低糖血症与急性失代偿性肝硬化患者病死率增加的相关性研究

Correlation between hypoglycemia and increased mortality of patients with acute decompensated liver cirrhosis

目的探讨低糖血症与急性失代偿性肝硬化患者病死率增加的相关性。方法回顾性分析2011年12月至2014年12月就诊于河北医科大学第二医院肝胆外科的120例失代偿性肝硬化患者的临床资料，将患者分为低糖血症组（血糖〈5．0mmo]／L，21例）、正常血糖组（血糖5．1～10．0mmol／L，84例）、高糖血症组（血糖〉10．1mmol／L，15例），比较3组患者肝癌、代偿失调症状、已知糖代谢紊乱发生率及住院情况、肝功能指标和血气分析指标的差异，对患者的年龄、肝癌、腹水、肝肾综合征、脑病、出血、黄疸、糖代谢紊乱等资料进行单因素分析，将有统计学差异的危险因素进行多因素logistie回归分析，筛选出患者病死率增加的危险因素。结果低糖血症组患者肝肾综合征发生率[42．9％（9／21）比22．6％（19／84）、33．3％（5／15）]、黄疸发生率[38．1％（8／21）比20．2％（17／84）、13．3％（2／15）]、重症加强治疗病房（ICU）人住率[14．3％（3／21）比10．7％（9／84）、13．3％（2／15）]、住院病死率[23．8％（5／21）比10．7％（9／84）、20．0％（3／15）]均显著高于正常血糖组和高糖血症组（P〈0．05或P〈0．01）；低糖血症组患者天冬氨酸转氨酶（AST（U／L）：628．412±78．625比170．167±87．035、156．716±98．047]、总胆红素[TBil（μmol／L）：154．122±34．201比86．712±48．905、74．313±39．883]、血肌酐[SCr（μmol／L）：160．243±56．341比107．211±59，692、121．342±84．059]及国际标准化比值（INR：1．951±0．987比1．439±0．919、1．423±0．653）水平均显著高于正常血糖组和高血糖组，3组比较差异有统计学意义（p〈0．05或P〈0．01）；碳酸氢根[HCO，-（mmol／L）：18．154±10．937比23．135±11．119、19．081±12．022]和剩余碱[BE（mmol／L）：～7．578±2．042比-1．648±0．887、-5．402±2．005]均低于正常血糖组和高糖血症组，3组比较差异有统计学意义（均P〈0．01）；3组pH值水平比较差异亦有统计学意义（7．352±2．878比7．461±2．036、7．219±2．017，P〈0．01），3组丙氨酸转氨酶（ALT）、血氨、动脉血氧分压（PaO，）、动脉血二氧化碳分压（PaCO2）、乳酸（Lac）比较差异均无统计学意义（均P〉O．05）。单因素分析显示：高龄、肝癌、肝肾综合征、出血、黄疸、糖代谢紊乱低糖血症是急性失代偿性肝硬化患者的死亡危险因素（P〈0．05或P〈0．01）；多因素logistie回归分析显示：高龄[优势比（OR）值=2．101，95％可信区间（95％C／）=1．297～3．403，P=O．000]、肝肾综合征（OR值=3．032，95％CI=1．462～6．286，P=O．000）、低糖血症（OR值=3．267，95％c，=2．135—4．999，P=0．031）是导致患者死亡的危险因素。结论低糖血症与急性失代偿性肝硬化患者病死率增加有一定的相关性。

Objective To explore the correlation between hypoglycemia and the increased mortality of patients with acute decompensated liver cirrhosis. Methods A retrospective study was conducted on the clinical data of 120 patients with acute decompensated liver cirrhosis admitted to the Department of Hepatobiliary Surgery of the Second Hospital of Hebei Medical University from December 2011 to December 2014. The patients were divided into three groups： hypoglycemia group （glucose 〈 5.0 mmol/L, 21 cases）, normoglycemia group （glucose 5.1 - 10.0 mmol/L, 84 cases）, and hyperglycemia group （glucose 〉 10.0 mmol/L, 15 cases）. The differences in hepatic carcinoma, decompensation symptoms, the incidence of known glycometabolic disorder, hospitalization situation, indicators of liver function and indexes of blood gas analysis were compared among three groups. The patients＇ age, hepatic carcinoma, ascites, hepatorenal syndrome, encephalopathy, bleeding, jaundice and glycometabolic disorder, etc were analyzed by the univariate analysis. The resulting risk factors with statistically significant differences were analyzed by multivariate logistic regression method in order to screen out the risk factors of increased mortality. Results The incidences of hepatorenal syndrome [42.9% （9/21） vs. 22.6% （19/84）, 33.3% （5/15）] and jaundice [38.1% （7/21） vs. 20.2% （17/84）, 13.3% （2/15）], rate of admission into intensive care unit （ICU） [14.3% （3/21） vs. 10.7% （9/84）, 13.3% （2/15）] and in- hospital mortality [23.8% （5/21） vs. 10.7% （9/84）, 20.0% （3/15）] in the hypoglycemia group were significantly higher than those in the normoglyeemia group and hyperglycemia group （P 〈 0.05 or P 〈 0.01）. The levels of aspartate- aminotransferase （AST）, total bilirubin （TBil）, serum creatininc （SCr） and international normalized ratio （INR） in hypoglycemia group were obviously higher than those in normoglyeemia group and hyperglycemia group [AST （U/L）： 628.412.± 78.625 vs. 170.167± 87.035, 156.716 ± 98.047; TBil （μmol/L）： 154.122± 34.201 vs. 86.712± 48.905, 74.313 ± 39.883; SCr （μmol/L）： 160.243 ± 56.34l vs. 107.211 ± 59.692, 121.342 ±84.059; INR： 1.951 ± 0.987 vs. 1.439 ± 0.919, 1.423 ± 0.653, P 〈 0.05 or P 〈 0.01]. The levels of HCO3- and base excess （BE） in hypoglycemia group were signieantly lower than those of normoglyeemia group and hyperglycemia group [HCO3- （mmol/L）： 18.154 ± 10.937 vs. 23.135 ± 11.119, 19.081± 12.022; BE （mmol/L）： -7.578 ± 2.042 vs. -1.648 ±0.887, -5.402±2.005, all P 〈 0.01]. The pH value among three groups showed significant difference （7.352 ± 2.878, 7.461 ± 2.036, 7.219 ± 2.017, P 〈 0.01）. There were no statistically significant differences in alanine transaminase （ALT）, blood ammonium, arterial partial pressure of oxygen （PaO2） and arterial partial pressure of carbon dioxide （PaCO2） and lactate among the three groups （all P 〉 0.05）. Univariate analysis showed that advanced age, hepatic carcinoma, hepatorenal syndrome, bleeding, jaundice and glyeometabolie disorder hypoglycemia were the risk factors of the death in patients with acute deeompensated liver cirrhosis （P 〈 0.05 or P 〈 0.01）. Multivariate logistic regression analysis showed that advanced age [odds ratio （OR） = 2.101, 95% confidence interval （95%C/） = 1.297 - 3.403, P = 0.000], hepatorenal syndrome （OR = 3.032, 95%CI = 1.462 - 6.286, P = 0.000） and hypoglycemia （OR = 3.267, 95%C1 = 2.135 - 4.999, P = 0.031） were the independent risk factors of the patients＇ death. Conclusion Hypoglycemia has certain correlation to the increase of mortality in patients with acute decompensated liver cirrhosis.