肝移植术后患者预后不良的独立危险因素分析

Analysis of independent risk factor in patients with poor prognosis after liver transplantation

目的了解肝移植手术患者术后的预后情况，并阐明与预后相关的危险因素。方法回顾性分析上海交通大学医学院附属仁济医院首次接受原位经典尸体肝移植手术成人患者，收集患者术前、术中和术后临床资料。运用急性肾损伤网络（AKIN）定义的急性肾损伤（AKI）诊断和分期标准观察肝移植手术患者术后AKI的发生情况；应用Kaplan—Meier生存曲线分析患者术后28d和1年的预后情况，采用Cox风险回归模型分析患者死亡危险因素，重点观察AKI对患者预后的影响。结果符合入选标准的病例共193例，年龄（48．07±10．02）岁，男女比例4：1，术后共有116例（占60．1％）患者发生了AKI。AKI患者术后28d病死率明显高于非AKI患者[15．5％（18／116）比0，P〈0．053，1年存活率明显低于非AKI患者（70．7％（82／116）比90．9％（70／77），P〈0．053；Kaplan—Meier生存分析显示，非AKI患者（77例）和术后AKI1、2、3期（分别为58、25、33例）患者1年生存率分别为90．9％、81．0％、84．0％、42．4％，术后28d死亡患者均发生术后AKI，Cox回归显示，术前高血压及术后AKI、感染、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分≥10分是术后1年患者死亡的独立危险因素；术前高血压死亡危险度（HR）为4．398，95％可信区间（CI）为1．535～12．604；术后AKI的HR为12．100，95％CI为1．565～93．540；术后感染的HR为4．709，95％CI为1．813～12．226；术后APACHEⅡ评分的HR为3．627，95％CI为1．244～10．573（P〈0．05或P〈0．01）。结论AKI是肝移植患者术后预后不良的独立危险因素，预防AKI的发生可能有助于提高患者的生存率。

Objective To investigate the prognosis after orthotopic liver transplantation （OLT）, and to elucidate the risk factors of poor prognosis in these patients. Methods Adult recipients of OLT in Renji Hospital of Shanghai Jiaotong Universit： were retrospectively analyzed. Data in pre-, intra- and post-OLT periods of these patients were collected. Acute kidney injury net （AKIN） criteria were used to analyze the post-OLT acute kidney injury （AKI）. By following up all the patients for over a year, Kaplan-Meier survival analysis was used to evaluate the prognosis within 28 days and 1 year. Cox regression analysis was performed to evaluate risk factors of patient death, especially the influence of AKI on patient prognosis. Results There were 193 patients enrolled, the average age was （48.07±10.02） years old. The ratio of male to female was 4 ： 1. One hundred and sixteen patients （60. 1%） were found to have AKI after OLT. Twenty-eight-day mortality of post-OLT AKI patients was higher than that without AKI patients [15.5% （18/116） vs. 0, P〈0.05）, 1 year survival rate of post-OLT AKI patients was lower than that without AKI patients [（70. 7% （82/116） vs. 90. 9 （70/77）, P〈0. 053. Kaplan-Meier survival analysis showed the survival rate of non-AKI （77 patients）, AKI stage 1, 2 and 3 patients （58, 25 and 33 patients respectively） post-OLT were 90. 9%, 81.0%, 84. 0% and 42.4%, respectively. All the non-survivors were discovered to have AKI within 28 days post-OLT. Cox regression analysis showed pre-OLT hypertension [hazard ratio （HR）= 4. 398, 95% confidence interval （CI）.. 1.535 12.604, P= 0.0061, post-OLT AKI （HR = 12.100, 95%CI： 1.565-93.540, P=0.017）, infection （HR=4.709, 95%CI： 1.813 12.226, P=0.001） and acute physiology and chronic health evaluation Ⅱ （APACHE Ⅰ ） score ≥10 （HR= 3. 627, 95%CI： 1. 244 -10. 573, P= 0. 018） were risk factors of 1 year death. Conclusion AKI is an independent risk factor of poor prognosis after liver transplantation. Prevention of AKI may improve the survival rate of OLT patients.