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慢加急性肝衰竭急性静脉曲张出血的危险因素及预后分析
DOI: 10.3969/j.issn.1001-5256.2022.11.018
伦理学声明：本研究方案经过原解放军第302医院临床研究伦理委员会批准，批号：2013005D、2019085D。
利益冲突声明：本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明：刘婉姝、申力军负责课题设计，资料分析，撰写论文；翟庆慧参与收集及分析数据；辛绍杰、游绍莉负责拟定写作思路，指导撰写文章并最后定稿。
Risk factors for acute variceal bleeding in acute-on-chronic liver failure and its influence on prognosis
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摘要:
目的 探讨慢加急性肝衰竭(ACLF)急性静脉曲张出血(AVB)的危险因素及对预后的影响。 方法 对解放军总医院第五医学中心2009年—2015年收治ACLF患者1409例随访6个月，根据是否出现AVB分为AVB组(n=167)和非AVB组(n=1242)。计量资料符合正态分布两组间比较使用Student t检验；不符合正态分布资料两组间比较采用Mann-Whitney U检验。Kaplan-Meier法绘制生存曲线，对随访过程中组间病死率及进展进行Log-rank检验。采用二元Logistic回归分析AVB发生的危险因素。 结果 1409例患者发生AVB 167例，占11.85%。AVB及非AVB患者30 d存活率分别为43.42%、67.79%(χ2=33.558，P＜0.001)；两组患者180 d存活率分别为18.91%、53.97%(χ2=76.881，P＜0.001)。Log-rank检验显示AVB与非AVB患者30 d生存率、180 d生存率差异均有统计学意义(χ2值分别为40.950、89.320，P值均＜0.05)。Logistic回归分析AVB发生的危险因素，胸腔积液(OR=1.522，95%CI: 1.071 ~2.162，P=0.019)、急性肾损伤(OR=2.201，95%CI: 1.415~3.426，P＜0.001)、ACLF分型(OR=2.491，95%CI: 1.489~4.168，P=0.001)、ACLF分期(OR=2.403，95%CI: 1.687~3.421，P＜0.001)及尿素(OR=2.567，95%CI：1.570~4.196，P＜0.001)与ACLF患者AVB的发生独立相关。 结论 AVB是影响ACLF近期生存的重要因素，胸腔积液、急性肾损伤、ACLF分型BC型、ACLF晚期以及尿素是AVB发生的独立危险因素。 Abstract:Objective To investigate the risk factors for acute variceal bleeding (AVB) in acute-on-chronic liver failure (ACLF) and its influence on prognosis. Methods A total of 1409 ACLF patients who were admitted to The Fifth Medical Center of Chinese PLA General Hospital from 2009 to 2015 were followed up for 6 months, and according to the presence or absence of AVB, they were divided into AVB group and non-AVB group. The Student's t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The Kaplan-Meier curves were plotted and the Log-rank test was performed to analyze mortality rate and progression during follow-up, and a binary Logistic regression analysis was used to investigate the risk factors for AVB. Results Among these 1409 patients, 167 (11.85%) experienced AVB. The 30-day survival rate was 43.42% in the AVB group and 67.79% in the non-AVB group (χ2=33.558, P < 0.001), and the 180-day survival rate was 18.91% in the AVB group and 53.97% in the non-AVB group (χ2=76.881, P < 0.001). The Log-rank test showed significant differences in 30- and 180-day survival rates between the AVB group and the non-AVB group (χ2=40.950 and 89.320, both P < 0.05). The Logistic regression analysis showed that pleural effusion (odds ratio [OR]=1.522, 95% confidence interval [CI]: 1.071-2.162, P=0.019), acute kidney injury (AKI) (OR=2.201, 95%CI: 1.415-3.426, P < 0.001), ABC subtype of ACLF (OR=2.491, 95%CI: 1.489-4.168, P=0.001), ACLF stage (OR=2.403, 95%CI: 1.687-3.421, P < 0.001), and urea(OR=2.567, 95%CI: 1.570-4.196, P < 0.001)were independently associated with AVB in ACLF patients. Conclusion AVB is an important influencing factor for the short-term survival of ACLF patients, and pleural effusion, AKI, BC subtype of ACLF, advanced ACLF, and urea are independent risk factors for the onset of AVB. -
Key words:
- Acute-On-Chronic Liver Failure /
- Varicose Veins /
- Risk Factors /
- Prognosis
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表 1 1409例ACLF基线特征
Table 1. Baseline and clinical characteristics of 1409 cases of ACLF
指标 AVB组(n=167) 非AVB组(n=1242) 统计值 P值 年龄(岁) 46.48±9.37 46.70±9.97 t=0.079 0.778 性别[例(%)] χ2=0.721 0.396 男 145(12.16) 1047(87.84) 女 22(10.14) 195(89.86) ACLF分型[例(%)] χ2=47.069 ＜0.001 A型 20(4.17) 460(95.83) B型 115(14.71) 667(85.29) C型 32(21.77) 115(78.23) ACLF分期[例(%)] χ2=47.902 ＜0.001 早期 3(8.82) 31(91.18) 中期 69(7.61) 838(92.39) 晚期 95(20.30) 373(79.70) 并发症[例(%)] 腹水 157(94.01) 1103(88.81) χ2=3.683 0.055 胸腔积液 77(46.11) 373(30.03) χ2=16.769 ＜0.001 肺部感染 70(41.92) 196(15.78) χ2=63.960 ＜0.001 SBP 80(47.90) 373(30.03) χ2=20.743 ＜0.001 菌血症 24(14.37) 123(9.90) χ2=3.145 0.076 肝性脑病 124(74.25) 446(35.91) χ2=88.252 ＜0.001 AKI 126(75.45) 497(40.02) χ2=73.500 ＜0.001 白蛋白(g/L) 28.89±5.73 31.20±4.26 t=6.134 0.013 TBil(μmol/L) 280.55(172.50~421.78) 284.25(194.93~388.43) Z=0.260 0.795 PTA(%) 19.01±10.93 25.72±9.77 t=67.070 ＜0.001 INR 2.07±0.54 2.07±0.61 t=0.011 0.917 血清钠(mmol/L) 132.47±5.87 133.29±5.89 t=2.861 0.091 胆碱酯酶(U/L) 2 583.30±1 420.97 2 770.91±1 404.29 t=2.056 0.040 纤维蛋白原(g/L) 1.68±0.90 1.74±0.96 t=0.568 0.451 血肌酐(μmol/L) 95.00(78.75~120.25) 89.00(78.00~105.00) Z=2.740 0.006 血尿素(mmol/L) 12.65(7.98~21.04) 6.70(4.60~11.30) Z=10.085 ＜0.001 血清铁(μmol/L) 22.16±8.63 24.61±7.79 t=13.826 ＜0.001 血红蛋白(g/L) 112.20(85.75~137.25) 121.70(104.00~139.00) Z=3.512 ＜0.001 血小板计数(×109/L) 80.32±61.09 94.01±55.35 t=8.741 0.003 MELD评分 25.82±6.69 25.40±5.36 t=0.830 0.363 MELD-Na评分 31.93±11.21 29.93±9.82 t=5.875 0.015 30 d存活率(%) 43.42(66/152) 67.79(722/1065) χ2=33.558 ＜0.001 180 d存活率(%) 18.91(21/111) 53.97(421/780) χ2=76.881 ＜0.001 
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表 2 Logistic回归方程中的变量
Table 2. Variables in the equation for the multilevel Logistic regression
变量 回归系数 标准误 Wald值 自由度 P值 OR 95%CI 胸腔积液 0.420 0.179 5.491 1 0.019 1.522 1.071~2.162 ACLF分型B、C型 0.913 0.263 12.089 1 0.001 2.491 1.489~4.168 ACLF分期晚期 0.877 0.180 23.644 1 ＜0.001 2.403 1.687~3.421 AKI 0.789 0.226 12.235 1 ＜0.001 2.201 1.415~3.426 尿素 0.943 0.251 14.122 1 ＜0.001 2.567 1.570~4.196 血小板计数 0.370 0.199 3.447 1 0.063 1.448 0.980~2.141 MELD-Na评分 -0.311 0.184 2.853 1 0.091 0.733 0.511~1.051
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