HBV相关慢加急性肝衰竭患者并发细菌感染影响因素及预后结局分析

Influencing factors and prognosis of bacterial infection in patients with hepatitis B virus-related acute-on-chronic liver failure

目的探讨HBV相关慢加急性肝衰竭(HBV-ACLF)患者并发细菌感染(BI)的影响因素及预后。方法选择南通大学附属台东医院2016年1月至2021年4月收治的HBV-ACLF患者128例。符合以下任一项即为BI:自发性细菌性腹膜炎、肺部感染、胆道感染及尿路感染。根据资料类型,采用t检验、卡方检验或秩和检验比较;多因素logistic回归分析HBV-ACLF患者并发BI的影响因素。结果128例HBV-ACLF患者中未并发BI 24例,并发BI 104例。非BI组患者预防性使用抗生素、肝性脑病、静脉曲张出血及低钠血症分别为7例(29.2%)、3例(12.5%)、2例(8.3%)及4例(16.7%),BI组分别为13例(15.5%)、42例(40.4%)、28例(26.9%)及57例(54.8%),差异均有统计学意义(P<0.05);非BI组WBC、PLT、Alb、TBil、Cr、血清钠、INR及MELD评分分别为5.3(4.3,6.8)×10^(9)/L、98(62,133)×10^(9)/L、(29.5±3.4)g/L、225.4(139.5,292.8)μmol/L、55(47,66)μmol/L、136(133,138)mmol/L、1.9(1.6,2.2)及(19.0±2.5)分,BI组分别为7.3(4.8,10.5)×10^(9)/L、76(46,110)×10^(9)/L、(27.7±3.0)g/L、214.0(120.6,314.7)μmol/L、66(50,103)μmol/L、132(128,136)mmol/L、2.1(1.7,2.7)及(23.2±3.1)分,差异均有统计学意义(P<0.05)。logistic回归结果提示,肝性脑病、MELD评分是HBV-ACLF患者并发BI的独立危险因素(P<0.05),预防性使用抗生素是保护性因素(P<0.05)。生存组年龄、WBC、Alb、TBil、Cr、血清钠、INR及MELD评分分别为48(40,54)岁、6.2(4.1,9.6)×10^(9)/L、(28.7±3.3)g/L、198.4(106.5,284.5)μmol/L、59(47,86)μmol/L、134(130,137)mmol/L、2.0(1.7,2.4)及(20.5±4.8)分,死亡组分别为54(45,62)岁、8.3(5.6,12.0)×10^(9)/L、(27.0±2.8)g/L、228.2(126.7,364.0)umol/L、78(55,116)umol/L、132(127,134)mmol/L、2.3(1.8,2.9)及(25.2±5.9)分,差异有统计学意义(P<0.05)。两组患者肝性脑病、静脉曲张出血、机械通气、休克、肝肾综合征及肾脏替代疗法等差异有统计学意义(P<0.05)。结论肝性脑病、MELD评分是HBV-ACLF患者并发BI的独立危险因素,预防性使用抗生素可有效改善HBV-ACLF患者预后。

Objective To investigate the influencing factors and prognosis of bacterial infection(BI)in patients with hepatitis B virus-associated acute-on-chronic liver failure(HBV-ACLF).Methods A total of 128 patients(94 males and 34 females)with HBV-ACLF admitted to our hospital from January 2016 to April 2021 were enrolled.The average age was 52(40,62)years.BI was defined as patients with one of the followings:spontaneous bacterial peritonitis,pulmonary infection,biliary tract infection or urinary tract infection.The clinical data was analyzed and compared by t test,chi-square test or rank sum test;Multivariate logistic regression analysis was used to investigate influencing factors of BI in patients with HBV-ACLF.Results Among 128 patients with HBV-ACLF,24 of which without BI(non-BI group)and 104 of which with BI(BI group).The numbers of patients with prophylactic antibiotics use,hepatic encephalopathy(HE),varicose bleeding and hyponatremia in non-BI group were 7(29.2%),3(12.5%),2(8.3%)and 4(16.7%)respectively,which were significantly higher than those in BI group[13 cases(15.5%),42 cases(40.4%),28 cases(26.9%)and 57 cases(54.8%),P<0.05].The scores of white blood cell(WBC),platelet(PLT),albumin(Alb),total bilirubin(TBil),creatinine(Cr),serum sodium,international normalized ratio(INR)and model for end-stage liver disease(MELD)in non-BI group were 5.3(4.3,6.8)×10^(9)/L,98(62,133)×10^(9)/L,(29.5±3.4)g/L,225.4(139.5,92.8)μmol/L,55(47,66)μmol/L,136(133,138)mmol/L,1.9(1.6,2.2)and(19.02.5),which were significantly higher than those in BI group[7.3(4.8,10.5)×10^(9)/L,76(46,110)×10^(9)/L,(27.7±3.0)g/L,214.0(120.6,314.7)μmol/L,66(50,103)μmol/L,132(128,136)mmol/L,2.1(1.7,2.7)and(23.2±3.1)points,P<0.05].All the indexes with significant differences were taken as independent variables for BI in patients with HBV-ACLF(assignment 0=not complicated,1=complicated).Logistic regression analysis showed that HE and MELD score were independent risk factors(P<0.05),and preventive antibiotic use was protective factor(P<0.05).Patients with HBV-ACLF and BI were divided into survival group and dead group according to the survival outcome.The clinical data of age,WBC,Alb,TBil,Cr,serum sodium,INR and MELD in survival group were 48(40,54)years old,6.2(4.1,9.6)×10^(9)/L,(28.7±3.3)g/L,59(47,86)μmol/L,134(130,137)mmol/l,2.0(1.7,2.4)and(20.5±4.8)points,which were significantly higher than those in the dead group[54(45,62)years old,8.3(5.6,12.0)×10^(9)/L,228.2(126.7,364.0)μmol/L,78(55,116)μmol/L,132(127,134)mmol/l,2.3(1.8,2.9)and(25.2±5.9)points,(P<0.05).There were significant differences in HE,variceal bleeding,mechanical ventilation,shock,hepatorenal syndrome and renal replacement therapy between the 2 groups(P<0.05).Conclusion HE and MELD score are independent risk factors of BI in patients with HBV-ACLF.Preventive antibiotics can effectively improve the prognosis,which has important clinical value.