慢加急性肝衰竭患者血小板计数及其动态变化的临床意义

Clinical significance of platelet count and its dynamic change in patients with acute-on-chronic liver failure

目的肝衰竭患者往往存在严重的血小板减少现象。对慢加急性肝衰竭(ACLF)患者血小板的动态变化进行监测分析,探讨血小板水平及其变化与患者预后的关系,并分析血小板减少的原因。方法收集2014年9月-2016年9月于首都医科大学附属北京佑安医院住院的54例ACLF患者的临床资料。血小板由全自动血常规分析仪检测获得,促血小板生成素(TPO)水平采用ELISA方法检测获得。正态分布的计量资料2组间比较采用t检验;非正态分布的计量资料2组间比较采用Mann-Whitney U检验;计数资料组间比较采用χ2检验。预后相关参数采用单因素及多因素logistic回归分析;应用受试者工作特征曲线(ROC曲线)分析血小板计数变化对肝衰竭的诊断价值。结果 ACLF患者出院时死亡18例,病死率为33.3%。ACLF患者基线血小板为80.0(36.0~334.0)×109/L,较正常值明显下降。出院前血小板下降幅度在死亡组显著大于存活组[(-43.4±58.9)×109/L vs(-11.5±29.1)×109/L,t=-2.827,P=0.041]。以血小板变化-27.5×109/L为cut-off值,血小板变化>-27.5×109/L和≤-27.5×109/L组病死率比较,差异有统计学意义(22.2%vs 72.2%,χ2=12.623,P<0.01)。单因素分析表明:血小板变化、PTA、Glu为患者预后的影响因素。多因素分析表明血小板变化为ACLF患者预后的独立影响因素,ROC曲线下面积为0.743。其中24例ACLF患者检测了血浆TPO水平,出院时死亡8例,病死率为33.3%。ACLF存活组与死亡组TPO水平分别为(91.8±39.8)pg/ml和(93.3±46.5)pg/ml,2组比较差异无统计学意义(t=0,P=0.938)。结论 ACLF患者基线血小板显著低于正常血小板的范围,血小板下降幅度是ACLF患者出院时死亡的独立影响因素,血小板减少与TPO水平下降无关。

Objective To investigate the dynamic change of platelets in patients with acute-on-chronic liver failure（ACLF）,the association of platelet count and its change with patients’ prognosis,and the cause of thrombocytopenia,since severe thrombocytopenia is often seen in patients with liver failure.Methods A total of 54 patients with ACLF who were hospitalized in Beijing You’ an Hospital,Capital Medical University,from September 2014 to September 2016 were enrolled,and their clinical data were collected.An automatic blood analyzer was used to measure platelet count,and ELISA was used to measure the level of thrombopoietin（TPO）.The t-test was used for comparison of normally distributed continuous data between two groups,and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between groups.The univariate and multivariate logistic regression analyses were used for prognostic parameters,and the receiver operating characteristic（ROC）curve was used to analyze the value of the change in platelet count in the diagnosis of liver failure.Results A total of 18 ACLF patients died before discharge,resulting in a mortality rate of 33.3%.These patients had a mean platelet count of 80.0 × 10^9/L [range（36.0-334.0） ×10^9/L],which was significantly lower than the normal value.The death group had a significantly greater reduction in platelet count than the survival group [（-43.4 ± 58.9） × 10^9/L vs（-11.5 ± 29.1） × 10^9/L,t =-2.827,P = 0.041].With -27.5 × 10^9/L as the cut-off value of the change in platelet count,there was a significant difference in mortality rate between the platelet count change 〉-27.5 × 10^9/L group and the platelet count change ≤-27.5 × 109/L group（22.2% vs 72.2%,χ^2= 12.623,P 〈 0.01）.The univariate analysis showed that platelet change,prothrombin time activity,and fasting blood glucose were influencing factors for patients’ prognosis,and the multivariate analysis showed that platelet change was an independent influencing factor for the prognosis of ACLF patients,with an area under the ROC curve of0.743.The plasma level of TPO was measured for 24 patients,among whom 8 died before discharge,resulting in a mortality rate of 33.3%.There was no significant difference in the level of TPO between the survival group and the death group（91.8 ± 39.8 pg/ml vs 93.3 ± 46.5 pg/ml,t = 0,P = 0.938）.Conclusion Baseline platelet count in ACLF patients is significantly lower than the normal value.The reduction in platelet count is an independent risk factor for death before discharge in ACLF patients.Thrombocytopenia may not be associated with the reduction in TPO.