系统性红斑狼疮患者消化系统受累的临床特点及危险因素分析

Clinical characteristics and risk factors of gastrointestinal involvement in patients with systemic lupus erythematosus

目的研究SLE患者合并消化系统受累的临床特点及预后不良因素,提升医务工作者对SLE合并消化系统受累的认知。方法回顾性收集2012年9月1日至2019年9月1日我院收治的SLE住院患者的资料,分为2组,有消化系统病变的为消化系统受累组243例,随机抽取无消化系统病变的患者为对照组486例,采用t检验、秩和检验或χ^(2)检验,比较2组患者的临床表现、各项检查及治疗效果等,Logistic回归分析SLE合并消化系统受累的影响因素。结果①SLE合并消化系统受累的患者共243例,发生率为6.4%(243/3820),以消化系统表现为首发症状的占20.2%(49/243),常见的原因依次为狼疮性肝炎52.3%(127/243),肠系膜血管炎(LMV)35.0%(85/243),假性肠梗阻(IPO)9.9%(24/243),狼疮相关性胰腺炎8.6%(21/243),蛋白丢失性肠病(PLE)7.0%(17/243)。②与无消化系统受累的患者比较,消化系统受累组年龄较低[(38±14)岁和(32±15)岁,t=-2.47,P=0.014],中位病程短[12.0(3.0,72.0)个月和5.0(1.1,24.8)个月,Z=-5.67,P<0.001],SLEDAI评分高[(10(6,28)分和16(9,37)分,Z=2.24,P<0.001],出现皮疹(38.7%和53.5%,χ^(2)=14.46,P<0.001)、关节肿痛(36.4%和46.7%,χ^(2)=7.12,P=0.008)、心包积液(43.0%和56.4%,χ^(2)=11.53,P=0.001)、血小板下降[(216±111)×10^(9)/L和(175±114)×10^(9)/L,t=-4.69,P<0.001]、肾盂和输尿管积水(1.0%和12.8%,χ^(2)=47.47,P<0.001)的发病率高,而肺动脉高压(PAH)(31.2%和10.7%,χ^(2)=36.99,P<0.001)发病率较低;ALT[(17(10,29)U/L和59(16,127)U/L,Z=9.65,P<0.001]、AST[25.0(18.0,37.0)U/L和82.5(25.0,289.0)U/L,Z=10.57,P<0.001]、ALP[58(46,76)U/L和82(56,187)U/L,Z=8.42,P<0.001]、肌酸激酶(CK)[44.0(28.0,83.0)U/L和58.5(34.0,176.0)U/L,Z=4.46,P<0.001]、LDH[(309±206)U/L和(443±332)U/L,t=5.64,P<0.001]、空腹血糖(FBS)[(5.0±1.5)mmol/L和(5.3±1.7)mmol/L,t=2.16,P=0.031]、TG增高[(2.0±1.3)mmol/L和(2.7±2.2)mmol/L,t=4.55,P<0.001],白蛋白[(30±7)g/L和(27±7)g/L,t=5.87,P<0.001]和高密度脂蛋白(HDL)[(1.1±0.8)mmol/L和(0.9±0.5)mmol/L,t=-4.20,P<0.001]降低,抗SSB抗体阳性比率(16.0%和9.5%,χ^(2)=5.60,P=0.018)降低。③随访90 d,203例合并消化系统受累的SLE患者缓解,30例(12.3%)死亡,对照组9例(1.8%)死亡,缓解组使用环磷酰胺95例(46.8%)比未缓解组5例(12.5%)明显增加(χ^(2)=16.23,P<0.001)。Logistic回归分析发现无PAH、ESR、ALT、谷氨酰转肽酶(GGT)、间接胆红素和SLEDAI评分增多、肾盂和输尿管积水、白蛋白、HDL减少为SLE合并消化系统受累发病的危险因素,而腹腔积液、FBS增高是SLE合并消化系统受累预后差的影响因素。结论SLE合并消化系统受累死亡率较无消化道系统受累高,常见狼疮性肝炎和LMV。肾盂输尿管积水,SLEDAI评分增高,肝功能异常是其发病的危险因素,黄疸、FBS增高是预后不良的影响因素,使用环磷酰胺治疗是保护性因素。

Objective To study the clinical features and prognostic risk factors of gastrointestinal(GI)involvement in systemic lupus erythematosus(SLE),and improve clinicians'understanding of GI involvement in SLE.Methods The clinical data of SLE patients admitted to the First Affiliated Hospital of Guangxi Medical University from September 1,2012 to September 1,2019 were retrospectively analyzed.Two hundred and forty-three patients with GI system involvement were the GI system affected group,and 486 patients with-out GI system involvement at the same period were randomly selected as the control group.The clinical mani-festations,laboratory tests and treatment effects of the two groups were compared by t test,Wilcoxon signed-rank test andχ^(2) test and Logistic regression was used to analyze the prognostic risk of SLE with GI system involvement.Results①There were 243 SLE patients with GI involvement,with the proportion of GI involvement in SLE patients of 6.4%(243/3820),and as the first manifestation with GI system symptoms accounted for 20.2%(49/243).The common causes were lupus hepatitis accounted for 52.3%(127/243),lupus mesenteric vasculitis(LMV)for 35.0%(85/243),pseudo Intestinal obstruction(IPO)for 9.9%(24/243),lupus-related pancreatitis for 8.6%(21/243),and protein-losing enteropathy(PLE)as 7.0%(17/243).②Compared with the control group,the group with GI involvement had a lower average age[(38±14)year vs(32±15)year,t=-2.47,P=0.014],a shorter median duration of illness[12.0(3.0,72.0)months vs 5.0(1.1,24.8)months,Z=-5.67,P<0.001],a higher median systemic lupus erythematosus disease activity index(SLEDAI)score[10(6,28)vs 16(9,37),Z=2.24,P<0.001],the occurrence of skin rash(38.7%vs 53.5%,χ^(2)=14.46),arthritis(36.4%vs 46.7%,χ^(2)=7.12,P=0.008),myositis(43.0%vs 56.4%,χ^(2)=11.53,P=0.001),pericarditis[(216±111)×10^(9)/L vs(175±114)×10^(9)/L,t=-4.69,P<0.001],thrombocytopenia,and hydroureterosis(1.0%vs 12.8%,χ^(2)=47.47,P<0.001)were high,but the incidence of pulmonary arterial hypertension(PAH)(31.2%vs 10.7%,χ^(2)=36.99,P<0.001)was low;Serum alanine aminotransferase(ALT)[17(10,29)U/L vs 59(16,127)U/L,Z=9.65,P<0.001],aspartate aminotransferase(AST)[25.0(18.0,37.0)U/L vs 82.5(25.0,289.0)U/L,Z=10.57,P<0.001],alkaline phosphatase(ALP)[58(46,76)U/L vs 82(56,187)U/L,Z=8.42,P<0.001],Creatine kinase(CK)[44.0(28.0,83.0)U/L vs 58.5(34.0,176.0)U/L,Z=4.46,P<0.001],lactate dehydrogenase(LDH)[(309±206)U/L vs(443±332)U/L,t=5.64,P<0.001],fasting blood glucose(FBS)[(5.0±1.5)mmol/L vs(5.3±1.7)mmol/L,t=2.16,P=0.031],triglyceride(TG)[(2.0±1.3)mmol/L vs(2.7±2.2)mmol/L,t=4.55,P<0.001]increased,albumin(ALB)[(30±7)g/L vs(27±7)g/L,t=5.87,P<0.001)]and high-density lipoprotein(HDL)[(1.1±0.8)mmol/L vs(0.9±0.5)mmol/L,t=-4.20,P<0.001]decrease,and anti SSB antibody positive rate(16.0%vs 9.5%,χ^(2)=5.60,P=0.018)decreased.③After 3 months'follow-up,203 patients with SLE GI involvement were relieved,30 patients(12.3%)died,and 9 patients(1.8%)died in the control group.Ninety-five(46.8%)patients in the remission group had a significantly higher rate of cyclophosphamide treatment when compared with 5(12.5%)in the non-remission group(χ^(2)=16.23,P<0.001).Logistic regression analysis showed that no increase of PAH,elevated erythrocyte sedimentation rate(ESR),ALT,glutamyl transpeptidase(GGT),indirect bilirubin(IBIL)and high SLEDAI scores,hydroureteral dilatation,decreased ALB and HDL were independent related factors for SLE GI involvement,while ascites and elevated FBS were SLE GI involvement factors of poor prognosis.Conclusion SLE patients with GI involvement have a high mortality rate,and lupus hepatitis and LMV are common.Hydroureterosis,high SLEDAI score,abnormal liver function are risk factors for GI involvement.Jaundice and elevated FBS are the risk factors for poor prognosis,and treatment with cyclophosphamide is the protective factor.