DPMAS联合LPE与PE治疗乙型肝炎病毒相关早期肝衰竭的疗效对比和预后影响因素分析

Comparison and analysis of prognostic factors of DPMAS combination with LPE and PE in early HBV-associated liver failure

目的比较血浆置换(PE)与双重血浆分子吸附系统(DPMAS)联合半量血浆置换(LPE)治疗乙型肝炎病毒相关的早期慢加急性肝衰竭(HBV-ACLF)的临床疗效,并寻找影响患者预后的因素。方法将2020年6月至2021年6月沧州市第三医院收治的80例早期HBV-ACLF患者纳入本次回顾性研究,根据人工肝治疗方案选择的不同,分为PE组(n=40)和DPMAS+LPE组(n=40)。比较两组的临床疗效及治疗前、治疗28 d后肝功能[丙氨酸氨基转移酶(ALT)、天门冬氨酸氨基转移酶(AST)、总胆红素]、凝血功能[国际标准化比值(INR)、凝血酶原时间(PT)、凝血酶原活动度(PTA)]、炎症指标[C-反应蛋白(CRP)、肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)]及血常规指标[血小板计数(PLT)、白细胞计数(WBC)、血红蛋白],二元Logistic回归分析影响早期HBV-ACL患者短期生存的影响因素。结果DPMA+LPE组患者的临床总有效率为80.00%,显著高于PE组(57.50%),差异有统计学意义(P<0.05)。治疗28 d后,两组的肝功能指标均较治疗前显著下降,且DPMAS+LPE组治疗后的ALT、AST、总胆红素均较PE组明显下降,差异均有统计学意义(P<0.05)。治疗28 d后,两组的PT、INR均较治疗前显著下降,而PTA刚好相反,DPMAS+LPE组治疗后的INR、PT与PE组间差异无统计学意义(P>0.05),但PTA明显高于PE组,差异有统计学意义(P<0.05)。治疗28 d后,两组的CRP、TNF-α、IL-6均较治疗前显著下降,且DPMAS+LPE组治疗后的CRP、TNF-α、IL-6均较PE组明显下降,差异均有统计学意义(P<0.05)。DPMAS+LPE组治疗后的PLT、血红蛋白与PE组差异无统计学意义(P>0.05),但WBC明显高于PE组,差异有统计学意义(P<0.05)。死亡组与生存组在ALT、AST、总胆红素、PT、INR、PTA、WBC、PLT、CRP、TNF-α、IL-6方面差异均有统计学意义(P<0.05),Logistic分析显示:总胆红素、PTA、WBC、IL-6是影响患者短期死亡的独立危险因素。结论DPMAS+LPE治疗早期HBV-ACLF患者效果优于单独PE治疗,能更好地抑制炎性反应,促进肝功能和凝血功能恢复。回归分析提示总胆红素、PTA、WBC、IL-6是影响患者短期死亡的独立危险因素,因此在治疗过程中需关注监测。

Objective To compare the clinical efficacy of plasma exchange(PE)and dual plasma molecular adsorption system(DPMAS)combined with half-volume plasma exchange(LPE)in the treatment of early HBV-related acute-on-chronic liver failure(HBV-ACLF),and to find out the factors affecting the prognosis of the patients.Methods Eighty patients with early HBV-ACLF treated in Cangzhou Third Hospital from June 2020 to June 2021 were enrolled in this retrospective study.According to different artificial liver therapy,they were divided into PE group(n=40)and DPMAS+LPE group(n=40).The clinical efficacy,liver function[alanine aminotransferase(ALT),aspartate aminotransferase(AST),total bilirubin],coagulation function[international normalized ratio(INR),prothrombin time(PT),prothrombin activity(PTA)],inflammatory indicators[C-reactive protein(CRP),tumor necrosis factor-α(TNF-α),interleukin-6(IL-6)]and blood routine indicators[platelet count(PLT),white blood cell count(WBC),hemoglobin]were compared before and 28 days after treatment.Logistic regression analysis was used to analyze the factors affecting the short-term survival of patients with early HBV-ACL.Results The total effective rate of DPMAS+LPE group was 80.00%,which was significantly better than that of PE group(57.50%),the difference was statistically significant(P<0.05).After 28 days of treatment,the liver function indexes of the two groups were significantly lower than those before treatment,and the ALT,AST and total bilirubin in DPMAS+LPE group after treatment were significantly lower than those in PE group,the differences were statistically significant(P<0.05).After 28 days of treatment,PT and INR of the two groups were significantly lower than those before treatment,while PTA was just the opposite;there was no significant difference between DPMAS+LPE group and PE group after treatment(P>0.05),but PTA was significantly higher than that of PE group,the difference was statistically significant(P<0.05).After 28 days of treatment,the levels of CRP and TNF-α,IL-6 in both groups were significantly lower than those before treatment,and the levels of CRP and TNF-α,IL-6 in DPMAS+LPE group after treatment in PE group were significantly lower than that in PE group,the differences were statistically significant(P<0.05).There were significant differences in ALT,AST,TBIL,PT,INR,PTA,WBC,PLT,CRP,TNF-αand IL-6 between the death group and the survival group,the differences were statistically significant(P<0.05).Logistic analysis showed that TBIL,PTA,WBC and IL-6 were independent risk factors for short-term death.Conclusion The therapeutic effect of DPMAS+LPE in patients with early HBV-ACLF is better than that of PE alone.It can better inhibit inflammatory reaction and promote the recovery of liver function and blood coagulation.Regression analysis showed that TBIL,PTA,WBC and IL-6 were independent risk factors for short-term death,so attention should be paid to monitoring during treatment.