中文English
ISSN 1001-5256 (Print)
ISSN 2097-3497 (Online)
CN 22-1108/R

Logistic regression analysis of prognostic risk factors for hepatic encephalopathy

DOI: 10.3969/j.issn.1001-5256.2016.01.026
  • Received Date: 2015-05-11
  • Published Date: 2016-01-20
  • Objective To analyze the prognostic risk factors for hepatic encephalopathy( HE),and to explore the risk factors for prognosis.Methods A total of 385 patients with HE who were treated in Liaocheng People's Hospital from January 2006 to June 2014 were enrolled in this study and analyzed retrospectively. These patients were divided into improved group( n = 125) and deteriorated group( n = 260). A total of 25 clinical indices were selected,and non- conditional binary logistic regression analysis was performed for related data with SPSS.Results Univariate analysis showed that HE stage,upper gastrointestinal hemorrhage,hepatorenal syndrome( HRS),total bilirubin( TBil),and international normalized ratio( INR) were risk factors affecting the prognosis of HE( P = 0. 000,0. 009,0. 047,0. 002,and0. 027,respectively). Multivariate logistic regression analysis was further performed for the variables with statistical significance and the results showed that HE stage,upper gastrointestinal hemorrhage,HRS,TBil,and INR were independent risk factors affecting the prognosis of HE( P = 0. 000,0. 009,0. 000,0. 000,and 0. 008,respectively; OR( 95% CI) = 4. 388( 2. 997- 6. 424),2. 805( 1. 300- 6. 050),4. 036( 2. 018- 8. 072),1. 005( 1. 003- 1. 007),and 1. 446( 1. 099- 1. 901),respectively). Conclusion HE stage,upper gastrointestinal hemorrhage,HRS,TBil,and INR are risk factors affecting the prognosis of HE,and advanced HE stages,a high level of bilirubin,high INR,and presence of upper gastrointestinal hemorrhage and HRS indicate poor prognosis. The patient's HE stage,upper gastrointestinal hemorrhage,HRS,TBil,and INR are applied as the indices for prognosis of HE,and the equation based on the these indices may have a reference value in clinical practice.

     

  • 急性胰腺炎(acute pamcreatitis,AP)是临床常见消化系统急腹症之一[1],近年来,其发病率不断上升[2]。Yokoe等[3]研究显示,15%~20%的AP进展为重症急性胰腺炎(severe acute pancreatic, SAP)。脓毒症是病原微生物侵入血液引起的全身感染性疾病,据Sagana等[4]报道美国每年约有0.6%的人发生脓毒症。SAP病情凶险极易引发脓毒症,SAP一旦发生脓毒症不仅加重医疗费用负担、延长住院时间,还可能并发脓毒性休克,多器官功能障碍,病情进展甚至会引起死亡[5],临床诊治极为困难。本研究回顾性分析SAP患者的临床资料,分析SAP患者并发脓毒症的相关因素,旨在为临床防治提供参考。

    收集2007年1月—2020年3月贵州医科大学第三附属医院与黔南州人民医院收治的SAP患者临床资料。SAP诊断标准参考中华医学会制定的《急性胰腺炎诊治指南(2014)》[6]。脓毒症诊断标准参照国家卫生健康委颁发的《医院感染诊断标准(试行)》[7]。纳入标准:(1)年龄≥16周岁;(2)符合SAP诊断。剔除标准:(1)病历记录不全;(2)伴有恶性肿瘤晚期或使用糖皮质激素患者;(3)入院手术前已合并脓毒症者;(4)伴有其他部位原发性感染者。

    根据SAP是否发生脓毒症分为脓毒症与非脓毒症,记录每例患者年龄、性别、APACHEⅡ评分、血糖、血钙、血清总胆固醇、血清甘油三酯、血尿素氮、血清白蛋白、血清肌酐、胰腺坏死范围所占比例,以及入住ICU、低氧血症、深静脉置管、机械通气、预防性使用抗生素、血液净化、手术病灶坏死组织清除方式、留置导尿情况,血培养检出病原菌种类等临床资料。本研究所纳入SAP患者采取急诊手术清除病灶坏死组织,手术方式分为开腹与腹腔镜两种方式。

    本研究通过贵州医科大学第三附属医院伦理委员会审批,批号:2020-002,并经患者及家属知情同意。

    采用SPSS 24.0软件进行数据分析。计量资料以x±s表示,两组间比较采用t检验,计数资料两组间比较采用χ2检验。多因素分析采用logistic回归分析。P < 0.05为差异有统计学意义。

    研究共纳入SAP患者178例,其中男106例、女72例, 年龄16~77岁,平均(49.69±14.77) 岁。发生脓毒症56例(31.46%),其中男36例、女20例,平均(51.29±13.92)岁。

    在56例SAP并发脓毒症患者血培养中共分离出61株病原菌,其中革兰阳性菌14株,占22.95%,革兰阴性菌39株,占63.93%,真菌8株,占13.11%(表 1)。

    表  1  SAP合并脓毒症患者的菌种构成比
    病原菌 株数(n=61) 构成比(%)
    革兰阳性菌 14 22.95
    表皮葡萄球菌 8 13.11
    溶血葡萄球菌 4 6.56
    粪肠球菌 2 3.28
    革兰阴性菌 39 63.93
    肺炎克雷伯菌 11 18.03
    鲍曼不动杆菌 9 14.75
    铜绿假单胞菌 9 14.75
    大肠埃希菌 7 11.48
    嗜麦芽窄食假单胞菌 2 3.28
    阴沟肠杆菌 1 1.64
    真菌 8 13.11
    白色假丝酵母菌 5 8.20
    光滑假丝酵母菌 2 3.28
    热带假丝酵母菌 1 1.64
    下载: 导出CSV 
    | 显示表格

    单因素分析显示,APACHEⅡ评分、血糖、血钙、血清总胆固醇、血清甘油三酯、血尿素氮、血清肌酐、血清白蛋白,以及入住ICU、低氧血症、深静脉置管、机械通气、手术方式、血液净化、留置导尿、胰腺坏死范围在脓毒症和非脓毒症患者间差异均有统计学意义(P值均 < 0.05)(表 2)。

    表  2  SAP并发脓毒症的单因素分析
    因素 非脓毒症(n=122) 脓毒症(n=56) 统计值 P
    年龄(岁) 48.95±15.14 51.29±13.92 t=1.011 0.314
    男/女(例) 70/52 36/20 χ2=0.761 0.383
    APACHEⅡ评分(分) 24.35±5.86 27.71±5.56 t=3.683 < 0.001
    入住ICU(例) 41 31 χ2=7.538 0.006
    低氧血症(例) 36 31 χ2=10.926 0.001
    深静脉置管(例) 82 46 χ2=4.235 0.040
    机械通气(例) 44 30 χ2=4.842 0.028
    血糖(mmol/L) 11.37±3.80 13.13±4.34 t=2.596 0.011
    预防性使用抗生素(例) 51 21 χ2=0.295 0.587
    手术方式(例) χ2=8.249 0.004
    腹腔镜 43 8
    开腹 79 48
    血液净化(例) 83 29 χ2=4.343 0.037
    留置导尿(例) 34 34 χ2=17.539 < 0.001
    胰腺坏死范围(例) χ2=13.386 0.001
    >50% 9 12
    30%~50% 39 25
    < 30% 74 19
    血钙(mmol/L) 2.26±0.32 2.14±0.33 t=-2.144 0.034
    血清总胆固醇(mmol/L) 6.13±2.26 7.03±2.20 t=2.498 0.014
    血清甘油三酯(mmol/L) 2.02±1.12 2.59±1.23 t=2.946 0.004
    血尿素氮(mmol/L) 7.13±2.52 9.05±4.56 t=2.951 0.004
    血清肌酐(μmol/L) 116.46±46.78 147.87±67.31 t=3.160 0.002
    血清白蛋白(g/L) 36.08±7.95 32.62±10.22 t=-2.246 0.027
    下载: 导出CSV 
    | 显示表格

    将单因素分析中有统计学意义的指标纳入logistic多因素回归分析,结果显示,APACHEⅡ评分、低氧血症、血糖、胰腺坏死范围、血清肌酐是SAP并发脓毒症的独立危险因素,采用腹腔镜清除病灶坏死组织为SAP并发脓毒症的独立保护因素(P值均 < 0.05)(表 3)。

    表  3  SAP并发脓毒症的多因素分析
    变量 B SE Wald P OR 95%CI
    APACHEⅡ评分(分) 1.909 0.574 11.063 0.001 6.748 2.191~20.788
    入住ICU 0.994 0.652 2.321 0.128 2.701 0.752~9.700
    低氧血症 1.219 0.568 4.607 0.032 3.383 1.112~10.293
    深静脉置管 0.577 0.677 0.728 0.394 1.781 0.473~6.710
    机械通气 0.750 0.560 1.794 0.180 2.118 0.706~6.350
    血糖(mmol/L) 1.665 0.767 4.714 0.030 5.288 1.176~23.781
    手术方式(腹腔镜) -1.387 0.682 4.133 0.042 0.250 0.066~0.951
    血液净化 -0.185 0.554 0.112 0.738 0.831 0.280~2.463
    留置导尿 0.636 0.559 1.293 0.256 1.889 0.631~5.651
    胰腺坏死范围 1.709 0.640 7.130 0.008 5.523 1.575~19.360
    血钙(mmol/L) -0.964 0.586 2.710 0.100 0.381 0.121~1.202
    血清总胆固醇(mmol/L) 0.498 0.593 0.703 0.402 1.645 0.514~5.263
    血清甘油三酯(mmol/L) 0.740 0.840 0.777 0.378 2.097 0.404~10.880
    血尿素氮(mmol/L) 1.066 0.630 2.862 0.091 2.903 0.845~9.977
    血清肌酐(μmol/L) 1.612 0.671 5.771 0.016 5.012 1.345~18.672
    血清白蛋白(g/L) -0.719 0.705 1.041 0.308 0.487 0.122~1.939
    下载: 导出CSV 
    | 显示表格

    SAP是常见消化系统急症,后期继发感染性胰腺坏死的概率较高[8-9]。脓毒症是SAP的严重并发症之一,也是患者后期死亡的重要原因。本研究显示,在178例SAP患者中发生脓毒症56例(31.46%),与陈莎燕等[10]报道结果相近,提示SAP患者并发脓毒症的概率较高,直接影响治疗的预后,临床应予以注意。本研究在56例SAP并发脓毒症患者血培养中共分离出61株病原菌,其中革兰阳性球菌14株,占22.95%,革兰阴性杆菌39株,占63.93%,真菌8株,占13.11%,与廖全凤等[11]研究结果相似,临床应根据其感染病原菌特点选用抗菌药物。

    APACHE-Ⅱ评分是判断SAP严重程度与预后的重要评分系统,评分越高提示病情越严重,免疫功能越差,病原菌越易进入血液形成脓毒症[12];SAP胰腺组织灌注不足,此时合并低氧血症可增加胰腺组织缺氧程度与坏死范围,导致胰腺感染增加并侵入血流[13],同时SAP常伴发肺部感染等胰腺外感染,后者又可加重SAP患者的感染严重程度,严重者引起低氧血症与呼吸功能衰竭,甚至发生多器官功能衰竭风险[14];胰腺的内分泌部分泌的胰岛素是调节血糖的重要激素,SAP胰腺坏死损伤胰岛导致胰岛素分泌不足,糖代谢紊乱,血糖升高,有利于病原菌入侵,同时其免疫功能下降,更利于病原菌入侵血流,增加脓毒症的发生[15]。肌酐是肌肉代谢产物, 肌肉中肌酸通过非酶脱水反应产生,再释放进入血液中,随尿排出体外。因此血清肌酐与人体肌肉总量密切相关,而不易受饮食等影响;再加上肌酐为小分子物质,通过肾小球滤过,很少被肾小管吸收,每日体内产生量几乎均随尿排出,不受尿量影响,因此,临床上将血清肌酐作为肾功能重要指标之一,血清肌酐升高提示肾功能受损[16];本研究显示,血清肌酐与脓毒症密切相关,可能原因为肾功能不全时白细胞趋化性功能受损,淋巴细胞功能障碍,体内免疫球蛋白降低,免疫功能下降,容易发生脓毒症[17-18]。手术病灶清除引流是治疗感染性胰腺坏死的重要手段[19];感染性胰腺坏死病灶清除引流手术的方式有开腹与微创手术两种,手术可清除炎性病灶减少感染,但是开放手术创伤大,可引起坏死炎性胰腺组织扩散,感染病原菌侵入血流,同时开腹手术破坏人体自然屏障,外界环境中的病原菌也易通过切口侵入引起脓毒症[20],而微创手术方式既可清除炎性坏死组织,又可减少外界病原菌侵入,可减少脓毒症[21]。胰腺坏死程度越高提示感染性胰腺坏死病灶越大,产生的炎性坏死组织越多,对周围组织破坏也越大,病原菌越易侵入血流产生胰外感染[22]。多因素分析显示,APACHEⅡ评分、低氧血症、血糖、胰腺坏死程度高、血清肌酐等因素是SAP并发脓毒症的独立危险因素,采用微创手术方式清除病灶坏死组织为SAP并发脓毒症的独立保护因素。

    总之,SAP并发脓毒症与多因素相关。控制血糖,保护肺肾等重器官功能,采用微创手术方式清除病灶坏死组织,注意重症、胰腺坏死程度高患者的救治是减少SAP并发脓毒症的重要措施。

  • [1]SHI YY,CUL JG.Progresses of MRI in hepatic encephalopathy[J].Chin J Med Imaging Technol,2014,30(2):291-294.(in Chinese)史勇跃,崔进国.肝性脑病的MR研究进展[J].中国医学影像技术,2014,30(2):291-294.
    [2]Expert Committee on the Diagnosis and Treatment of Hepatic Encephalopathy.Expert consensus on the diagnosis and treatment of hepatic encephalopathy[J/CD].Chin J Exp Clin Infect Dis:Electronic Edition,2009,3(4):449-473.(in Chinese)肝性脑病诊断治疗专家委员会.肝性脑病诊断治疗专家共识[J/CD].中华实验和临床感染病杂志:电子版,2009,3(4):449-473.
    [3]YU YH,JIANG JN,WU JZ,et al.Logistic regression analysis of prognostic factors for patients with hepatic encephalopathy[J].Chin J Infect Dis,2009,27(5):305-307.(in Chinese)玉艳红,江建宁,吴继周,等.肝性脑病患者预后影响因素的Logistic回归分析[J].中华传染病杂志,2009,27(5):305-307.
    [4]HAUSSINGER D,SCHLIESS F.Pathogenetic mechanisms of hepatic encephalopathy[J].Gut,2008,57(8):1156-1165.
    [5]LYU RY,LI SX.Study on the risk factors influencing the prognosis of hepatic encephalopathy[J].Chin J Gen Prac,2012,10(11):1687-1688.(in Chinese)吕日英,李仕雄.肝性脑病患者预后的危险因素分析[J].中华全科医学,2012,10(11):1687-1688.
    [6]NIE X,HE Y,LI GX,et al.Research on relationship between hepatorenal syndrome and hepatic encephalopathy[J].Chin J Lab Diag,2012,16(3):475-478.(in Chinese)聂鑫,贺勇,李贵星,等.肝肾综合征与肝性脑病的关系研究[J].中国实验诊断学,2012,16(3):475-478.
    [7]DING JB,LUO XL,TIAN YM,et al.Logistic regression analysis of prognostic factors for chronic severe hepatitis B[J].Infect Dis Info,2012,25(3):161-163.(in Chinese)丁剑波,罗晓岚,田一梅,等.慢性乙型重型肝炎预后影响因素Logistic回归分析[J].传染病信息,2012,25(3):161-163.
    [8]YE PY,YANG ZG,CHEN XR,et al.Risk factors associated with prognosis of progressive stages of acute-on-chronic hepatitis B liver failure[J].J Clin Hepatol,2013,29(4):270-275.(in Chinese)叶佩燕,杨宗国,陈晓蓉,等.HBV相关慢加急性肝衰竭不同分期的预后评价及影响因素分析[J].临床肝胆病杂志,2013,29(4):270-275.
    [9]CHEN DF,SUN WJ.Recent advances in understanding the pathogenesis of hepatic encephalopathy[J].Chin J Hepatol,2014,22(2):84-85.(in Chinese)陈东风,孙文静.肝性脑病发病机制的研究进展[J].中华肝脏病杂志,2014,22(2):84-85.
    [10]KHUNGAR V,POORDAD F.Hepatic encephalopathy[J].Clin Liver Dis,2012,16(2):301-320.
    [11]BANARES R,NEVENS F,LARSEN FS,et al.Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure:the relief trial[J].Hepatology,2013,57(3):1153-1162.
    [12]HASSANEIN TI,TOFTENG F,BROWN RS,et al.Randomized controlled study of extracorporeal albumin dialysis for hepatic encephalopathy in advanced cirrhosis[J].Hepatology,2007,46(6):1853-1862.
  • Relative Articles

    [1]Ao WANG, Ning LI. Application progress of transpapillary biliary drainage in endoscopic treatment of choledocholithiasis[J]. Journal of Clinical Hepatology, 2022, 38(12): 2868-2872. doi: 10.3969/j.issn.1001-5256.2022.12.036
    [2]Jincheng WANG, Peihe YU, Song SU, Bo LI. Clinical effect of endoscopic nasobiliary drainage versus endoscopic biliary stenting in preoperative biliary drainage for low-level malignant obstructive jaundice: A Meta-analysis[J]. Journal of Clinical Hepatology, 2021, 37(4): 863-867. doi: 10.3969/j.issn.1001-5256.2021.04.027
    [3]Yang DongXiao, Zhang Yong, Wang XueFeng, Li Jiang. Application of ultrasound-guided real-time percutaneous transhepatic-cholangial or transhepatic-cholecyst drainage in treatment of acute obstructive cholangitis in primary hospitals[J]. Journal of Clinical Hepatology, 2020, 36(4): 847-849. doi: 10.3969/j.issn.1001-5256.2020.04.027
    [4]Chen WeiWei, Huang Kun, Liu Rui, Liu ChengLi. Clinical effect of percutaneous transhepatic cholangial drainage combined with biliary stent implantation in treatment of high malignant obstructive jaundice and the influencing factors for prognosis[J]. Journal of Clinical Hepatology, 2019, 35(3): 559-564. doi: 10.3969/j.issn.1001-5256.2019.03.021
    [5]Peng FengHui, Liu Kai, Yang Yang, Liu YaHui, Ji Bo. Biliary stent implantation for malignant obstructive jaundice through the percutaneous transhepatic biliary drainage pathway: A report of 2 cases[J]. Journal of Clinical Hepatology, 2019, 35(7): 1601-1603. doi: 10.3969/j.issn.1001-5256.2019.07.038
    [6]The Society of Interventional Therapy, China Anti-Cancer Association. Expert consensus of percutaneous transhepatic biliary drainage and stent implantation in treatment of obstructive jaundice(2018 Edition)[J]. Journal of Clinical Hepatology, 2019, 35(3): 504-508. doi: 10.3969/j.issn.1001-5256.2019.03.010
    [7]Li GuangKuo, Yang Hong, Wang HongBo, Liao Wei, Lan Yan, Zhou Jie, Zhou JingJing, Chen Jun, Li Xin. A clinical study of endoscopic naso-gallbladder drainage-assisted laparoscopic subtotal cholecystectomy[J]. Journal of Clinical Hepatology, 2018, 34(3): 521-525. doi: 10.3969/j.issn.1001-5256.2018.03.014
    [8]Zhao HongGuang, Liu Kai, Liu YaHui. The most appropriate timing for selective laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage in patients with acute severe cholecystitis aged above 60 years[J]. Journal of Clinical Hepatology, 2017, 33(4): 705-710. doi: 10.3969/j.issn.1001-5256.2017.04.021
    [9]Wan JingLei, Shi YaoPu, Wang Bin, Gong ZhiWen, Yang Hang, Yang YongSheng. Clinical effect of laparoscopic internal drainage in treatment of pancreatic pseudocyst[J]. Journal of Clinical Hepatology, 2017, 33(9): 1762-1765. doi: 10.3969/j.issn.1001-5256.2017.09.027
    [10]Huang Jie, Ren ShiPu, Yang LiWen. Clinical effect of ultrasound- guided percutaneous transhepatic gallbladder drainage in treatment of acute cholecystitis[J]. Journal of Clinical Hepatology, 2017, 33(2): 286-288. doi: 10.3969/j.issn.1001-5256.2017.02.016
    [11]Wu ErBin, Zhang JinWei. Clinical application of selective intraoperative cholangiography in biliary system surgery[J]. Journal of Clinical Hepatology, 2016, 32(7): 1357-1359. doi: 10.3969/j.issn.1001-5256.2016.07.031
    [12]Tao Ping, Wu XiangYang, Zhang Lei. Clinical effect of ultrasound-guided percutaneous transhepatic gallbladder drainage in treatment of acute cholecystitis in elderly patients[J]. Journal of Clinical Hepatology, 2016, 32(10): 1929-1931. doi: 10.3969/j.issn.1001-5256.2016.10.021
    [13]Qi WenLei, Zhang RuoYan, Chai WenGang, Liu MingJiang, Du XiaoHong, Ye JunFeng. Diagnosis of clonorchiasis during and after biliary tract surgery: a clinical analysis of 15 cases[J]. Journal of Clinical Hepatology, 2016, 32(11): 2134-2137. doi: 10.3969/j.issn.1001-5256.2016.11.026
    [14]Chen QiuLian, Wu ShanShan, Liu ChaoHui. Clinical application of preoperative biliary drainage in malignant obstructive jaundice with acute cholangitis[J]. Journal of Clinical Hepatology, 2015, 31(10): 1652-1655. doi: 10.3969/j.issn.1001-5256.2015.10.023
    [15]Cheng XiangChao, Yuan QiDong, Zhao JianHong, Liu Bin. Percutaneous transhepatic approach for intrahepatic and extrahepatic bile duct stones: a clinical analysis of 19 cases[J]. Journal of Clinical Hepatology, 2015, 31(10): 1685-1687. doi: 10.3969/j.issn.1001-5256.2015.10.031
    [16]Sun JinChun. Clinical effect of laparoscopic common bile duct exploration combined with endobiliary drainage in treatment of acute biliary pancreatitis[J]. Journal of Clinical Hepatology, 2015, 31(5): 687-690. doi: 10.3969/j.issn.1001-5256.2015.05.013
    [17]Wang WenJun, Yu CongHui. Improvement in liver function in patients with malignant obstructive jaundice after endoscopic biliary metallic stent drainage[J]. Journal of Clinical Hepatology, 2015, 31(8): 1295-1298. doi: 10.3969/j.issn.1001-5256.2015.08.027
    [18]Wang Hua, Wang Tao, Tang LiJun. Application of fast-track surgery concept in perioperative patients with biliary calculi and liver cirrhosis: a prospective study[J]. Journal of Clinical Hepatology, 2014, 30(11): 1140-1143. doi: 10.3969/j.issn.1001-5256.2014.11.012
    [19]Zhu ZiMan, Jiao HuaBo, Wang DaDong, Li Tao, Zhang WenZhi. Clinical analysis of biliary duct reoperation after biliary duct multiple operations[J]. Journal of Clinical Hepatology, 2012, 28(4): 296-298.
    [20]Li JingYu, Lu JunLiang, Zhang Qiang, Liu Tao. The effect of PTCD in patients with hilar biliary obstruction using biliary drainage tube with added side holes[J]. Journal of Clinical Hepatology, 2010, 26(4): 415-417.
  • Cited by

    Periodical cited type(0)

    Other cited types(1)

  • 加载中

Catalog

    通讯作者: 陈斌, bchen63@163.com
    • 1. 

      沈阳化工大学材料科学与工程学院 沈阳 110142

    1. 本站搜索
    2. 百度学术搜索
    3. 万方数据库搜索
    4. CNKI搜索

    Article Metrics

    Article views (2249) PDF downloads(420) Cited by(1)
    Proportional views
    Related

    /

    DownLoad:  Full-Size Img  PowerPoint
    Return
    Return