肝硬化患者急性肾损伤与出血的相关性

Clinical study of the correlation between acute kidney injury and bleeding in patients with cirrhosis

目的 探究肝硬化失代偿期患者急性上消化道出血(AUGIB)与并发急性肾损伤(AKI)之间的相关性。方法 采取回顾性研究的方法,收集2017年1月至2021年12月在常熟市第一人民医院就诊的289例肝硬化患者(肝硬化AUGIB组),分析其连续发生的327次上消化道出血的临床记录。选取同一时间段内就诊的非肝硬化AUGIB患者(非肝硬化AUGIB组)作为对照。使用倾向性评分匹配法(PSM)对肝硬化AUGIB组和非肝硬化AUGIB组进行1∶1匹配,以消除出血严重程度(低危、中高危)、年龄、性别在组间分布的不均衡性,对比两组患者AKI的发生情况。采用Blatchford评分系统对肝硬化AUGIB患者进行风险评估,分为出血低危组(Blatchford评分<6分)136例、中高危组(Blatchford评分≥6分)173例。评估肝硬化患者出血严重程度和AKI的相关性。将肝硬化AUGIB患者根据AKI状态分为AKI组和无AKI组,对比两组患者的短期死亡率差异并绘制生存曲线。结果 经过筛选最终入组并分析了肝硬化AUGIB患者的309次就诊记录,肝硬化AUGIB患者AKI的发生率为35.60%,出血低危组和中高危组患者AKI发生率分别为26.02%(32/123)和41.94%(78/186),差异有统计学意义(χ^(2)=4.00,P<0.05)。另外,发生低血容量性休克患者的AKI发生率为57.89%(22/38),显著高于无低血容量休克表现的肝硬化AUGIB患者[32.47%(88/271)],差异有统计学意义(χ^(2)=3.92,P<0.05)。以并发AKI为主要终点,PSM匹配后,肝硬化AUGIB组患者AKI发生率40.59%(82/202),高于非肝硬化AUGIB组AKI发生率15.84%(32/202),差异有统计学意义(χ^(2)=8.26,P<0.01)。肝硬化AUGIB伴有AKI组短期死亡率37.27%(41/110),显著高于肝硬化AUGIB不伴有AKI组的短期死亡率[13.57%(27/199)],两组患者短期死亡率差异有统计学意义(χ^(2)=23.19,P<0.01),两组患者生存曲线存在差异(P<0.01)。结论 肝硬化失代偿期患者出现急性上消化道出血会显著增加AKI的发生率和短期死亡的风险,应引起临床的高度重视。

Objective To investigate the correlation between acute upper gastrointestinal bleeding(AUGIB)and complicated acute kidney injury(AKI)in patients with decompensated liver cirrhosis.Methods This retrospective study collected clinical records of 289 cirrhotic patients who visited the First People′s Hospital of Changshu from January 2017 to December 2021.A total of 327 episodes of upper gastrointestinal bleeding(UGIB)in these patients were analyzed.Non-cirrhotic patients with UGIB who visited during the same period were selected as the control group.Propensity score matching(PSM)was employed to eliminate intergroup distribution imbalances.The study compared the incidence of AKI between the cirrhotic and non-cirrhotic UGIB patients and assessed the correlation between the severity of bleeding and AKI in cirrhotic patients.The cirrhotic UGIB patients were divided into AKI and non-AKI groups,and the short-term mortality rate was compared between these groups,with survival curves plotted.Results After screening,309 clinical records of cirrhotic UGIB patients were included in the analysis.The incidence of AKI in cirrhotic UGIB patients was 35.60%.The incidence of AKI in the low-risk bleeding group and the moderate-to-high-risk bleeding group was 26.02%(32/123)and 41.94%(78/186),respectively,with a statistically significant difference(χ^(2)=4.00,P<0.05).Furthermore,in the group of patients who developed hypovolemic shock,the incidence of AKI was 57.89%(22/38),significantly higher than the 32.47%(88/271)in cirrhotic UGIB patients without hypovolemic shock symptoms,with a statistically significant difference(χ^(2)=3.92,P<0.05).Using propensity score matching(PSM)with a 1∶1 ratio to eliminate imbalances in bleeding severity(low-risk,moderate-to-high-risk),age,and gender distribution between the cirrhotic UGIB and non-cirrhotic UGIB groups,the incidence of AKI in cirrhotic UGIB patients was 40.59%(82/202),higher than the 15.84%(32/202)in the non-cirrhotic UGIB group after PSM,with a statistically significant difference(χ^(2)=8.26,P<0.01).The short-term mortality rate in the cirrhotic UGIB with AKI group was 37.27%(41/110),significantly higher than the 13.57%(27/199)in the cirrhotic UGIB without AKI group,with a statistically significant difference(χ^(2)=23.19,P<0.01).There were differences in the survival curves between the two groups(P<0.01).Conclusion In decompensated cirrhotic patients,the occurrence of acute upper gastrointestinal bleeding significantly increases the risk of acute kidney injury and short-term mortality,warranting heightened clinical attention.