肝硬化自发性门体分流与肝肾综合征的相关性研究
DOI: 10.3969/j.issn.1001-5256.2023.12.012
Association between spontaneous portosystemic shunt and hepatorenal syndrome in liver cirrhosis
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摘要:
目的 探讨肝硬化合并自发性门体分流(SPSS)与肝肾综合征(HRS)的相关性。 方法 回顾性选取山东大学齐鲁医院德州医院2015年1月—2022年1月SPSS患者93例,并以HRS的发生作为观察终点随访12个月。以有无HRS分组,93例SPSS患者分为HRS组(38例,40.86%)与非HRS组(55例,59.14%),分析两组间临床资料、实验室数据、并发症情况、分流直径大小的差异。以分流静脉最大直径1.5 cm分组,93例SPSS患者分为高分流组(52例,55.91%)与低分流组(41例,44.09%),以HRS的发生为观察终点,比较两组HRS的发生率及生存时间曲线。符合正态分布且方差齐的计量资料两组间比较采用成组t检验,计数资料两组间比较采用χ2检验。截断值预测采用受试者工作特征曲线(ROC曲线),生存时间对比采用Kaplan-Meier曲线分析,生存曲线的差异分析采用Log-rank检验法。危险因素分析采用单因素及多因素Cox回归。 结果 与非HRS组对比,HRS组Child-Pugh评分及分级、MELD评分、血肌酐(SCr)、尿素氮(BUN)、ALT、AST、分流静脉最大直径、肝性脑病、自发性腹膜炎发生率、腹水程度增高,门静脉主干直径、血清钠(Na)、血清Alb降低,差异均有统计学意义(P值均<0.05)。与低分流组对比,高分流组的HRS发生率增高(51.92% vs 26.83%,χ2=5.974,P=0.015)、发生时间缩短(Log-rank,P=0.033)。SPSS患者发生HRS的独立危险因素包括分流静脉最大直径>1.5 cm(HR=1.123,95%CI:1.041~1.211,P=0.003)、MELD评分增加(HR=1.205,95%CI:1.076~1.437,P=0.039)、血清Alb降低(HR=0.890,95%CI:0.814~0.974,P=0.011)、腹水程度增加(HR=2.099,95%CI:1.066~4.130,P=0.032)、自发性腹膜炎(HR=2.259,95%CI:1.020~5.003,P=0.045)。 结论 SPSS与HRS存在相关性,分流直径>1.5 cm是SPSS患者发生HRS的独立危险因素,需临床重视并早期干预。 Abstract:Objective To investigate the association between spontaneous portosystemic shunt (SPSS) and hepatorenal syndrome (HRS) in patients with liver cirrhosis. Methods A retrospective analysis was performed for 93 patients with SPSS from Dezhou Hospital, Qilu Hospital of Shandong University, from January 2015 to January 2022, and the patients were followed up for 12 months with the onset of HRS as the observation endpoint. According to the presence or absence of HRS, the 93 patients with SPSS were divided into HRS group with 38 patients (40.86%) and non-HRS group with 55 patients (59.14%), and the two groups were compared in terms of clinical data, laboratory data, complication, and shunt diameter. Based on the maximum shunt vein diameter of 1.5 cm, the 93 patients with SPSS were divided into high shunt group with 52 patients (55.91%) and low shunt group with 41 patients (44.09%), and with the onset of HRS as the observation endpoint, the two groups were compared in terms of the incidence rate of HRS and survival time curve. The independent-samples t test was used for comparison of normally distributed continuous data with homogeneity of variance between two groups, and the chi-square test was used for comparison of categorical data between two groups. The receiver operating characteristic (ROC) curve was used to predict cut-off values, the Kaplan-Meier curve was used for comparison of survival time, and the Log-rank test was used to compare the differences in survival curves. The multivariate Cox regression analysis was used to investigate risk factors. Results Compared with the non-HRS group, the HRS group had significant increases in Child-Pugh score, Child-Pugh class, MELD score, serum creatinine, blood urea nitrogen, alanine aminotransferase, aspartate aminotransferase, maximum shunt vein diameter, the incidence rates of hepatic encephalopathy and spontaneous bacterial peritonitis, and the degree of ascites, as well as significant reductions in main portal vein diameter, serum sodium and albumin (all P<0.05). Compared with the low shunt group, the high shunt group had a significant increase in the incidence rate of HRS (51.92% vs 26.83%, χ²=5.974, P=0.015) and a significant reduction in the time to the onset of HRS (Log-rank P=0.033). A maximum shunt vein diameter of >1.5 cm (hazard ratio [HR]=1.123, 95% confidence interval [CI]: 1.041 — 1.211, P=0.003), an increase in MELD score (HR=1.205, 95%CI: 1.076 — 1.437, P=0.039), a reduction in serum albumin (HR=0.890, 95%CI: 0.814 — 0.974, P=0.011), an increase in the degree of ascites (HR=2.099, 95%CI: 1.066 — 4.130, P=0.032), and spontaneous bacterial peritonitis (HR=2.259, 95%CI: 1.020 — 5.003, P=0.045) were independent risk factors for the onset of HRS in SPSS patients. Conclusion There is an association between SPSS and HRS, and shunt diameter >1.5 cm was an independent risk factor for HRS in SPSS patients, which should be taken seriously and require early intervention in clinical practice. -
表 1 SPSS患者基本资料比较
Table 1. Comparison of basic information of patients in SPSS
指标 HRS组(n=38) 非HRS组(n=55) 统计值 P 值 男/女(例) 20/18 26/29 χ2=0.258 0.676 年龄(岁) 57.39±11.81 59.91±12.48 t=0.976 0.332 病因(乙型肝炎/丙型肝炎/酒精性,例) 24/7/7 41/10/4 χ2=2.779 0.249 Child-Pugh评分 9.29±2.12 8.20±2.18 t=2.397 0.019 Child-Pugh分级(A/B/C,例) 4/18/16 14/31/10 χ2=7.533 0.023 MELD评分 29.51±9.92 22.78±16.41 t=2.259 0.026 Na(mmol/L) 102.33±20.32 125.43±18.73 t=5.648 <0.001 K(mmol/L) 4.02±0.86 4.12±0.97 t=0.539 0.592 Alb(g/L) 19.36±5.85 29.22±8.40 t=6.262 <0.001 RBC(×1012/L) 3.62±0.54 3.45±0.51 t=1.598 0.113 WBC(×109/L) 10.05±2.59 8.98±2.25 t=2.113 0.037 LY(×109/L) 1.01±0.15 1.07±0.17 t=1.729 0.087 SCr(μmol/L) 157.79±27.87 123.68±35.71 t=4.939 <0.001 BUN(μmol/L) 14.41±3.79 11.69±4.85 t=2.997 0.004 ALT(U/L) 46.31±16.40 30.21±16.88 t=4.572 <0.001 AST(U/L) 58.79±18.71 47.16±23.22 t=2.563 0.012 肝性脑病[例(%)] 26(68.42) 12(21.82) χ2=20.198 <0.001 上消化道出血[例(%)] 14(36.84) 21(38.18) χ2=0.017 0.896 自发性腹膜炎[例(%)] 23(60.53) 13(23.64) χ2=12.890 <0.001 门静脉血栓[例(%)] 12(31.58) 19(34.55) χ2=0.089 0.765 腹水程度(无/少/中/大量,例) 3/10/11/14 21/23/9/2 χ2=25.568 <0.001 门静脉主干直径(mm) 11.53±4.70 13.17±2.92 t=5.968 0.041 分流静脉最大直径(mm) 20.19±8.63 13.11±5.97 t=4.686 <0.001 注:K,血清钾;RBC,红细胞计数;LY,淋巴细胞计数。 表 2 SPSS患者发生HRS的单因素Cox回归分析
Table 2. Univariate Cox regression analysis of HRS occurrence in SPSS patients
因素 Wald值 HR 95%CI P值 Child-Pugh评分 0.270 1.054 0.864~1.287 0.603 Child-Pugh分级(A/B/C) 0.177 1.143 0.614~2.127 0.674 MELD评分 5.942 1.058 1.011~1.107 0.015 Na(mmol/L) 4.013 0.942 0.889~0.999 0.045 Alb(g/L) 4.873 0.936 0.882~0.993 0.027 WBC(×109/L) 5.788 1.297 1.107~1.520 0.016 SCr(μmol/L) 4.666 1.016 1.001~1.030 0.031 BUN(μmol/L) 0.643 0.422 0.957~1.110 0.422 ALT(U/L) 3.813 1.019 1.001~1.039 0.049 AST(U/L) 2.561 1.014 0.997~1.031 0.110 肝性脑病(有/无) 5.279 1.220 1.047~3.784 0.022 门静脉主干直径(mm) 0.095 0.758 0.912~1.069 0.758 分流直径(>1.5 cm/≤1.5 cm) 4.186 2.309 1.036~5.145 0.041 自发性腹膜炎(有/无) 6.463 1.786 1.378~3.211 0.011 腹水程度(无/少/中/大量) 8.648 1.726 1.200~2.483 0.003 表 3 SPSS患者发生HRS的多因素Cox回归分析
Table 3. Multivariate Cox regression analysis of HRS occurrence in SPSS patients
因素 B值 SE Wald值 HR 95%CI P值 MELD评分 0.129 0.320 4.267 1.205 1.076~1.437 0.039 Na(mmol/L) -0.008 0.014 0.355 0.992 0.965~1.019 0.551 Alb(g/L) -0.116 0.046 6.445 0.890 0.814~0.974 0.011 SCr(μmol/L) -0.004 0.012 0.115 0.996 0.972~1.020 0.735 ALT(U/L) -0.001 0.012 0.013 0.999 0.975~1.023 0.909 分流直径(>1.5 cm/≤1.5 cm) 0.116 0.039 9.012 1.123 1.041~1.211 0.003 肝性脑病(有/无) -0.326 0.607 0.288 0.722 0.220~2.373 0.592 自发性腹膜炎(有/无) 0.815 0.406 4.034 2.259 1.020~5.003 0.045 腹水程度(无/少/中/大量) 0.741 0.345 4.604 2.099 1.066~4.130 0.032 -
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