人工肝治疗HBV相关慢加急性肝衰竭的血小板计数变化及其影响因素

Influence of artificial liver support system therapy on platelet in treatment of hepatitis B virus-related acute-on-chronic liver failure

目的探究乙型肝炎相关慢加急性肝衰竭(HBV-ACLF)患者接受人工肝治疗后PLT计数的变化趋势和影响因素。方法选取2018年1月—2021年11月在中山大学附属第三医院住院接受血浆置换治疗(n=102)和双重血浆分子吸附系统联合低剂量血浆置换(n=50)的152例HBV-ACLF患者,分析患者的临床资料和实验室指标。计量资料两组间比较采用独立样本t检验或Mann-Whitney U检验,计数资料两组间比较采用χ^(2)检验;采用logisitic多因素分析影响人工肝治疗后PLT>50×10^(9)/L的危险因素,采用ROC曲线分析基线PLT计数对人工肝治疗后PLT>50×10^(9)/L的预测价值。结果纳入患者以中年男性为主,70例(46.1%)患者在入院时合并肝硬化,114例(75.0%)患者接受3次人工肝治疗,基线PLT>50×10^(9)/L患者占比为88%。总体患者人工肝治疗后PLT计数较基线水平显著下降(79.5±47.7 vs 112.5±64.1,t=4.965,P<0.001),治疗后1周PLT计数升高至基线水平(97.2±50.7 vs 112.5±64.1,t=1.787,P=0.075)。进一步比较人工肝治疗后1周PLT计数较基线的变化量,发现肝硬化组PLT下降幅度显著高于非肝硬化组(U=1986.5,P=0.026),而在不同人工肝术式、治疗次数(3~5次)之间无显著差异(P值均>0.05)。通过logisitic多因素分析发现,合并肝硬化(OR=3.097,95%CI:1.255~7.645,P=0.014)和基线PLT>50×10^(9)/L(OR=0.019,95%CI:0.002~0.154,P<0.001)是影响人工肝治疗后PLT>50×10^(9)/L的独立危险因素。对基线PLT计数进行ROC曲线分析,发现基线PLT>80.5×10^(9)/L是影响治疗后PLT>50×10^(9)/L的最佳截断值,ROC曲线下面积为0.818。结论人工肝治疗对PLT的影响是暂时性的,但肝硬化患者的PLT生长能力弱于非肝硬化患者;基线PLT>80.5×10^(9)/L是降低人工肝治疗后出血风险的最佳界值。

Objective To investigate the changing trend of platelet count(PLT)and related influencing factors in patients with hepatitis B virus-related chronic-on-acute liver failure(HBV-ACLF)after artificial liver support system(ALSS)therapy.Methods A total of 152 patients with HBV-ACLF who were hospitalized and treated in The Third Affiliated Hospital of Sun Yat-Sen University from January 2018 to November 2021 were included in the study,among whom 102 patients received plasma exchange(PE)and 50 patients received double plasma molecular absorption system combined with low-dose PE,and their clinical data and laboratory marker were measured.The independent samples t-test or the Mann-Whitney U test was used for the comparison of continuous data between two groups,and the chi-square test was used for the comparison of categorical data between two groups;a multivariate logistic regression analysis was used to investigate the risk factors for PLT>50×10^(9)/L after ALSS therapy;the receiver operating characteristic(ROC)curve was used to investigate the value of baseline PLT in predicting PLT>50×10^(9)/L after ALSS therapy.Results The patients were mostly middle-aged male adults;among the 152 patients,70(46.1%)had liver cirrhosis on admission,114(75.0%)received three sessions of ALSS therapy,and 88%had a baseline PLT count of>50×10^(9)/L.There was a significant reduction in PLT from baseline to after ALSS therapy(79.5±47.7 vs 112.5±64.1,t=4.965,P<0.001),and at 1 week after treatment,PLT increased to the baseline level(97.2±50.7 vs 112.5±64.1,t=1.787,P=0.075).As for the change in PLT from baseline to 1 week after ALSS therapy,the liver cirrhosis group had a significantly greater reduction in PLT than the non-liver cirrhosis group(U=1986.5,P=0.026),while there was no significant difference between different procedures of ALSS therapy and different sessions of treatment(3-5 sessions)(all P>0.05).The multivariate logistic regression analysis showed that cirrhosis(odds ratio[OR]=3.097,95%confidence interval[CI]:1.255-7.645,P=0.014)and PLT>50×10^(9)/L at baseline(OR=0.019,95%CI:0.002-0.154,P<0.001)were independent risk factors for PLT>50×10^(9)/L after ALSS therapy.The ROC curve analysis of baseline PLT showed that PLT>80.5×10^(9)/L at baseline was the optimal cut-off value affecting PLT>50×10^(9)/L after treatment,with an area under the ROC curve of 0.818.Conclusion The influence of ALSS therapy on PLT is temporary,but cirrhotic patients have a weaker PLT generation ability than non-cirrhotic patients.PLT>80.5×10^(9)/L at baseline is the optimal cut-off value to reduce the risk of bleeding after ALSS therapy.