Baveno Ⅶ国际共识[2]和美国肝病学会2016版指导意见[3]均明确指出和强调了HVPG对门静脉高压危险分层的作用和预后预测价值,HVPG≥20 mmHg提示肝硬化静脉曲张出血患者的止血治疗失败率和死亡风险升高[4]。然而,HVPG测定是一项有创性操作,且对操作者技术水平和医疗设备有一定要求,并在测定过程中可能引起一过性的心律失常和迷走神经反应等不良反应,这些不足在很大程度上限制了HVPG的临床应用和推广。
近年来,非侵入性测量肝组织弹性的方法得到了发展。许多研究[5-7]已证实肝炎患者和肝硬化代偿期患者的肝脏硬度(liver stiffnes, LS)与HVPG相关,但对于肝硬化失代偿期患者仍欠缺研究,LS对肝硬化食管胃静脉曲张破裂出血二级预防的患者预测能力尚不明确。此外,以往的大多数研究使用瞬时弹性成像(transient elastography, TE)来评估LS,少有研究探讨声脉冲辐射力成像技术(acoustic radiation force impulse, ARFI)检测的LS值的预测作用。因此,通过ARFI测量门静脉高压患者LS和脾脏硬度(spleen stiffness, SS),验证LS、SS与HVPG的相关性,在临床上具有重要意义。
1. 资料与方法
1.1 研究对象
选取2013年4月—2021年6月在南京鼓楼医院消化内科同时接受HVPG测定及ARFI测量LS、SS的病毒性或酒精性失代偿期肝硬化患者。
1.2 纳入标准
(1) 确诊病毒性肝炎相关肝硬化或酒精性肝硬化失代偿期;既往食管胃底静脉曲张破裂出血病史。(2)年龄18~75岁。(3)在本院行经颈静脉HVPG测定,并于术前3 d内行ARFI测定LS、SS。术前3 d检验血常规、凝血功能、肝功能、肾功能,腹部彩超评估肝右叶斜径、脾肋间直径、门静脉血流速度(portal vein flow rate, PVF)、脾静脉直径(splenic vein diameter, SVD),术前或术后1周内的内镜评估食管胃底静脉曲张程度。
1.3 排除标准
(1) 合并肝癌或肝外肿瘤;(2)严重的心、肺、肝、肾功能不全,或严重出血性疾病或局部、全身感染、甲状腺功能低下、雷诺综合征、周围血管疾病等;(3)脾脏切除患者;(4)严重门静脉血栓患者;(5)计划怀孕或已怀孕或哺乳的妇女。
1.4 观察指标
根据既往研究[1],HVPG≥20 mmHg提示早期再出血及高治疗失败率,故在本研究中,根据术中测定的HVPG值,将纳入患者分为严重门静脉高压组(SPH组,HVPG≥20 mmHg)和非严重门静脉高压组(非SPH组,HVPG<20 mmHg)。收集纳入患者的临床资料,包括性别、年龄、既往史、HVPG值、LS、SS、血常规、凝血功能、肝功能、肾功能,腹部彩超评估肝右叶斜径、脾肋间直径、SVD、PVF、内镜下静脉曲张程度等指标。
1.5 统计学方法
应用SPSS 22.0软件进行统计分析。符合正态分布的计量资料以x ±s表示,2组间比较采用t检验;不符合正态分布的计量资料以M(P25~P75)表示,2组间比较采用Mann-Whitney U秩和检验。计数资料2组间比较采用χ2检验。相关性分析采用Pearson检验。用Pearson r系数评估不同无创检测指标与HVPG的相关性强度。若r<0.3,提示弱强度相关;若0.3≤r≤0.5,提示中等强度相关;若r>0.5,说明高强度相关。采用Logistic回归分析不同无创检测指标与SPH发生风险之间的关系。绘制不同无创指标预测HVPG≥20 mmHg发生的受试者工作特征曲线(ROC曲线)并计算曲线下面积(AUC)、敏感度、特异度、最大约登指数及对应的临界值,以评估各指标对SPH的预测价值。P<0.05为差异有统计学意义。
2. 结果
2.1 基线资料比较
共纳入符合条件的受试者88例,其中SPH组24例,非SPH组64例。两组患者的年龄、性别、白细胞计数、血红蛋白、血小板计数、凝血酶原时间、谷丙转氨酶、谷草转氨酶、白蛋白、血钠、血肌酐、Child-Pugh肝功能分级等比较,差异均无统计学意义(P值均>0.05)(表 1)。
表 1 受试者基线资料Table 1. Baseline of the patients included指标 所有患者(n=88) 非SPH组(n=64) SPH组(n=24) 统计值 P值 男/女(例) 65/23 48/16 17/7 χ2=0.157 0.79 年龄(岁) 53.93±11.39 54.35±12.08 53.54±9.68 t=0.132 0.90 病因(病毒性/酒精性,例) 76/12 56/8 20/4 χ2=0.257 0.73 肝右叶斜径(cm) 12.20±1.48 12.56±1.28 12.57±1.66 t=-1.245 0.22 内镜下静脉曲张程度(轻/中/重,例) 4/19/65 3/14/47 1/5/18 χ2=0.025 0.99 白细胞计数(×109/L) 2.25(1.70~3.30) 1.90(1.55~3.30) 2.50(2.05~3.20) Z=-1.918 0.06 血红蛋白(g/L) 86.64±26.66 82.35±25.97 86.64±26.66 t=0.124 0.90 血小板计数(×109/L) 59.49±33.65 60.10±28.95 57.35±30.83 t=0.367 0.72 凝血酶原时间(s) 14.89±2.74 14.35±1.64 15.90±3.10 t=-1.772 0.08 国际标准化比值 1.31±0.20 1.25±0.15 1.39±0.26 t=-1.525 0.07 谷丙转氨酶(U/L) 22.75(16.40~29.40) 24.75(15.90~29.00) 18.75(15.85~29.40) Z=-0.932 0.35 谷草转氨酶(U/L) 26.75(21.25~35.55) 26.80(22.35~36.25) 23.15(20.10~31.50) Z=-1.466 0.14 总胆红素(μmol/L) 16.90(11.00~22.35) 15.85(10.10~20.10) 18.70(13.10~31.70) Z=-1.743 0.08 白蛋白(g/L) 35.43±4.77 36.43±4.45 33.96±5.31 t=1.155 0.25 血肌酐(μmol/L) 67.14±19.23 64.15±14.74 64.29±21.46 t=0.787 0.43 血钠(mmol/L) 141.20±2.60 141.16±3.13 141.23±2.84 t=-0.137 0.89 腹水(有/无,例) 30/58 25/39 5/19 χ2=2.581 0.13 Child-Pugh评分 6.85±1.32 6.40±1.05 7.25±1.29 t=-1.982 0.05 Child-Pugh分级(A/B/C,例) 37/48/3 31/32/1 6/16/2 χ2=5.517 0.06 2.2 不同无创测定指标与HVPG的相关性分析
相关分析结果显示HVPG与LS呈中等强度正相关(r=0.458,P<0.001);而SS(r=0.117,P=0.300)、PVF(r=0.010,P=0.940)、SVD(r=-0.090,P=0.420)与HVPG不相关。
2.3 SPH组和非SPH组不同无创测定指标的比较
结果显示,两组间LS比较差异有统计学意义(P<0.05),而SS、PVF、SVD两组间比较,差异均无统计学意义(P值均>0.05)(表 2)。
表 2 SPH组和非SPH组不同无创测定指标的比较Table 2. The comparison of different noninvasive indexes between SPH group and non-SPH group指标 所有患者(n=88) 非SPH组(n=64) SPH组(n=24) t值 P值 LS(m/s) 2.00±0.43 1.88±0.34 2.33±0.50 -3.970 <0.01 SS(m/s) 3.48±0.53 3.46±0.56 3.54±0.46 -0.612 0.54 PVF(m/s) 27.56±9.53 27.65±9.59 27.33±9.58 0.139 0.89 SVD(cm) 1.19±0.30 1.18±0.30 1.22±0.30 -0.430 0.67 2.4 SPH发生风险的Logistic回归分析
将LS、SS、PVF、SVD根据中位数水平转化为二分类变量,采用Logistic回归分析不同LS、SS、PVF、SVD、肝功能(Child-Pugh分级)水平下SPH的发生风险。结果显示,以低LS组为参考,在调整各危险因素后,高LS组SPH发生风险为低LS组的3.941倍(95%CI:1.245~12.476,P=0.020)(表 3)。
表 3 SPH发生风险的Logistic回归分析Table 3. Logistic regression analysis of SPH risk无创指标 OR 95%CI P值 LS 3.941 1.245~12.476 0.020 SS 0.840 0.281~2.507 0.754 PVF 0.542 0.192~1.527 0.246 SVD 1.452 0.497~4.241 0.496 Child-Pugh分级 B级 0.184 0.011~3.192 0.245 C级 0.402 0.027~5.948 0.507 注:LS≤1.925 m/s赋值为0,LS>1.925 m/s赋值为1;SS≤3.50 m/s赋值为0,SS>3.50 m/s赋值为1;PVF≤25.85 m/s赋值为0,PVF>25.85 m/s赋值为1;SVD≤1.12 cm赋值为0,SVD>1.12 cm赋值为1;Child-Pugh分级以Child-Pugh A级为参考。 2.5 不同无创指标预测SPH的ROC曲线
绘制不同无创指标预测SPH的ROC曲线(图 1)。其中LS预测SPH发生的AUC为0.751,最佳临界值为2.295 m/s,敏感度为54.17%,特异度为90.63%。
3. 讨论
由于失代偿期肝硬化患者存在显著的高死亡风险,因此精确评估、风险分层、个体化干预显得尤为重要[8]。对于失代偿期肝硬化患者,基于HVPG的风险分层进行个体化干预治疗在Baveno Ⅶ共识[2]中被推荐,即HVPG≥20 mmHg可考虑早期经颈静脉肝内门体分流术,而对于低危患者首选非选择性β受体阻滞剂联合内镜治疗进行二级预防。然而,HVPG检查属于有创操作,有一定技术难度,且患者接纳程度相对较低。因此,对无创指标的预测诊断模型的探索非常必要。近年来国内外学者在门静脉高压的预测诊断模型研究方面进行了诸多探索,其中比较有代表性的包括门静脉影像学模型、血流动力学评分模型等,但多数仍处于研究阶段且缺乏外部验证,不能广泛应用于临床[9]。
近几年来,随着超声技术的发展,LS和SS主要测量方式包括TE、实时弹性成像、ARFI。许多研究表明,LS和SS可能是评估肝硬化失代偿期风险的潜在的无创指标[2, 10]。既往研究[11]表明原发性硬化性胆管炎患者随着时间推演肝纤维化的程度增加,LS逐渐增加,且LS与发生并发症的风险呈正相关。既往一项国外Meta分析[12]发现:TE测得的LS在诊断临床显著门静脉高压方面具有出色的诊断性能,AUC为0.93;TE测得的LS诊断食管静脉曲张的AUC为0.84。Baveno Ⅶ共识[2]提出,应用TE检测LS可能有助于对门静脉高压患者的门静脉压力进行评估。与此同时,既往有大样本临床研究[13-14]得出结论:结合LS、血小板计数和脾脏直径的评分(即LSPS评分,TE测得LS×脾肋间直径/外周血血小板计数)在门静脉高压的诊断中也具有较高的预测价值;国内研究[15]表明肝脾硬度联合血清学检测对重度食管胃底静脉曲张具有较好的预判价值。
目前TE已被广泛用于LS和SS的评估,但TE在技术上存在局限性,其在大量腹水、肥胖、肋间隙狭窄的患者中应用受限。欧洲超声医学与生物学联合会(EFUSUMB)指南[16]提出,TE不能用于肝周腹水患者。而失代偿期肝硬化患者多发生腹水,因此,尽管TE在代偿性肝硬化患者中表现良好,但在失代偿期肝硬化患者中存在不确定性。
ARFI是一种新兴的、以超声为基础的无创评估组织弹性的方法。其检测原理为利用调制的聚焦超声波束向指定区域发射短程、低频的声脉冲波,使受检组织产生微小形变,通过追踪感兴趣区域内产生的横向剪切波的传播速度,从而将组织弹性转化为一个简单的速度值。组织的硬度越大,相应剪切波的速度值也越大[17]。ARFI目前是一种具有良好应用前景的无创、快速、简单、客观、易重复的检测肝脏纤维化程度的手段。可在测量组织弹性的同时进行常规B超检査,无需更换仪器,较TE更为方便。同时,ARFI受到腹水及肝脏脂质沉积等影响较小。既往研究[18]表明,通过ARFI测得的LS在诊断显著纤维化或肝硬化方面具有与TE相似的准确性,并且不需要单独的设备,亦不易受肝周腹水的影响。在失代偿期肝硬化患者中与TE相比具有一定的优势,几乎可以在每一例患者中清晰地显示解剖结构和进行成功的测量[17]。
既往本课题组小样本研究[19]表明,在不区分病因的情况下,提示ARFI测得的LS与HVPG呈中等强度相关(r=0.449,P<0.05)。Baveno Ⅶ共识[2]中提出HVPG是反映病毒性肝炎相关失代偿期肝硬化或失代偿期酒精性肝硬化合并门静脉高压患者门静脉压力的金标准。因此本研究纳入人群为乙型肝炎肝硬化失代偿期或酒精性肝硬化失代偿期合并门静脉高压患者。本研究评估了LS对病毒性肝炎相关肝硬化失代偿期和酒精性肝硬化失代偿期合并门静脉高压患者的诊断价值,并将其与门静脉压力值金标准HVPG进行比较。根据Pearson相关分析、Logistic回归分析及ROC曲线结果分析后认为,在临床较为常用的评估门静脉压力的无创指标中,LS对评估肝硬化型门静脉高压患者的门静脉压力具有较好的预测价值。但本研究也存在一定的不足之处,如本研究为回顾性研究,样本量较小且为单中心研究,LS临床诊断价值未来仍需多中心、大样本量的前瞻性研究进一步证实。
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[1] Liver Failure and Artificial Liver Group,Chinese Society of Infectious Diseases,CMA; Severe Liver Disease and Artificial Liver Group,Chinese Society of Hepatology,CMA. Guideline for diagnosis and treatment of liver failure[J]. J Clin Hepatol,2019,35(1):38-44.(in Chinese)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)[J].临床肝胆病杂志,2019,35(1):38-44. [2] ZHOU ZJ,LI JQ,BIN YY,et al. Effect of donor risk index on early prognosis of liver transplantation for acute-on-chronic liver failure:Experience of 159 cases in one single center[J].Ogran Transplantation,2019,10(3):318-322.(in Chinese)周政俊,李杰群,宾阳阳,等.供体风险指数对慢加急性肝衰竭肝移植治疗早期预后的影响:单中心159例经验[J].器官移植,2019,10(3):318-322. [3] Chinese Society of Hepatology and Chinese Society of Infectious Diseases,Chinese Medical Association. The guideline of prevention and treatment for chronic hepatitis B:A 2015 update[J]. J Clin Hepatol,2015,31(12):1941-1960.(in Chinese)中华医学会肝病学分会,中华医学会感染病学分会.慢性乙型肝炎防治指南(2015年更新版)[J].临床肝胆病杂志,2015,31(12):1941-1960. [4] ANGELI P,GINES P,WONG F,et al. Diagnosis and management of acute kidney injury in patients with cirrhosis:Revised consensus recommendations of the International Club of Ascites[J]. Gut,2015,64(4):531-537. [5] KAMATH PS,KIM WR. The model for end-stage liver disease(MELD)[J]. Hepatology,2007,45(3):797-805. [6] DING R,ZHAO H,YAN J,et al. Defination and treatment progress of acute-on-chronic liver failure[J/CD]. Chin J Liver Dis(Electronic Version),2018,10(1):1-5.(in Chinese)丁蕊,赵红,闫杰,等.慢加急性肝衰竭的定义及治疗进展[J/CD].中国肝脏病杂志(电子版),2018,10(1):1-5. [7] WONG F,O’LEARY JG,REDDY KR,et al. New consensus definition of acute kidney injury accurately predicts 30-day mortality in patients with cirrhosis and infection[J]. Gastroenterology,2013,145(6):1280-1288. [8] WU ZP,ZHONG YB,LI XP,et al. The analysis of acute kidney injury in hepatitis B virus related acute-on-chronic liver failure[J]. Chin J Infect Dis,2016,34(12):714-716.(in Chinese)吴振平,钟渊斌,李小鹏,等.乙型肝炎病毒相关慢加急性(亚急性)肝功能衰竭患者中急性肾损伤的分析[J].中华传染病杂志,2016,34(12):714-716. [9] SARIN SK,KUMAR A,ALMEIDA JA,et al. Acute-on-chronic liver failure:Consensus recommendations of the Asian Pacific Association for the study of the liver(APASL)[J]. Hepatol Int,2009,3(1):269-282. [10] MOREAU R,JALAN R,GINES P,et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis[J]. Gastroenterology,2013,144(7):1426-1437. [11] ZHANG LF,WANG JF. Anaysis of related factors of HBVACLF pateintsoccured AKI[J]. Chin Hepatol,2015,20(8):606-609.(in Chinese)张玲芳,王介非.乙型肝炎相关慢加急性肝衰竭患者发生急性肾损伤的相关因素分析[J].肝脏,2015,20(8):606-609. [12] TANG XJ,MEI CL. Interpretation of KDIGO guideline for diagnosis and treatment of acute kidney injury[J]. Chin J Pract Intern Med,2012,32(12):914-917.(in Chinese)汤晓静,梅长林.KDIGO指南解读:急性肾损伤的诊治[J].中国实用内科杂志,2012,32(12):914-917. [13] KARVELLAS CJ,DURAND F,NADIM MK. Acute kidney injury in cirrhosis[J]. Critical Care Clinics,2015,31(4):737-750. [14] CAI JJ,HAN T. Diagnosis and treatment of acute kidney injury in patients with cirrhosis[J]. J Clin Hepatol,2014,30(12):1352-1356.(in Chinese)蔡均均,韩涛.肝硬化患者急性肾损伤的诊断与治疗[J].临床肝胆病杂志,2014,30(12):1352-1356. [15] JUSTIN MB,ARUN JS,GUADDALUPE GT,et al. Early trends in cystatin C and outcomes in patients with cirrhosis and acute kidney injury[J]. Int J Nephrol,2014,2014(3):1-8. [16] VANDREA DS,AOUMEUR HA,OLGA D,et al. Creatinineversus cystatine C-based equations in assessing the renal function of candidates for liver transplantation with cirrhosis[J]. Hepatology,2014,59(4):1522-1531. [17] MINDIKOGL AL,DOWLING TC,WEIR MR,et al. Performance of chronic kidney disease epidemiology collaboration creatinine-cystatin C equation for estimating kidney function in cirrhosis[J]. Hepatology,2014,59(4):1532-1542. [18] ALLEN AM,KIM WR,LARSON JJ,et al. Serum cystatin C as an indicator of renal function and mortality in liver transplant recipients[J]. Transplantation,2015,99(7):1431-1435. [19] PECO-ANTIC'A,IVANIEVIC'I,VULIC'EVIC'I,et al. Biomarkers of acute kidney injury in pediatric cardiac surgery[J]. Clin Biochem,2013,46(13-14):1244-1251. [20] WAN ZH,WANG JJ,YOU SL,et al. Cystatin C is a biomarker for predicting acute kidney injury in patients with acute-onchronic liver failure[J]. World J Gastroenterol,2013,19(48):9432. [21] MARKWARDT D,HOLDT L,STEIB C,et al. Plasma cystatin C is a predictor of renal dysfunction,acute-on-chronic liver failure,and mortality in patients with acutely decompensated liver cirrhosis[J]. Hepatology,2017,66(4):1232-1241. [22] CONTI M,MOUTEREAU S,ZATER M,et al. Urinary cystatin C as a specific marker of tubular dysfunction[J]. Clin Chem Lab Med,2006,44(3):288-291. [23] LI XP,WU ZP,ZHANG LL,et al. Advances in diagnosis and treatment of patients with acute-on-chronic liver failure complicated by acute kidney injury[J]. J Clin Hepatol,2016,32(9):1688-1693.(in Chinese)李小鹏,吴振平,张伦理,等.慢加急性肝衰竭并发急性肾损伤的诊治进展[J].临床肝胆病杂志,2016,32(9):1688-1693. [24] XU SS,WEI XH,LIN W,et al. Clinical significance of platelet count and its dynamic change in patients with acute-onchronic liver failure[J]. J CIin Hepatol,2018,34(4):810-813.(in Chinese)许姗姗,韦新焕,林伟,等.慢加急性肝衰竭患者血小板计数及其动态变化的临床意义[J].临床肝胆病杂志,2018,34(4):810-813. [25] SHI XX,ZHANG YQ,ZHU P,et al. Prognostic risk factors in patients with acute-on-chronic hepatitis B liver failure[J]. J Clin Hepatol,2016,32(4):700-705.(in Chinese)石新星,张艳琼,朱鹏,等.乙型肝炎相关慢加急性肝衰竭患者预后的危险因素分析[J].临床肝胆病杂志,2016,32(4):700-705. [26] LESURTEL M,GRAF R,ALEIL B,et al. Platelet-derived serotonin mediates liver regeneration[J]. Science,2006,312(5770):104-107. [27] FENG N,FENG B,XING XM. Value of red blood cell distribution width,platelet count,and lactate level in evaluating the prognosis of patients with acute-on-chronic liver failure after plasma exchange[J]. Clin J Med Offic,2019,47(3):320-322.(in Chinese)冯楠,冯波,邢星敏.红细胞分布宽度、血小板计数与乳酸水平对慢加急性肝衰竭患者经血浆置换治疗预后评估价值[J].临床军医杂志,2019,47(3):320-322. [28] MICHAEL M,PATRICK SK,FREDRIC DG,et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts[J]. Hepatology,2000,31(4):864-871. [29] WU TZ,LI J,SHAO L,et al. Development of diagnostic criteria and a prognostic score for hepatitis B virus-related acute-on-chronic liver failure[J]. Gut,2017,67(12):2181-2191. [30] CHOUDHURY A,JINDAL A,MAIWALL R,et al. Liver failure determines the outcome in patients of acute-on-chronic liver failure(ACLF):Comparison of APASL ACLF research consortium(AARC)and CLIF-SOFA models[J]. Hepatol Int,2017,11(5):461-471. 期刊类型引用(2)
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