不同非生物人工肝治疗慢加急性肝功能衰竭的效果比较

Comparison on effects of three non-biological artificial liver methods in treatment of acute-on-chronic liver failure

目的比较不同非生物人工肝(NBAL)方法治疗慢加急性肝功能衰竭(ACLF)的效果。方法回顾分析2014年1月至2018年12月在桂林市第三人民医院接受NBAL治疗的320例ACLF患者的临床资料,根据治疗方法不同将患者分为血浆置换组(PE组,106例)、PE联合血浆胆红素吸附(PBA)组(PE+PBA组,106例)和PE联合双重血浆分子吸附系统(DPMAS)组(PE+DPMAS组,108例)。记录治疗前后各组患者黄疸、乏力、食欲不振、腹胀、尿少、肝性脑病等临床症状和体征,检测血常规〔白细胞计数(WBC)、血红蛋白(Hb)、血小板计数(PLT)〕、凝血功能指标〔凝血酶原时间(PT)、凝血酶原活动度(PTA)、国际标准化比值(INR)〕、肝功能指标〔丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TBil)、血清球蛋白(GLB)、γ-谷氨酰转移酶(GGT)、碱性磷酸酶(ALP)、血氨(BA)、前白蛋白(PA)〕,以及电解质指标〔钠离子(Na^(+))、钙离子(Ca^(2+))〕;采用多因素线性回归方差分析筛选影响预后的危险因素;采用单因素重复测量方差分析(ANOVA)和最小显著性差异检验(LSD)比较各组实验室指标改善情况,评估不同NBAL方法的短期疗效。结果多因素线性回归方差分析显示,INR和TBil均为影响患者预后的独立危险因素(B值分别为1.880、0.001,P值分别为0.01、0.00),且INR的诊断价值优于TBil。治疗28 d后,各组实验室指标均较治疗前有所改善;PE+PBA组的ALT、AST、GGT、ALP、BA、PT、Na^(+)、Ca^(2+)、Hb、PLT、PTA、INR改善效果明显优于PE组,PE+DPMAS组的ALT、AST、GGT、ALP、BA、PA、PT、Ca^(2+)、WBC、Hb、PTA、INR改善效果明显优于PE组,PE+DPMAS组的PA、BA、Na^(+)、WBC、Hb改善效果明显优于PE+PBA组。PE+PBA组的病死率明显低于PE组〔4.72%(5/106)比9.43%(10/106),P<0.05〕。结论PE联合DPMAS治疗ACLF的短期实验室指标改善效果优于PE联合PBA和单纯PE治疗,且PE联合PBA方法的临床症状好转率和实验室指标改善效果优于单纯PE治疗。

Objective To compare the clinical efficacies of using different methods of non-biological artificial liver(NBAL)for treatment of patients with acute-on-chronic liver failure(ACLF).Methods The clinical data of 320 patients with ACLF with NBAL treatment from January 2014 to December 2018 in the Third People's Hospital of Guilin were retrospectively reviewed,and according to different therapeutic methods,they were divided into 3 groups:plasma exchange(PE,106 cases),PE+plasma bilirubin adsorption(PE+PBA,106 cases),and PE+double plasma molecular adsorption system(PE+DPMAS,108 cases)groups.The clinical symptoms and signs of jaundice,fatique,lack of appetite,abdominal distension,oliguria,hepatic encephalopathy,etc.,blood routine analyses[white blood cell count(WBC),hemoglobin(Hb),blood platelet count(PLT)],blood coagulation indexes[prothrombin time(PT),prothrombin activity(PTA),international normalized ratio(INR)],liver function indexes[alanine aminotransferase(ALT),aspartate transaminase(AST),total bilirubin(TBil),seroglobulin(GLB),γ-glutamyltransferase(GGT),alkaline phosphatase(ALP),blood ammonia(BA),prealbumin(PA)],and electrolyte indexes[sodium ion(Na^(+)),calcium ion(Ca^(2+))]before and after treatment in patients of 3 groups were recorded.One way repeated measure analysis of variance(ANOVA)and least significant difference test(LSD)were used to compare the improvement of laboratory indexes in each group,and to evaluate the short-term efficacy of different NBAL methods.Results Multivariable linear regression analysis showed that INR and TBil were the independent risk factors for the prognosis of patients with NBAL treatment(B value was 1.880 and 0.001,P value was 0.01 and 0.00),and the diagnostic value of INR was better than that of TBil.After 28 days of treatment,the laboratory indexes of each group were improved compared with those before treatment;the improvement effects of ALT,AST,GGT,ALP,BA,PT,Na^(+),Ca^(2+),Hb,PLT,PTA and INR in PE+PBA group were significantly better than those in PE group;the improvement effects of ALT,AST,GGT,ALP,BA,PA,PT,Ca^(2+),WBC,Hb,PTA and INR in PE+DPMAS group were significantly better than those in PE group;the improvement effects of PA,BA,Na^(+),WBC and Hb in PE+DPMAS group were significantly better than those in PE+PBA group.The mortality in PE+PBA group was obviously lower than that in the PE grouop[4.72%(5/106)vs.9.43%(10/106),P<0.05].Conclusion The short-term laboratory index improvement effect of PE combined with DPMAS in the treatment of ACLF is better than those of PE combined with PBA and PE alone,and the clinical symptom improvement rate and laboratory index improvement effect of PE combined with PBA are better than that of PE alone.