PDF下载 ( 2062 KB)
急性肝衰竭并发急性肾损伤的影响因素及预测模型
DOI: 10.3969/j.issn.1001-5256.2023.02.016
伦理学审查：本研究方案于2022年8月2日经由郑州大学第一附属医院医院伦理委员会审批，批号：2022-KY-0980。
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：尚梦月负责课题设计，收集数据，资料分析，撰写论文；仝亚林负责参与收集数据，修改论文；陈永忠、保洁负责拟定写作思路，指导撰写文章并最后定稿。
Influencing factors for acute kidney injury in acute liver failure and establishment of a predictive model
-
摘要:
目的 探讨急性肝衰竭(ALF)患者并发急性肾损伤(AKI)的预测因素，建立新型预测模型。 方法 收集2015年1月—2021年10月郑州大学第一附属医院确诊为ALF的253例患者的临床资料，根据是否发生AKI分为非AKI组(n=170)和AKI组(n=83)。收集并分析两组患者的临床资料和实验室指标。计量资料不服从正态分布采用M(P25~P75)表示，两组间比较采用Mann-Whitney U检验，计数资料用例(%)表示，两组间比较采用χ2检验。采用二元Logistic回归分析ALF患者发生AKI的危险因素，通过受试者工作特征曲线(ROC曲线)分析所得指标对ALF患者发生AKI的预测效能。 结果 AKI组高血压、糖尿病、肝性脑病、腹水、肺部感染的比率以及WBC、INR、CRP、PCT、NLR、MELD评分均高于非AKI组，PLT、LMR、PNI水平低于非AKI组，差异均具有统计学意义(P值均＜0.05)。多因素Logistic回归分析结果显示，WBC(OR=1.267，95%CI：1.124~1.428，P＜0.001)、INR(OR=1.663，95%CI：1.205~2.293，P=0.002)、PCT(OR=1.416，95%CI：1.137~1.764，P=0.002)、MELD(OR=1.098，95%CI：1.029~1.172，P=0.005)是ALF患者并发AKI的危险因素。ROC曲线分析显示，WBC+INR+PCT+MELD联合预测ALF患者并发AKI的ROC曲线下面积(AUC)最高(AUC=0.908)，而WBC、INR、PCT、MELD单独预测的AUC分别为0.776、0.771、0.746、0.780。 结论 WBC、INR、PCT、MELD是ALF患者并发AKI的独立影响因素，四者联合建立的预测模型预测价值较高。 Abstract:Objective To investigate the predictive factors for acute kidney injury (AKI) in patients with acute liver failure (ALF), and to establish a new predictive model. Methods Clinical data were collected from 253 patients who were diagnosed with ALF in The First Affiliated Hospital of Zhengzhou University from January 2015 to October 2021, and according to the presence or absence of AKI, these patients were divided into non-AKI group with 170 patients and AKI group with 83 patients. Related clinical data and laboratory markers were collected. Non-normally distributed continuous data were expressed as M(P25-P75), and the Mann-Whitney U test was used for comparison between two groups; categorical data were expressed as cases (%), and the chi-square test was used for comparison between two groups. The binary logistic regression analysis was used to investigate the risk factors for AKI in ALF patients, and the receiver operating characteristic (ROC) curve was used to evaluate the performance of the indices obtained in predicting AKI in ALF patients. Results Compared with the non-AKI group, the AKI group had a significantly higher proportion of patients with hypertension, diabetes, hepatic encephalopathy, ascites, and pulmonary infection, significantly higher levels of white blood cell count (WBC), international normalized ratio (INR), C-reactive protein, procalcitonin (PCT), neutrophil-to-lymphocyte ratio, and Model for End-Stage Liver Disease (MELD) score, and significantly lower levels of platelet count, lymphocyte-to-monocyte ratio, and PNI (all P < 0.05). The multivariate logistic regression analysis showed that WBC (odds ratio [OR]=1.267, 95% confidence interval [CI]: 1.124-1.428, P < 0.001), INR (OR=1.663, 95%CI: 1.205-2.293, P=0.002), PCT (OR=1.416, 95%CI: 1.137-1.764, P=0.002), and MELD score (OR=1.098, 95%CI: 1.029-1.172, P=0.005) were risk factors for the development of AKI in patients with ALF. The ROC curve analysis showed that the combination of WBC+INR+PCT+MELD had the largest area under the ROC curve (AUC) of 0.908 in predicting AKI in ALF patients, while WBC, INR, PCT, and MELD alone had an AUC of 0.776, 0.771, 0.746, and 0.780, respectively, in predicting AKI. Conclusion WBC, INR, PCT, and MELD score are independent influencing factors for AKI in patients with ALF, and the predictive model established based on these four indices has a relatively high predictive value. -
Key words:
- Liver Failure, Acute /
- Acute Kidney Injury /
- Risk Factors
-
图 1 WBC、INR、PCT、MELD单独及联合预测ALF患者并发AKI的ROC曲线
Figure 1. WBC、INR、PCT、MELD alone and in combination to predict the ROC curve of concurrent AKI in patients with ALF
表 1 两组临床资料比较
Table 1. Comparison of clinical data between two groups
项目 非AKI组(n=170) AKI组(n=83) 统计值 P值 男性[例(%)] 94(55.3) 48(57.8) χ2=0.146 0.703 年龄(岁) 49(37~57) 49(41~62) Z=1.625 0.104 高血压[例(%)] 30(17.6) 25(30.1) χ2=5.100 0.024 糖尿病[例(%)] 14(8.2) 16(19.3) χ2=6.506 0.011 肝性脑病[例(%)] 76(44.7) 60(72.3) χ2=17.069 ＜0.001 腹水[例(%)] 105(61.8) 63(75.9) χ2=4.997 0.025 消化道出血[例(%)] 13(7.6) 12(14.5) χ2=2.905 0.088 肺部感染[例(%)] 126(74.1) 77(92.8) χ2=12.238 ＜0.001 腹腔感染[例(%)] 8(4.7) 7(8.4) χ2=1.390 0.238 血流感染[例(%)] 7(4.1) 5(6.0) χ2=0.449 0.503 泌尿系感染[例(%)] 6(3.5) 5(6.0) χ2=0.835 0.361 
下载: 导出CSV
表 2 两组生化指标比较
Table 2. Comparison of biochemical indicators between two groups
项目 非AKI组(n=170) AKI组(n=83) Z值 P值 WBC(×109/L) 7.20(5.38~9.17) 11.20(8.40~16.88) 7.114 ＜0.001 RDW(%) 16.55(14.89~19.23) 15.90(14.20~19.10) 1.323 0.186 PLT(×109/L) 122.00(87.50~176.00) 104.00(53.00~141.00) 3.039 0.002 ALT(U/L) 555.00(199.75~1077.50) 360.00(64.00~1844.00) 0.716 0.474 AST(U/L) 450.00(153.75~931.75) 334.00(141.00~1358.30) 0.233 0.816 白蛋白(g/L) 31.25(28.58~35.23) 30.90(27.50~33.50) 1.925 0.054 TBil(μmol/L) 272.55(174.00~371.15) 269.30(141.00~431.90) 0.100 0.921 INR 2.03(1.56~2.75) 3.41(2.32~5.25) 6.985 ＜0.001 CRP(mg/L) 9.11(5.02~18.01) 29.08(9.66~46.89) 5.472 ＜0.001 PCT(ng/L) 0.64(0.32~0.96) 2.10(0.58~6.09) 6.344 ＜0.001 NLR 3.79(2.16~8.05) 13.45(6.91~23.83) 7.413 ＜0.001 PLR 103.91(70.66~166.12) 120.97(80.30~225.49) 1.811 0.070 LMR 1.74(1.08~2.52) 0.95(0.59~1.39) 5.524 ＜0.001 PNI 37.90(33.84~43.06) 34.55(31.00~39.60) 3.591 ＜0.001 MELD评分 25.00(21.00~29.00) 35.00(27.00~40.00) 7.246 ＜0.001
下载: 导出CSV
表 3 ALF患者发生AKI的多因素Logistic回归分析
Table 3. Binary Logistic regression of risk factors for concurrent AKI in patients with ALF
变量 B值 SE Wald OR 95%CI P值 WBC 0.237 0.061 15.054 1.267 1.124~1.428 ＜0.001 INR 0.508 0.164 9.604 1.663 1.205~2.293 0.002 PCT 0.348 0.112 9.655 1.416 1.137~1.764 0.002 MELD 0.094 0.033 8.052 1.098 1.029~1.172 0.005
下载: 导出CSV
-
[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. DOI: 10.3969/j.issn.1001-5256.2019.01.007.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. DOI: 10.3969/j.issn.1001-5256.2019.01.007. [2] TUJIOS SR, HYNAN LS, VAZQUEZ MA, et al. Risk factors and outcomes of acute kidney injury in patients with acute liver failure[J]. Clin Gastroenterol Hepatol, 2015, 13(2): 352-359. DOI: 10.1016/j.cgh.2014.07.011. [3] 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. DOI: 10.1136/gutjnl-2014-308874. [4] KAMATH PS, WIESNER RH, MALINCHOC M, et al. A model to predict survival in patients with end-stage liver disease[J]. Hepatology, 2001, 33(2): 464-470. DOI: 10.1053/jhep.2001.22172. [5] CHEN J, LIU XY, TONG JJ, et al. Clinical features of patients with acute/subacute liver failure complicated by acute kidney injury[J]. J Clin Hepatol, 2018, 34(2): 364-367. DOI: 10.3969/j.issn.1001-5256.2018.02.029.陈婧, 刘晓燕, 童晶晶, 等. 急性/亚急性肝衰竭合并急性肾损伤的临床特征分析[J]. 临床肝胆病杂志, 2018, 34(2): 364-367. DOI: 10.3969/j.issn.1001-5256.2018.02.029. [6] MOU YD, ZHANG LL, ZHANG PR. New advances in the study of early biological markers of acute kidney injury[J/CD]. Chin J Care Med(Electronic Edition), 2015, 8(3): 191-196. DOI: 10.3877/cma.j.issn.1674-6880.2015.03.013 .牟迎东, 张琳琳, 张培荣. 急性肾损伤早期生物学标志物研究的新进展[J/CD]. 中华危重症医学杂志(电子版), 2015, 8(3): 191-196. DOI:10.3877/cma.j.issn.1674-6880.2015.03.013 .[7] de SEIGNEUX S, MARTIN PY. Preventing the progression of AKI to CKD: The role of mitochondria[J]. J Am Soc Nephrol, 2017, 28(5): 1327-1329. DOI: 10.1681/ASN.2017020146. [8] WADEI HM. Hepatorenal syndrome: a critical update[J]. Semin Respir Crit Care Med, 2012, 33(1): 55-69. DOI: 10.1055/s-0032-1301735. [9] SHI X, ZHU P, YAN G, et al. Clinical characteristics and long-term outcome of acute kidney injury in patients with HBV-related acute-on-chronic liver failure[J]. J Viral Hepat, 2016, 23(11): 920-929. DOI: 10.1111/jvh.12566. [10] HAN SS, AHN SY, RYU J, et al. U-shape relationship of white blood cells with acute kidney injury and mortality in critically ill patients[J]. Tohoku J Exp Med, 2014, 232(3): 177-185. DOI: 10.1620/tjem.232.177. [11] PIERI G, AGARWAL B, BURROUGHS AK. C-reactive protein and bacterial infection in cirrhosis[J]. Ann Gastroenterol, 2014, 27(2): 113-120. [12] LUO Y, LU JJ, WANG YD, et al. The change of procalcitonin in patients with liver failure and its clinical application value[J]. Chin J Infect Dis, 2021, 39(7): 449-452. DOI: 10.3760/cma.j.cn311365-20200819-00760.罗越, 逯晶晶, 王亚东, 等. 肝衰竭患者降钙素原的变化规律及其临床应用价值[J]. 中华传染病杂志, 2021, 39(7): 449-452. DOI: 10.3760/cma.j.cn311365-20200819-00760. [13] KAN WC, HUANG YT, WU VC, et al. Predictive ability of procalcitonin for acute kidney injury: a narrative review focusing on the interference of infection[J]. Int J Mol Sci, 2021, 22(13). DOI: 10.3390/ijms22136903. [14] NIE X, TANG JT, CAI B, et al. Analysis of procalcitonin in patients with end stage liver disease complicated with acute kidney injury[J]. Chin J Lab Med, 2013, 36(11): 1018-1021. DOI: 10.3760/cma.j.issn.1009-9158.2013.11.012.聂鑫, 唐江涛, 蔡蓓, 等. 终末期肝衰竭伴急性肾损伤患者血清降钙素原水平研究[J]. 中华检验医学杂志, 2013, 36(11): 1018-1021. DOI: 10.3760/cma.j.issn.1009-9158.2013.11.012. [15] HUANG ZL, GAO ZL. Triple blows and treatment strategies for liver failure[J]. J Intern Intensive Med, 2014, 20(3): 154-156. DOI: 10.11768/nkjwzzzz20140304.黄湛镰, 高志良. 肝衰竭的三重打击及治疗策略[J]. 内科急危重症杂志, 2014, 20(3): 154-156. DOI: 10.11768/nkjwzzzz20140304. [16] HUANG Z, LIN C, FANG J, et al. Acute kidney injury in hepatitis B-related acute-on-chronic liver failure without preexisting liver cirrhosis[J]. Hepatol Int, 2015, 9(3): 416-423. DOI: 10.1007/s12072-015-9636-y. [17] HU H, HUANG BB, NING L, et al. Establishment and evaluation of a predictive model for short-time prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure[J]. J Clin Hepatol, 2020, 36(1): 123-127. DOI: 10.3969/j.issn.1001-5256.2020.01.027.胡辉, 黄贝贝, 宁玲, 等. HBV相关慢加急性肝衰竭患者短期预后预测模型的建立与评价[J]. 临床肝胆病杂志, 2020, 36(1): 123-127. DOI: 10.3969/j.issn.1001-5256.2020.01.027. [18] 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): 713-716. DOI: 10.3760/cma.j.issn.1000-6680.2016.12.003.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): 713-716. DOI: 10.3760/cma.j.issn.1000-6680.2016.12.003. [19] ZHANG ZQ, YE YN, HE G, et al. Study of risk factors and high-risk population of acute kidney injury in patients with hepatitis B virus related acute on chronic liver failure[J]. Chin Hepatol, 2019, 24(9): 997-1001, 1006. DOI: 10.3969/j.issn.1008-1704.2019.09.008.张志侨, 叶一农, 何纲, 等. 乙型肝炎相关慢加急性肝衰竭患者急性肾损伤的影响因素和高危人群分析[J]. 肝脏, 2019, 24(9): 997-1001, 1006. DOI: 10.3969/j.issn.1008-1704.2019.09.008. [20] YUAN W, ZHANG YY, ZHANG ZG, et al. Risk factors and outcomes of acute kidney injury in patients with hepatitis B virus-related acute-on-chronic liver failure[J]. Am J Med Sci, 2017, 353(5): 452-458. DOI: 10.1016/j.amjms.2017.03.005. -
本文二维码
图(1) / 表(3)
计量
- 文章访问数: 821
- HTML全文浏览量: 408
- PDF下载量: 80
- 被引次数: 0
