肝衰竭相关病因学对临床结局的预测价值

The predictive value of liver failure-related etiology for clinical outcomes

目的评估影响不同亚型肝衰竭结局预判指标及人工肝支持系统治疗肝衰竭的效果。方法收集2020年1月至12月无锡市第五人民医院重症监护病房(ICU)收治的112例乙型肝炎(乙肝)和非乙肝肝衰竭患者的临床资料,分析急性、亚急性、慢加急性、慢加亚急性、慢性肝衰竭各亚型的相关病因,并比较人工肝支持系统治疗各型肝衰竭的疗效差异。采用Spearman相关性分析法分析各指标的相关性;采用多因素Logistic回归方程分析影响肝衰竭患者预后的危险因素;绘制受试者工作特征曲线(ROC曲线),评价各危险因素对肝衰竭患者预后的预测价值。结果112例肝衰竭患者中由乙肝引起者63例,由非乙肝引起者49例;乙肝肝衰竭组男性是女性的6倍,高于非乙肝肝衰竭组(1.33倍)。乙肝肝衰竭组亚急性肝衰竭患者抗凝血酶Ⅲ(ATⅢ)和总胆红素(TBil)水平均高于肝衰竭前期〔ATⅢ:(59.33±14.57)%比(35.66±20.72)%,TBil(μmol/L):399.21±112.94比206.08±126.96,均P<0.05〕;非乙肝肝衰竭组肝衰竭前期、慢性肝衰竭患者ATⅢ均明显高于急性肝衰竭患者〔(58.33±15.28)%、(44.00±19.10)%比(31.33±7.57)%,均P<0.05〕,急性肝衰竭患者TBil明显低于肝衰竭前期(μmol/L:107.83±49.73比286.20±128.92,P<0.05),亚急性和慢加急性肝衰竭患者TBil水平也明显高于肝衰竭前期(μmol/L:417.27±118.60、373.00±187.00比286.20±128.92,均P<0.05)。非乙肝肝衰竭组中亚急性肝衰竭、慢加亚急性肝衰竭和慢性肝衰竭患者住院时间均较急性肝衰竭患者明显延长(d:36.00±8.31、27.52±11.71、27.72±22.71比11.00±1.41,均P<0.05)。乙肝肝衰竭组和非乙肝肝衰竭组采用人工肝支持系统治疗病死率比较差异无统计学意义(55.6%比50.0%,P>0.05),两组存活患者ATⅢ水平均较死亡者明显升高〔乙肝肝衰竭组:(36.20±6.26)%比(27.33±8.87)%,非乙肝肝衰竭组:(41.06±4.16)%比(28.71±12.35)%,均P<0.01〕。相关性分析显示:乙肝肝衰竭组死亡患者和非乙肝肝衰竭组存活、死亡患者ATⅢ与TBil均呈明显正相关(r值分别为0.069、0.341、0.064,P值分别为0.723、1.196、0.761);乙肝肝衰竭组存活患者ATⅢ与TBil呈明显负相关(r=-0.105,P=0.745)。多因素Logistic回归分析显示:ATⅢ是影响非乙肝肝衰竭患者预后的独立危险因素〔优势比(OR)=1.023,95%可信区间(95%CI)为-0.001~0.001,P=0.007〕;TBil是影响乙肝肝衰竭患者预后的独立危险因素(OR=1.005,95%CI为-0.002~-7.543,P=0.033〕。ROC曲线分析显示:ATⅢ对非乙肝肝衰竭患者的预后有一定预测价值,ROC曲线下面积(AUC)=0.747,95%CI为0.592~0.902,P=0.009;当最佳截断值为39.5%时,其敏感度和特异度分别为83.33%和56.25%。结论人工肝支持系统治疗仍难以有效降低肝衰竭晚期患者的病死率;除ATⅢ外,入院时TBil也可以作为评估急性肝衰竭患者肝脏代偿能力及预测预后的指标。

Objective To assess the predictors of outcomes for different subtypes of liver failure,and the effectiveness of artificial liver support systems in the treatment of liver failure.Methods The clinical data of 112 patients with hepatitis B virus(HBV)-and non-HBV-related liver failure admitted to the intensive care unit(ICU)of the Fifth People's Hospital of Wuxi were collected from January to December 2020.The relevant etiologies of acute,subacute,acute-on-chronic,subacute-on-chronic,chronic subtype liver failure were analyzed.The efficacies of artificial liver support systems in the treatment of various subtypes of liver failure were also compared.The correlation of various indicators was analyzed by Spearman correlation analysis,the risk factors affecting the prognosis of patients with liver failure were analyzed by multivariate Logistic regression equation,and receiver operator characteristic curve(ROC curve)of subjects was plotted to evaluate the predictive value of each risk factor for the prognosis of patients with liver failure.Results Among the 112 liver failure patients,63 were caused by hepatitis B and 49 were caused by non-hepatitis B.The liver failure caused by hepatitis B was 6 times higher than for men than for women,which was higher than that of non-HBV liver failure group(1.33 times).AntithrombinⅢ(ATⅢ)and total bilirubin(TBil)levels of subacute liver failure were higher than those of pre-liver failure in the HBV liver failure group[ATⅢ:(59.33±14.57)%vs.(35.66±20.72)%,TBil(μmol/L):399.21±112.94 vs.206.08±126.96,both P<0.05].The levels of ATⅢin patients with pre-liver failure and chronic liver failure in the non-HBV liver failure group were significantly higher than those with acute liver failure[(58.33±15.28%),(44.00±19.10)%vs.(31.33±7.57)%,both P<0.05],patients with acute liver failure had significantly lower level of TBil than pre-liver failure(μmol/L:107.83±49.73 vs.286.20±128.92,P<0.05),the TBil levels in patients with subacute and acute-on-chronic liver failure were also significantly higher than that in pre-liver failure group(μmol/L:417.27±118.60,373.00±187.00 vs.286.20±128.92,both P<0.05).Patients with subacute liver failure,subacute-on-chronic liver failure and chronic liver failure in the non-HBV failure group were significantly longer than those in acute liver failure(days:36.00±8.31,27.52±11.71,27.72±22.71 vs.11.00±1.41,all P<0.05).There was no statistically significant difference in the case fatality rate of using the artificial liver support system between the HBV failure group and the non-HBV failure group(55.6%vs.50.0%,P<0.05),the levels of ATⅢin the two groups of surviving patients were significantly higher than that of the dead[HBV liver failure group:(36.20±6.26)%vs.(27.33±8.87)%,non-HBV liver failure group:(41.06±4.16)%vs.(28.71±12.35)%,both P<0.01].Correlation analysis showed that there was a clear positive correlation between ATⅢand TBil in the dead patients of HBV liver failure group and the survival and death patients of non-HBV liver failure group(r values were 0.069,0.341,0.064,and P values were 0.723,1.196 and 0.761,respectively);there was a significant inverse correlation between ATⅢand TBil in the HBV liver failure group(r=-0.105,P=0.745).Multivariate Logistic regression analysis showed that ATⅢwas an independent risk factor affecting the prognosis of patients with non-HBV liver failure[odd ratio(OR)=1.023,95%confidence interval(95%CI)was-0.001 to 0.001,P=0.007].TBil was an independent risk factor affecting prognosis of patients with HBV liver failure(OR=1.005,95%CI was-0.002 to-7.543,P=0.033).The analysis of ROC curve showed that ATⅢhad a predictive value for the prognosis of patients with non-HBV liver failure,the area under the ROC curve(AUC)=0.747,the 95%CI was 0.592-0.902,P=0.009.When the optimal truncation value was 39.5%,its sensitivity and specificity were 83.33%and 56.25%,respectively.Conclusions Artificial liver support system treatment of liver failure was difficult to effectively reduce the mortality of patients with end-stage liver failure.In addition to ATⅢ,TBil also could be used as an indicator to assess liver compensatency and predict prognosis in liver failure patients.