143例肝硬化死亡患者的感染特征及中医证型特点分析

Characteristics of infection and Traditional Chinese Medicine syndromes in 143 death patients with cirrhosis

目的:探究肝硬化死亡患者的感染特征及中医证型特点。方法:回顾性分析2017年1月-2021年12月上海中医药大学附属曙光医院肝病科143例肝硬化伴或不伴感染的死亡患者的病例资料,包括肝硬化病因、中医证型、实验室指标、并发症、感染部位及感染病原体等,并计算Child-Turcotte-Pugh(CTP)评分、终末期肝病血清钠模型(MELD-Na)评分。计量资料两组间比较采用独立样本t检验或Mann-Whitney U秩和检验,计数资料组间比较采用χ^(2)检验或Fisher精确概率法。结果:143例患者肝硬化病因以乙型病毒性肝炎为主,酒精性肝病、自身免疫性肝病、血吸虫感染位列其后。肝硬化相关并发症发生率:腹腔积液(85.31%)、原发性肝癌(57.34%)、慢加急性肝衰竭(54.55%)、急性肾损伤(50.35%)、胸腔积液(45.45%)、肝性脑病(42.66%)、门静脉血栓(39.16%)、门脉高压相关消化道出血(32.87%)等。直接死亡原因为多脏器功能衰竭、循环衰竭、中枢性呼吸循环衰竭及呼吸衰竭。感染发生率为72.73%,感染部位包括肺部、腹腔、尿路、皮肤/软组织、血流等;感染组中微生物培养阳性率为36.47%,病原微生物包含细菌、真菌、支原体;检出27个多重耐药菌株,包括大肠埃希菌(6株)、肺炎克雷伯菌(6株)、溶血葡萄球菌(6株)等。感染组与非感染组在住院天数、胸腔积液方面比较差异有统计学意义(P<0.05);而年龄、直接死亡原因、并发症、CTP、MELD-Na评分、理化指标等两组差异无统计学意义。两组患者中医证型虚实兼见,感染组湿热蕴结证、气滞湿阻证、肝脾血瘀证等实证比例(23.07%)明显高于非感染组(7.69%)。结论:肝硬化失代偿期终末期患者并发感染以部位多、菌种复杂、耐药率高为特征。中医证型以肝肾阴虚为主,并兼有湿热、气滞、血瘀等邪实,并发感染者湿热证明显。

Objective:To explore the characteristics of infection and Traditional Chinese Medicine(TCM)syndromes in death patients with cirrhosis.Methods:The clinical data of 143 patients who died of cirrhosis with or without infection in Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine from January 2017 to December 2021 were retrospectively analyzed.Patients data included age,sex,cause of cirrhosis,length of hospital stay,TCM syndrome type,laboratory indicators,infection site,infection pathogen and complications,Child-Turcotte-Pugh(CTP)score and MELD-Na score.Independent sample t test or Mann-Whitney U rank sum test were used for comparison of measurement data between two groups,and Chi-square test or Fisher exact probability method was used for comparison of count data between two groups.Results:Among 143 patients,the main cause of cirrhosis was viral hepatitis B,followed by alcoholic liver disease,autoimmune liver disease and schistosomiasis infection.The incidence of complications related to cirrhosis were:abdominal effusion(85.31%),pleural effusion(45.45%),gastrointestinal bleeding associated with portal hypertension(32.87%),hepatic encephalopathy(42.66%),acute kidney injury(50.35%),portal vein thrombosis(39.16%),primary liver cancer(57.34%),acute-on-chronic liver failure(54.55%),etc.The immediate causes of death were multiple organ failure,circulatory failure,central failure,and respiratory failure.The incidence of infection was 72.73%,and the infection sites were mainly lung,abdominal cavity,urinary tract,skin/soft tissue,blood flow,etc.In the infection group,the positive rate of microbial culture was 36.47%,pathogenic microorganisms included bacteria,fungi and mycoplasma.27 strains were found to be multidrug resistan,among which Escherichia coli(6 cases),Klebsiella pneumoniae(6 cases),and Staphylococcus haemolyticus(6 cases)were the topthree.There were significant differences in length of stay,pleural effusion between the infected group and the non-infected group(P<0.05).But there were no significant differences in age,immediate cause of death,complications,CTP score,MELD-Na score and laboratory indicators between the two groups.TCM syndrome-type deficiency and excess were seen in both groups,and the excess syndrome such as Damp-heat,Qi-stagnation and Blood-stasis in the infected group(23.07%)was significantly higher than that in the non-infected group(7.69%).Conclusion:Patients with cirrhosis at the end of decompensation have more complications and a high incidence.The complicated infection of cirrhosis is characterized by multiple sites,complex strains and high drug resistance rate.TCM syndromes were mainly manifested as Yin deficiency of liver and kidney.Dampness and heat,Qi-stagnation and blood stasis were the important pathogenic factors.For patients complicated with infection,dampness and heat was particularly obvious.