2型糖尿病及空腹胰岛素水平对肝硬化腹水患者发生自发性细菌性腹膜炎的影响

Influence of type 2 diabetes mellitus and fasting insulin level on the risk of spontaneous peritonitis in patients with cirrhotic ascites

目的本研究拟讨论失代偿期肝硬化腹水患者发生自发性细菌性腹膜炎(SBP)的预测因素及2型糖尿病(T2DM)与空腹胰岛素水平对患者发生SBP风险的影响。方法选取2013年1月—2018年10月于天津市第二人民医院临床诊断为肝硬化伴腹水患者,回顾性分析其基本临床资料,并随访1年,记录发生SBP时间或随访终止时间,数据获取方式为查询患者的住院病历。计量资料两组间比较采用t检验或Mann-Whitney U检验,计数资料两组间比较采用χ^(2)检验或Wilcoxon秩和检验。Cox回归分析肝硬化伴腹水患者SBP发生的相关因素。用Kaplan-Meier分析方法计算生存曲线,log-rank检验分析差异性,采用ROC曲线计算空腹胰岛素的最佳临界值。结果共纳入肝硬化腹水患者268例,发生SBP者98例(36.6%),1年内发生SBP的独立预测因素为基线时合并T2DM(HR=2.848,95%CI:1.470~4.195),TBil水平(HR=1.004,95%CI:1.001~1.007)与中性粒细胞百分比(N%)(HR=1.032,95%CI:1.010~1.055)(P值均<0.05)。Kaplan-Meier生存曲线分析表明,T2DM患者1年内SBP累积发生率明显高于非T2DM患者(χ^(2)=16.821,P<0.05)。合并T2DM者88例(32.8%),基线空腹胰岛素≥20.49μU/mL(HR=2.757,95%CI:1.499~5.071)可显著增加发生SBP的风险(P<0.05)。Kaplan-Meier生存曲线分析表明,空腹胰岛素≥20.49μU/mL组比<20.49μU/mL组1年内发生SBP的风险显著增高(χ^(2)=13.297,P<0.05)。结论当肝硬化腹水患者出现无法解释的TBil与N%升高时,或合并T2DM及空腹胰岛素≥20.49μU/mL时,应警惕SBP的发生,必要时可行进一步的干预措施,从而延缓疾病进展,改善预后。

Objective To investigate the predictive factors for spontaneous bacterial peritonitis(SBP)in patients with decompensated cirrhotic ascites and the influence of type 2 diabetes mellitus(T2DM)and fasting insulin level on the risk of SBP.Methods A retrospective analysis was performed for the clinical data of patients who were diagnosed with liver cirrhosis and ascites in Tianjin Second People’s Hospital from January 2013 to October 2018,and the patients were followed up for 1 year to record the onset time of SBP and the ending time of follow-up.Related data were obtained by searching the patients’medical records.The t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups,and the chi-square test or the Wilcoxon test was used for comparison of categorical data between two groups;a Cox regression analysis was used to investigate the factors for SBP in patients with cirrhotic ascites.The Kaplan-Meier method was used to plot survival curves,the log-rank test was used for survival difference analysis,and the receiver operating characteristic(ROC)curve was used to calculate the optimal cut-off value of fasting insulin.Results A total of 268 patients with cirrhotic ascites were enrolled,among whom 98(36.6%)developed SBP.T2DM at baseline(hazard ratio[HR]=2.848,95%confidence interval[CI]:1.470-4.195,P<0.05),baseline total bilirubin(TBil)(HR=1.004,95%CI:1.001-1.007,P<0.05),and baseline percentage of neutrophils(N%)(HR=1.032,95%CI:1.010-1.055,P<0.05)were independent predictive factors for SBP within 1 year.The Kaplan-Meier survival curve analysis showed that the patients with T2DM had a significantly higher 1-year cumulative incidence rate of SBP than those without T2DM(χ^(2)=16.821,P<0.05).Of all 268 patients,88(32.8%)had T2DM,and baseline fasting insulin≥20.49μU/mL(HR=2.757,95%CI:1.499-5.071,P<0.05)significantly increased the risk of SBP.The Kaplan-Meier survival curve analysis showed that the fasting insulin≥20.49μU/mL group had a significantly higher risk of SBP within 1 year than the<20.49μU/mL group(χ^(2)=13.297,P<0.05).Conclusion The onset of SBP should be considered when patients with cirrhotic ascites have unexplained increases in TBil and N%or have T2DM or fasting insulin≥20.49μU/mL,and intervention measures can be adopted when necessary to delay disease progression and improve prognosis.