HBV相关慢加急性肝衰竭患者感染危险因素及其对预后影响

Risk factors of infection in patients with HBV-related ACLF and its influence on prognosis

目的 探索HBV相关慢加急性肝衰竭感染发生危险因素及其对预后的影响。方法 回顾性分析2007年至2016年华山医院感染科收治的HBV相关ACLF患者的临床资料,分析其不同类型感染的发生率和危险因素以及感染对60 d生存的影响。结果 共纳入293例HBV相关慢加急性肝衰竭患者,其中92例符合欧洲肝病学会CLIF-C2-3级ACLF标准。CLIF-C2-3级患者60 d总体感染发生率为54%,高于0-1级的34%(P=0.001)。共有162例ACLF患者病程中使用糖皮质激素,其肺部感染、真菌/其他机会性感染、全部感染发生率高于未使用激素者,为19%比7%、7%比0以及54%比24%,差异均有统计学意义(均P<0.01)。Cox多因素分析发现,糖皮质激素治疗是全部感染、肺部感染和真菌/其他机会性感染发生的独立危险因素。CLIF 0-1级发生感染者比未感染者60 d生存率更低(58%比77%,P=0.005),但CLIF2-3级发生感染者与未感染者60 d生存率无明显差异。单因素分析中,年龄≥45岁、基线CLIF等级为2-3、肺部感染和全部感染是60 d死亡的危险因素,在多因素分析中仅年龄≥45岁(HR1.585,95%CI:1.183~2.591)和基线ACLF等级为2-3(HR2.542,95%CI:1.427~3.673)是60 d死亡的独立危险因素。结论 HBV相关ACLF患者感染发生率较高,感染的主要危险因素是糖皮质激素使用,CLIF0-1级发生感染者生存下降。

Objective To investigate the risk factors of infection in hepatitis B virus-related acute-on-chronic liver failure(HBV-ACLF)and its prognosis.Methods Clinical data of patients with HBV-ACLF admitted from2007 to 2016were retrospectively analyzed.Risk factors and incidence rates of different kinds of infection were analyzed,as well as the influence of infection on 60-day survival.Results A total of 293 patients with HBV-ACLF in accordance with the Asian Pacific association for the study of the liver(APASL)criteria(except total bilirubin)were included,of which 92 patients complied with ACLF grade 2-3 of European association for the study of the liver(EASL)CLIF-C criteria.Compared with ACLF0-1(34%)patients,the incidence rate of overall infection within 60 days was higher in CLIF-C ACLF2-3(54%)patients(P=0.001).A total of 162 patients were treated with corticosteroid and the incidence rates of ’pulmonary infection’,’invasive fungal infection/other opportunistic infection’,and ’overall infection’were higher than the patients who were not treated with corticosteroid(19%vs 7% P=0.003,7%vs 0% P=0.001 and 54%vs 24% P<0.001).Cox multivariate analysis revealed that corticosteroid therapy was an independent risk factor of the infection mentioned above.Sixty-day survival rate of ACLF0-1 patients combined with infection was lower than that of patients without infection(58%vs 77%,P=0.005),but with no significant difference of 60-day survival rate between ACLF2-3 patients with infection and those without infection.In univariate analysis,age≥45,ACLF grade 2-3 at baseline,pulmonary infection and overall infection were risk factors of death within 60 days.In multivariate analysis,only age≥ 45(HR1.585,95%CI 1.183-2.591)and ACLF grade 2-3 at baseline(HR2.542,95%CI1.427-3.673)were independent risk factors of death within60days.Conclusion There is a high incidence rate of infection in patients with HBV-ACLF,and corticosteroid therapy was the major risk factor.The survival rates of patients belonging to ACLF grade 0-1 decline when infection occurs.