影响1型肝肾综合征患者预后因素的临床研究

The Clinical Research of Prognostic Factors for Patients with Type 1 Hepatorenal Syndrome

目的:寻找影响1型肝肾综合征(HRS)患者预后的危险因素,为降低HRS发病率,提高临床疗效,判断预后提供参考。方法:回顾性分析105例HRS患者的病历资料,采用1996年国际腹水联合会诊断标准分为1型HRS和2型HRS,记录所有入选患者人口统计学指标、生化指标、治疗情况和预后,计算终末期肝病(MELD)评分和简化MELD评分,比较分析1型HRS和2型HRS的MELD评分的起始值、中位值和平均值,了解两种类型HRS的差异;将血肌酐、胆红素、白蛋白、MELD评分等可能的危险因素纳入时间依存风险比例模型探讨影响1型HRS预后的因素。结果:(1)共105例患者入选,男56例,女49例,平均年龄(50±12)岁。其中1型HRS68例,占64.76%;2型HRS37例,占35.24%。随访时间为50(1～489)d,随访期间,85例死亡,3例失访,2例行肝移植,17例仍存活。(2)1型HRS组的MELD中位值和平均值显著高于2型HRS组,差异有统计学意义(P<0.05);Kaplan-Meier风险模型生存分析显示1型HRS的预后较2型HRS差,死亡分析明显增加;(3)时间依存风险比例模型分析显示,随访期间血肌酐和总胆红素每升高1单位,1型HRS患者死亡风险分别增加29.3%和4.2%;血白蛋白每降低1单位,1型HRS患者死亡风险增加30.1%;INR和传统MELD评分的变化与1型HRS的预后无关;但简化MELD每变化1个单位,死亡风险增加24.2%。结论:总胆红素、血肌酐、血白蛋白是影响1型HRS预后的重要因素;传统MELD评分并不能预测1型HRS的预后,而简化MELD值的变化却是影响1型HRS患者预后的重要因素。

Objective：We aimed to know the significant predictors of type 1 hepatorenal syndrome （HRS）.In addition to the initial model of end-stage liver disease （MELD） scores and biochemistry parameters,we want to further investigate the prognostic importance of changes in MELD scores and biochemistry parameters over time for patients with type 1 HRS.Methods：This is a retrospective study,data from type 1 HRS patients were incorporated,including their demographic,clinical progression,all recording biochemical parameters,therapeutic methods,and outcomes.MELD score simple were calculated by CRE and TBI.Kaplan-Meier estimates of survival curves were calculated for patients with type 1 and type 2 HRS.The probable danger factors,such as creatinine （CRE）,total bilirubin（TBI）,were included into the time-dependent proportional hazards model to get the prognostic factors.Results：A total of 105 patients were included in the study.According to the definition of the International Ascites Club,68 patients（or 64.76%） had type 1 HRS whereas 37（or 35.24%） had type 2 HRS.According to the multivariate COX proportional hazards regression model,either initial biochemistry parameters or MELD scores were not significantly associated with prognosis.By time-dependent proportional hazards model,each point elevated in CRE and total TBI levels during the admission increased mortality risk by 29.3% and 4.2%,respectively.Increasing albumin level during the admission showed its protective value.Changes in MELD score simple during the admission were significant predictor for patients with type 1 HRS.Conclusion：In patients with type 1 HRS,changes in TBI,CRE,and albumin level during the admission were associated with prognosis.Changes in MELD score simple is superior to initial and changes in MELD scores to predict prognosis in patients with type 1 HRS.