经颈静脉肝内门体分流术治疗慢加急性肝衰竭患者肝硬化急性失代偿的效果及安全性分析

Safety and efficacy of transjugular intrahepatic portosystemic shunt in treatment of acute decompensated cirrhotic events in patients with acute-on-chronic liver failure

目的研究经颈静脉肝内门体分流术(TIPS)治疗慢加急性肝衰竭(ACLF)患者肝硬化急性失代偿事件的安全性及有效性。方法回顾性选取2008年6月-2017年12月于空军军医大学消化病医院住院并接受TIPS治疗的35例伴有肝硬化急性失代偿事件的ACLF患者,通过倾向性评分的方法按照1∶1的比例与接受内科治疗的患者(35例)进行匹配,收集患者临床、实验室及影像学资料。连续型变量两组间比较采用t检验或Mann-Whitney U检验。分类变量两组间比较采用χ2检验。使用logistic回归模型分析影响患者疾病进程的危险因素,采用Kaplan-Meier方法估计累积生存概率,运用Cox回归模型分析影响患者生存的危险因素,以及竞争风险模型比较随访期间肝性脑病发生率。结果接受TIPS治疗的患者中,病情好转者20例,病情稳定或恶化者15例;内科治疗组中,病情好转者11例,病情恶化或稳定者24例,TIPS治疗组较多患者病情得到改善(χ2=4.69,P=0.03)。logistic回归模型调整了性别、年龄后,相对于内科治疗,TIPS治疗更有利于患者病情的改善(比值比=3.02,95%可信区间:0.12~0.91,P=0.03)。TIPS组28 d、180 d病死率分别为22.9%、42.9%,内科治疗组28 d、180 d病死率分别为17.1%、68.6%,TIPS组180 d生存率明显高于内科治疗组(χ2=3.92,P=0.048)。Cox多因素分析显示,血清总胆红素是影响患者预后的独立危险因素(风险比=1.04,95%可信区间:1.01~1.07,P=0.006)。随访期间两组中肝性脑病发生率差异无统计学意义(25.7%vs 20.0%,χ2=0.43,P=0.51)。结论与内科治疗相比,TIPS治疗ACLF肝硬化急性失代偿事件安全有效,显著改善患者病情进展,提高患者生存,同时不增加术后肝性脑病的发生率。

Objective To investigate the safety and efficacy of transjugular intrahepatic portosystemic shunt(TIPS)in the treatment of acute decompensated cirrhotic events in patients with acute-on-chronic liver failure(ACLF).Methods A retrospective analysis was performed for the clinical data of 35 patients with ACLF and acute decompensated cirrhotic events who were hospitalized and underwent TIPS in Xijing Hospital of Digestive Diseases,Air Force Medical University,from June 2008 to December 2017,and 35 patients,matched by the propensity score at a ratio of 1∶1,who underwent medical treatment were enrolled.Related clinical,laboratory,and imaging data were collected.The t-test or the Mann-Whitney U test was used for comparison of continuous variables between two groups,and the chi-square test used for comparison of categorical data.A logistic regression model was used to investigate the risk factors for disease progression;the Kaplan-Meier method was used to estimate cumulative survival probability;the Cox regression model was used to determine the risk factors for survival,and a competing-risk model was used to compare the incidence rate of hepatic encephalopathy during follow-up.Results Among the patients who underwent TIPS,20 achieved disease improvement and 15 had stable conditions or experienced aggravation,while among the patients who received medical treatment,11 achieved disease improvement and 24 had stable conditions or experienced aggravation;the TIPS group had a significantly higher proportion of patients with improvement than the medical treatment group(χ2=4.69,P=0.03).After the adjustment for sex and age in the logistic regression model,TIPS was more helpful for disease improvement than medical treatment(odds ratio=3.02,95%confidence interval[CI]:0.12-0.91,P=0.03).The 28-and 180-day mortality rates were 22.9%and 42.9%,respectively,in the TIPS group and 17.1%and 68.6%,respectively,in the medical treatment group,and the TIPS group had a significantly higher 180-day survival rate than the medical treatment group(χ2=3.92,P=0.048).The Cox multivariate analysis showed that serum total bilirubin was an independent risk factor for prognosis(hazard ratio=1.04,95%CI:1.01-1.07,P=0.006).There was no significant difference in the incidence rate of hepatic encephalopathy during follow-up between the TIPS group and the medical treatment group(25.7%vs 20.0%,χ2=0.43,P=0.51).Conclusion Compared with medical treatment,TIPS is a safe and effective method for acute decompensated cirrhotic events in patients with ACLF and can significantly improve disease progression and survival,and meanwhile,it does not increase the incidence rate of hepatic encephalopathy.