自身免疫性肝炎慢加急性肝衰竭的临床特征及预后分析

Clinical characteristics and prognosis of patients with autoimmune hepatitis-induced acute on chronic liver failure

目的探讨自身免疫性肝炎慢加急性肝衰竭(AIH-ACLF)的临床特征及预后。方法回顾性分析解放军总医院第五医学中心2016年1月至2020年12月收治的36例AIH-ACLF患者的临床特征。按治疗结果将患者分为好转组和无效组,比较两组患者的相关指标。t检验和秩和检验用于分类变量的数据分析,预后转归的多因素分析采用logistic回归。结果32例女性(88.9%)均为1型AIH,且既往未曾接受过激素治疗,86.1%患者有肝硬化基础。总治疗好转率为27.8%(10/36),有2例行肝移植治疗。腹水34例(94.4%)、肝性脑病20例(55.6%),为最常见并发症。好转组与无效组患者相比,PTA较高[32.80(26.25,37.70)%比22.95(14.86,35.25)%,P=0.044],而TBil[(171.03±69.19)μmol/L比(261.23±131.00)μmol/L,P=0.012]、MELD评分[19.00(17.75,23.50)比29.00(24.25,34.25),P<0.01]较低,肝性脑病的发生率较低(20.0%比69.2%,P=0.011),应用激素治疗患者比例高(80.0%比26.9%,P=0.007)。激素治疗及MELD评分是AIH-ACLF预后转归的独立危险因素。15例(41.2%)患者接受了激素治疗,其中8例好转。好转患者从诊断到应用激素治疗的时间更短,MELD评分更低。结论AIH-ACLF患者的预后差,是否应用激素治疗及MELD评分是AIH-ACLF预后转归的独立危险因素。早期应用激素治疗对于改善AIH-ACLF预后至关重要。

Objective To investigate the clinical characteristics and prognosis of autoimmune hepatitis acute on chronic liver failure(AIH-ACLF).Methods The clinical characteristics of 36 patients with AIH-ACLF treated in our hospital from January 2016 to December 2020 were retrospectively analyzed.According to the prognosis,patients were divided into improvement group and ineffective group,and the data between the 2 groups were compared.T test and rank sum test were used to analyze the data of classified variables,Logistic regression was used for multivariate analysis.Results Among the 36 cases,32 were female(88.89%)and the average age was 52.29±16.27 years.All the cases were AIH type 1 and had never received corticosteroid therapy before,86.1%of patients combined with liver cirrhosis.The total improvement rate was 27.8%(10 cases),and 2 cases were treated with liver transplantation.Ascitic fluid(34 cases,94.4%)and hepatic encephalopathy(HE)(20 cases,55.6%)were the most common complications.Compared with the ineffective group,the prothrombin activity(PTA)in the improved group was higher[32.80(26.25~37.70)%vs 22.95(14.86~35.25)%,P=0.044];the total bilirubin(TBil)(171.03±69.19μmol/L vs 261.23±131.00μmol/L,P=0.012),model for end-stage liver disease(MELD)score[19.00(17.75~23.50)vs 29.50(24.25~34.25),P<0.001]and the incidence of HE(20%vs 69.2%,P=0.011)was lower.The proportion of patients treated with corticosteroid therapy was high(80.0%vs 26.9%,P=0.007).Corticosteroid therapy and MELD score were independent risk factors for prognosis of AIH-ACLF.Fifteen patients(41.2%)received corticosteroid therapy,and 8 of them improved.The interval time from diagnosis to corticosteroid therapy and MELD scores of improved patients were lower.Conclusion The prognosis of patients with AIH-ACLF is poor,corticosteroid therapy and MELD score are independent risk factors for prognosis.Early corticosteroid therapy are essential for improving the prognosis of patients with AIH-ACLF.