血浆置换序贯双重血浆分子吸附治疗慢加急性乙型肝炎肝衰竭患者疗效及短期生存分析

Effect of plasma exchange and sequential double plasma molecular adsorbent therapy on short survival in patients with hepatitis B virus-induced acute on chronic liver failure

目的本研究主要是观察血浆置换(PE)序贯双重血浆分子吸附(DPMAS)治疗乙型肝炎相关性慢加急性肝衰竭(ACLF)患者的疗效。方法在83例ACLF患者,采用PE序贯DPMAS治疗,随访90 d。结果在本组83例ACLF患者中,早期29例,中期34例和晚期20例;在治疗90 d,早期生存率为65.5%,中期为38.2%,而晚期为15.0%(P<0.001);早中晚期ACLF患者肝性脑病发生率分别为20.7%、52.9%和60.0%(P<0.05);多因素COX回归分析显示,肝衰竭晚期(P=0.01),肝性脑病≥II级(P=0.001),血清TBIL≥350μmol/L(P=0.008)和CLIF-SOFA≥10分(P=0.043)是ACLF患者死亡的独立危险因素。结论 PE序贯DPMAS可有效降低血清胆红素水平,而对肾功能无不利影响,从而可以明显改善患者整体生存率,且对早中期患者疗效较好,仍需扩大研究进一步证实。肝衰竭晚期,肝性脑病≥II期,血清TBIL≥350μmol/L或CLIF-SOFA≥10分患者预后不良。

Objective The prognosis of patients with ACLF is extremely poor with mortality rates ranging from 30% to 70%. Hemoperfusion,plasma exchange(PE) and double plasma molecular absorb system(DPMAS)are the most popular non-biological artificial liver support system applied in China. The present study was to evaluate the effects of PE and sequential DPMAS therapy on short survival in patients with hepatitis B virus-induced acute-on-chronic liver failure(HBV-ACLF). Method 83 patients at different stages of HBV-ACLF were recruited in Xijing hospital between January 2011 and December 2016. All the laboratory parameters were collected at admission,before and after artificial liver support system therapy,and at the end of 90 day follow up.Result There were 29 cases at early stage,34 cases at middle stage and 20 cases at advanced stage at admission in this series of 83 patients with HBV-ACLF. At the end of 90 days of treatment,the survival rate in patients at early stage was 65.5%,in patients at middle stage was 38.2%,and in patients at advanced stage was15.0%(P<0.001);The incidence rates of hepatic encephalopathy in patients at early,middle and advanced stage were 20.7%,52.9% and 60.0%(P<0.05);Multivariate Logistic regression analysis showed that the advanced stage(P=0.01),serum bilirubin level being ≥350 μmol/L(P=0.008),hepatic encephalopathy being≥grade 2(P=0.001)and CLIF-SOFA being≥10(P=0.043) at presentation were the independent risk factors of mortality in patients with HBV ACLF. Conclusion Sequential PE and DPMAS therapy might remove toxin from blood,improve the overall survival rate,and the efficacy is obvious in patients at early and middle stage,which still needs further investigation. Patients at admission have serum bilirubin levels ≥350 μmol/L,with hepatic encephalopathy≥grade2,CLIF-SOFA scores≥10 and at advanced stage might hint poor prognosis.