急性肾损伤治疗48小时应答与否对HBV相关慢加急性肝衰竭短期预后的影响

Effect of response at 48 hours of treatment of acute kidney injury on short-term prognosis of hepatitis B virus-associated acute-on-chronic liver failure

目的探讨HBV相关慢加急性肝衰竭(HBV-ACLF)合并急性肾损伤(AKI)患者AKI治疗48 h应答与否对其28 d和90 d预后的影响。方法回顾性分析2012年12月-2014年12月在解放军总医院第五医学中心住院治疗的130例HBV-ACLF合并AKI患者的临床资料,根据AKI治疗48 h的情况分为应答组和无应答组,比较2组患者28 d和90 d生存率,进而筛选28 d和90 d预后独立影响因素。符合正态分布的计量资料2组间比较采用t检验;不符合正态分布的计量资料2组间比较采用Kolmogorow-Smirnov Z秩和检验。计数资料2组间比较则采用χ^2检验。采用Kaplan-Meier生存曲线分析2组患者的生存率,并应用logrank检验进行比较。采用Cox回归风险模型进行预后影响因素的单因素及多因素分析。结果 AKI治疗48 h应答组38例(29.2%),无应答组92例(70.8%)。无应答组28 d和90 d生存率均低于应答组(χ^2值分别为16.91、23.28,P值均<0.01)。Cox回归分析显示,AKI治疗48 h应答、年龄、血清肌酐、血清钠、INR、肝性脑病是HBV-ACLF合并AKI患者28 d死亡[风险比(95%可信区间)分别为0.271(0.116~0.631)、1.024(1.001~1.047)、1.002(1.000~1.005)、0.948(0.904~0.993)、1.451(1.139~1.849、1.987(1.076~3.670),P值均<0.05]及90 d死亡[风险比(95%可信区间)分别为0.292 (0.151~0.563)、1.024 (1.004~1.044)、1.002 (1.000~1.004)、0.946(0.909~0.984)、1.473(1.180~1.839)、2.135(1.232~3.700),P值均<0.05]的独立危险因素。结论 AKI治疗48 h应答能显著改善HBV-ACLF合并AKI患者的短期预后,临床加强对AKI的早期诊断和积极治疗有助于改善患者预后。

Objective To investigate whether response to the treatment of acute kidney injury( AKI) is achieved at 48 hours and its effect on the 28-and 90-day prognosis of patients with hepatitis B virus-associated acute-on-chronic liver failure( HBV-ACLF) and AKI.Methods A retrospective analysis was performed for the clinical data of 130 patients with HBV-ACLF and AKI who were hospitalized and treated in The Fifth Medical Center of Chinese PLA General Hospital from December 2012 to December 2014.According to the response to AKI treatment at 48 hours,the patients were divided into response group and non-response group,and the two groups were compared in terms of 28-and 90-day survival rates to screen out the independent influencing factors for 28-and 90-day prognosis.The t-test was used for comparison of normally distributed continuous data between two groups,and the Kolmogorov-Smirnov Z 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 two groups.The Kaplan-Meier survival curve was used to analyze survival rate,and the log-rank test was used for comparison.The Cox regression model was used to perform the univariate and multivariate analyses of influencing factors for prognosis.Results There were38 patients( 29.2%) in the response group and 92 patients( 70.8%) in the non-response group.The non-response group had significantly lower 28-and 90-day survival rates than the response group(χ^2= 16.91,23.28,both P<0.01).The Cox regression analysis showed that response to AKI treatment at 48 hours,age,serum creatinine,serum sodium,international normalized ratio,and hepatic encephalopathy were independent risk factors for 28-( HR( 95% CI)= 0.271( 0.116-0.631),1.024( 1.001-1.047),1.002( 1.000-1.005),0.948( 0.904-0.993),1.451( 1.139-1.849,1.987( 1.076-3.670),all P<0.05) and 90-day( HR( 95% CI)= 0.292( 0.151-0.563),1.024( 1.004-1.044),1.002( 1.000-1.004),0.946( 0.909-0.984),1.473( 1.180-1.839),2.135( 1.232-3.700),all P<0.05) mortality in patients with HBV-ACLF and AKI.Conclusion Response to AKI treatment at 48 hours can significantly improve the short-term prognosis of patients with HBV-ACLF and AKI.Early diagnosis and active treatment of AKI should be strengthened in clinical practice to improve patient prognosis.