HBV相关慢加急性肝衰竭患者短期预后的影响因素

Analysis of influencing factors for short-term outcome in patients with hepatitis B virus-related acute-on-chronic liver failure

目的探讨抗病毒药拉米夫定(LAM)和恩替卡韦(ETV)对HBV相关慢加急性肝衰竭(ACLF)患者短期预后的影响。方法收集福州市传染病医院2004年1月-2010年12月的445例HBV相关ACLF住院患者(其中LAM治疗333例,ETV治疗112例)的临床资料,包括年龄、性别、并发症、临床生化指标、凝血指标、抗病毒药使用情况、人工肝治疗及24周生存情况,进行单因素和多因素回归分析,筛选出影响患者24周预后的独立危险因素。其中单因素分析,计量资料采用t检验及Mann-Whithey U检验,计数资料采用χ2检验;多因素分析采用Logistic回归分析。结果单因素分析结果显示,LAM组的球蛋白(Glb)、TBil、国际标准化比值(INR)、血肌酐(Cr)、终末期肝病评分模型(MELD评分)较ETV组高,胆碱酯酶、凝血酶原活动度(PTA)较ETV组低,差异均有统计学意义(P值均<0.05);死亡组的年龄、肝硬化、肝性脑病、自发性腹膜炎、肺部感染、霉菌感染、电解质紊乱、肝肾综合征、上消化道出血等发生率、TBil、INR、白细胞(WBC)、MELD评分较存活组更高,白蛋白(Alb)、GGT、胆固醇、胆碱酯酶、血钠、PTA、甲胎蛋白(AFP)、血红蛋白(Hb)、血小板(PLT)、HBe Ag阳性率较存活组低,差异均有统计学意义(P值均<0.05),死亡组与存活组抗病毒药物使用(LAM∶ETV)差异无统计学意义(P=0.21)。多因素Logistic回归分析显示年龄、肝性脑病、肝肾综合征、胆碱酯酶及PTA降低、直接胆红素(DBil)升高是24周患者死亡的独立危险因素,人工肝治疗是保护性因素。结论抗病毒药LAM和ETV之间的选择并不影响HBV相关ACLF患者的短期预后,年龄、肝性脑病、肝肾综合征、胆碱酯酶及PTA降低、DBil升高是影响患者短期预后的独立危险因素,人工肝治疗是保护性因素。

Objective To investigate the effects of antiviral drugs,lamivudine （LAM）and entecavir （ETV）,on the short -term outcome in patients with hepatitis B virus （HBV）-related acute -on -chronic liver failure （ACLF）.Methods The demographic and clinical data of 445 patients with HBV -related ACLF （LAM∶ETV,333∶112）who were hospitalized in the First Clinical Medical College of Fujian Med-ical University from January 2004 to December 2010 were collected,including age,sex,complications,clinical biochemical parameters,co-agulation parameters,the use of antiviral drug,artificial liver treatment,and the survival at 24 weeks.The independent risk factors for the outcome at 24 weeks were determined by univariate and multivariate logistic regression analyses.Results The univariate analysis indicated that the LAM group had significantly higher globulin,total bilirubin （TBil）,alanine aminotransferase,international normalized ratio （INR）,serum creatinine,and model for end -stage liver disease （MELD）score than the ETV group （P 〈0.05）,but had significantly lower cholinesterase and prothrombin time activity （PTA）than the ETV group （P 〈0.05）.The death group had significantly older age, higher incidence rates of liver cirrhosis,hepatic encephalopathy,spontaneous bacterial peritonitis,pulmonary infection,mycotic infection, electrolyte disturbance,hepatorenal syndrome,and upper gastrointestinal hemorrhage,and higher TBil,INR,white blood count,and MELD score than the survival group （P 〈0.05）,but had significantly lower albumin,gamma -glutamyl transpeptidase,cholesterol,cholinesterase, serum sodium,PTA,alpha -fetoprotein,hemoglobin,platelet,and positive rate of HBeAg than the survival group （P 〈0.05）.And there was no significant difference in the use of antiviral drugs （LAM∶ETV）between the death group and the survival group （P =0.21 ）.The multivariate logistic regression analysis showed that older age,hepatic encephalopathy,hepatorenal syndrome,lower cholinesterase,lower＆nbsp;PTA,and higher DBil were the independent risk factors for overall mortality at 24 weeks,and the artificial liver treatment was a protective factor.Conclusion The selection of antiviral drugs （LAMand ETV）does not affect the short -term outcome in patients with HBV -relat-ed ACLF.The age,hepatic encephalopathy,hepatorenal syndrome,lower cholinesterase,lower PTA,and higher DBil are the independent risk factors for the short -term outcome,and the artificial liver treatment is a protective factor.