首发和复发急性高甘油三酯血症胰腺炎临床特征比较的全国多中心临床研究

Comparison of clinical characteristics between first‐episode and recurrent acute hypertrigly‐ceridemic pancreatitis:a national multicenter clinical research

目的探讨首发和复发急性高甘油三酯血症胰腺炎(HTGP)的临床特征。方法采用回顾性队列研究方法。收集2020年11月至2021年12月中国急性胰腺炎临床研究小组(CAPCTG)‑PERFORM数据库中全国26家医学中心收治的313例HTGP患者的临床资料;男219例,女94例;年龄为38(32,44)岁。313例患者中,193例为首次发病,设为首发组;120例为复发,设为复发组。观察指标:(1)倾向评分匹配情况及匹配后两组患者一般资料比较。(2)两组患者病程14 d内严重程度及预后情况比较。(3)复发性HTGP与持续器官衰竭(POF)发生风险之间的关联。(4)随访情况。正态分布的计量资料以x±s表示,组间比较采用独立样本t检验。偏态分布的计量资料以M(Q1,Q3)表示,组间比较采用Wilcoxon秩和检验。计数资料以绝对数或百分比表示,组间比较采用χ^(2)检验。等级资料采用Wilcoxon秩和检验。采用Kaplan‑Meier法绘制累积复发发生率曲线,Log‑Rank检验进行生存分析。多因素分析采用Logistic回归模型,连续变量按照均值或公认标准转换为分类变量。倾向评分匹配按1∶1最近邻匹配法匹配,卡钳值为0.02。匹配后组间比较采用配对t检验或Wilcoxon秩和检验以及McNemar′s检验分析。结果(1)倾向评分匹配情况及匹配后两组患者一般资料比较。313例患者中,208例配对成功,首发组和复发组各104例。倾向评分匹配后,两组患者人口学特征、病情严重程度评分、实验室检查结果比较,差异均无统计学意义(P>0.05)。消除性别、急性生理与慢性健康Ⅱ评分、计算机断层扫描严重程度指数评分、全身性炎症反应综合征评分、序贯器官衰竭评分、载脂蛋白E、C反应蛋白、肌酐、乳酸脱氢酶、降钙素原、连续肾脏替代治疗因素混杂偏倚,具有可比性。(2)两组患者病程14 d内严重程度及预后情况比较。首发组患者POF和局部并发症与复发组比较,差异均有统计学意义(P<0.05)。(3)复发性HTGP与POF发生风险之间的关联。未校正的单因素分析结果显示:复发性HTGP与POF发生风险之间无关联(优势比=0.78,95%可信区间为0.46~1.30,P>0.05);校正年龄、性别、急性生理与慢性健康Ⅱ评分、C反应蛋白、甘油三酯和总胆固醇等协变量的多因素结果显示:与首次发病患者比较,复发性HTGP患者与较高的POF风险之间有关联(优势比=2.22,95%可信区间为1.05~4.71,P<0.05)。亚组分析结果显示:年龄<40岁与POF发生风险增加有关联(优势比=3.31,95%可信区间为1.09~10.08,P<0.05)。(4)随访情况。313例患者中,12例住院期间死亡,其中首发组9例,复发组3例。301例生存患者(首发组184例、复发组117例)的随访时间为19.2(15.5,21.9)个月。随访结果显示:184例生存的首发组患者中,164例获得随访,其中24例复发;复发组117例获得随访,其中29例复发,两组患者出院后复发率比较,差异有统计学差异(χ^(2)=4.67,P<0.05)。结论与首次发病患者比较,复发性HTGP患者病程中易发生POF和局部并发症、出院后易复发;复发性HTGP患者POF发生风险是首次发病患者的2.22倍,且在年龄<40岁患者中发生风险更高。

Objective To investigate the clinical characteristics of first-episode and recurrent acute hypertriglyceridemic pancreatitis(HTGP).Methods The retrospective cohort study was conducted.The clinical data of 313 patients with HTGP admitted to 26 medical centers in China in the Chinese Acute Pancreatitis Clinical Research Group(CAPCTG)-PERFORM database from November 2020 to December 2021 were collected.There were 219 males and 94 females,aged 38(32,44)years.Of the 313 patients,193 patients with first‐episode HTGP were allocated into the first‐episode group and 120 patients with recurrent HTGP were allocated into the recurrent group.Observation indicators:(1)propensity score matching and comparison of general data of patients between the two groups after matching;(2)comparison of severity and prognosis in the course of disease within 14 days between the two groups;(3)the association between recurrent HTGP and the risk of persistent organ failure(POF);(4)follow‐up.Measurement data with normal distribution were represented as Mean±SD,and comparison between groups was conducted using the independent sample t test.Measurement data with skewed distribution were represented as M(Q1,Q3),and comparison between groups was conducted using the Wilcoxon rank sum test.Count data were expressed as absolute numbers or percentages,and comparison between groups was conducted using the chi‐square test.Comparison of ordinal data was conducted using the Wilcoxon rank sum test.The Kaplan‐Meier method was used to plot the cumulative recurrence rate curve and Log‐Rank test was used for survival analysis.The Logistic regression model was used for multivariate analysis,and continuous variables were converted into categorical variables according to the mean value or common criteria.Propensity score matching was performed by 1∶1 nearest neighbor matching method,with caliper value of 0.02.Paired t test or Wilcoxon rank sum test and McNemar′s test were used for comparison between matched groups.Results(1)Propensity score matching and comparison of general data of patients between the two groups after matching.Of the 313 patients,208 cases were successfully matched,including 104 cases in the first-episode group and 104 cases in the recurrent group.After propensity score matching,there was no significant difference in demographic characteristics,severity of illness scores and laboratory test between the two groups(P>0.05).The elimination of gender,acute physiology and chornic health evaluation(APACHE)Ⅱscore,computed tomography severity index score,systemic inflammatory response syndrome score,sequential organ failure assessment score,apolipoprotein E,C‐reactive protein,creatinine,lactic acid dehydrogenase,procalcitonin confounding bias ensured comparability between the two groups.(2)Comparison of severity and prognosis in the course of disease within 14 days between the two groups.There were significant differences in POF and local complications between the first‐episode group and the recurrent group(P<0.05).(3)The association between recurrent HTGP and the risk of POF.Results of uncorrected univariate analysis showed that there was no association between recurrent HTGP and the risk of POF(odds ratio=0.78,95%confidence interval as 0.46−1.30,P>0.05).Results of multivariate analysis after adjusting for covariates such as gender,age,APACHEⅡscore,C‐reactive protein,triglyceride and total cholesterol showed that compared with first‐episode HTGP,recurrent HTGP was associated with a higher risk of POF(odds ratio=2.22,95%confidence interval as 1.05−4.71,P<0.05).Results of subgroup analysis showed that age<40 years was associated with an increased risk of POF(odds ratio=3.31,95%confidence interval as 1.09−10.08,P<0.05).(4)Follow‐up.Twelve of the 313 patients died during hospitalization,including 9 cases in the first‐episode group and 3 cases in the recurrent group.The rest of 301 surviving patients,including 184 cases in the first‐episode group and 117 cases in the recurrent group,were followed up for 19.2(15.5,21.9)months.Results of follow‐up showed that for 184 survived patients of the first-episode group,164 cases were followed up and 24 cases experienced recurrence,for 117 survived patients of the recurrent group,29 cases experienced recurrence,showing a significant difference between the two groups(χ^(2)=4.67,P<0.05).Conclusion Compared with first‐episode HTGP,patients with recurrent HTGP are more prone to POF and local complications,and are more prone to recurrence after discharge.The risk of POF in recurrent HTGP patients is 2.22 times that of those with first‐episode,and the risk is higher in patients with age<40 years.