血浆透析滤过治疗HBV相关慢加急性肝衰竭预后的影响因素分析

Plasmadiafiltration in treatment of hepatitis B virus related acute-on-chronic liver failure:analysis of prognostic factors

目的探讨血浆透析滤过治疗HBV相关慢加急性肝衰竭(ACLF)的疗效及预后的影响因素。方法回顾性分析41例接受血浆透析滤过治疗的HBV相关ACLF患者的临床资料,根据患者的短期预后(随访3个月)分为存活组和死亡组,分析两组间的临床指标和实验室检查结果,采用卡方检验、t检验分析血浆透析滤过的疗效及影响预后的相关因素。结果 41例患者血浆透析滤过治疗前的PTA为(18.33±7.75)%、TBil为(445.66±209.67)μmol/L、MELD评分为(32.08±6.75)分,3次血浆透析滤过治疗后第3天,PTA为(29.20±15.07)%、TBil为(396.88±151.78)μmol/L、MELD评分为(29.67±7.70)分,治疗前后比较,差异有统计学意义(t值分别为-3.826、2.042、2.026,均P<0.05)。存活组12例,死亡组29例。存活组患者入院时合并肝硬化比例为16.7%,低于死亡组的68.9%(χ~2=7.351,P<0.05);存活组诊断为肝衰竭至行血浆透析滤过治疗的间隔时间为(2.58±0.67)d,明显短于死亡组的(6.07±4.38)d(t=-4.167,P<0.05);入院时存活组合并肝性脑病比例为83.3%,死亡组比例为96.6%,差异无统计学意义(χ~2=0.672,P>0.05);存活组急性肾损伤(AKI)II期及III期患者比例为8.3%,而死亡组为65.5%,差异有统计学意义(χ~2=8.711,P<0.05)。存活组患者3次血浆透析滤过治疗后第3天与治疗前相比,MELD评分下降(8.33±4.19)分、PTA增加(21.72±15.62)%,而死亡组患者与治疗前相比,MELD评分增加(0.55±6.66)分、PTA增加(6.38±17.47)%,两组比较,差异有统计学意义(t值分别为4.267、-2.633,均P<0.05)。结论血浆透析滤过治疗能改善HBV相关ACLF中晚期患者的肝功能及凝血功能;治疗前具有肝硬化基础、肝衰竭病程长、AKI分期高的患者预后差;治疗72 h后,PTA、MELD评分有显著改善的患者预后佳。

Objective To investigate the efficacy and the prognostic factors of plasmadiafiltration treatment in hepatitis B virus（HBV）related acute-on-chronic liver failure（ACLF）patients.Methods Clinical data of 41 HBV-related ACLF patients in our department was retrospectively analyzed.According to the 3-month prognosis,patients were divided into survival group and death group,and the clinical parameters and laboratory tests were compared between the 2 groups.Chi square test and t test were applied for statistical analyses.Results Among these patients,levels of plasma prothrombin activity（PTA）（18.33±7.75 % vs 29.20±15.07 %;t=-3.826,P〈0.05）,total bilirubin（TBil）（445.66±209.67μmol/L vs 396.88±151.78μmol/L;t=2.042,P〈0.05）and model for end-stage liver disease（MELD）score（32.08±6.75 vs 29.67±7.70;t=2.026,P〈0.05）were significantly changed on day 3 after three subsequent treatments of plasmadiafiltration.There were 12 cases in survival group and 29 cases in death group.In survival group,the ratio of patients with cirrhosis at admission was lower than that in death group（16.7% vs 68.9%,χ^2=7.351,P〈0.05）,while the ratio of hepatic encephalopathy showed no significant difference（83.3% vs 96.6%,χ^2=0.672,P〈0.05）.The duration from diagnosis to plasmadiafiltration treatment was significantly shorter in survival group than that in death group（2.58±0.67 d vs 6.07±4.38 d;t=-4.167,P〈0.05）.Compared with survival group,death group showed higher ratio of stage Ⅱ and Ⅲ acute kidney injury（AKI）at baseline（65.5% vs 8.3%,χ^2=8.711,P〈0.05）.After plasmadiafiltration therapy,the improvements of MELD score and PTA in the survival group were significantly higher than that in death group.Conclusion Plasmadiafiltration therapy can improve liver function and blood coagulation function in patients with HBV-related ACLF.Moreover,pre-existing with liver cirrhosis,liver failure for long course and serious AKI stage at admission might be indicators for poor prognosis after plasmadiafiltration therapy,while significant improvements of PTA and MELD score after therapy might suggest favorable prognosis.