肝硬化合并脾肾分流患者的数据分析与干预思考

Data analysis and intervention considerations for cirrhosis patients with splenorenal shunt

目的探讨肝硬化自发脾肾分流(SSRS)的临床特点及不同治疗方法的效果。方法本研究为回顾性队列研究。回顾性收集2015年6月至2022年6月郑州大学第一附属医院452例肝硬化合并SSRS患者的临床资料, 根据治疗方式分为保守治疗组(284例)、单纯栓塞组(53例)、经颈静脉肝内门体分流术(TIPS)联合栓塞组(71例)及肝移植组(44例)。分析治疗前后血氨、血红蛋白及肝功能变化, 对比其与生存率的组间差异, 并结合彩超探究门静脉血流状态与预后的关系。连续型变量组内比较采用Wilcoxon秩和检验, 组间比较应用Kruskal-Wallis检验;分类资料比较应用χ^(2)检验或Fisher精确概率检验。用Kaplan-Meier生存分析方法和Log-rank检验描述四组间的总生存期。结果 SSRS直径与血氨水平呈正相关(R=0.521, P<0.001), 与门静脉直径呈负相关(R=-0.308, P<0.001)。除TIPS联合栓塞组外(P=0.115), 治疗后肝移植组、单纯栓塞组和保守治疗组血氨水平均降低, 差异有统计学意义(均P<0.05);肝移植组和单纯栓塞组血氨降低程度组间差异无统计学意义(P=0.376), 且两组均优于保守治疗组, 差异有统计学意义(均P<0.001)。治疗后, 肝移植组血红蛋白升高(P=0.003), 保守治疗组降低(P<0.001), 差异有统计学意义;单纯栓塞组和TIPS联合栓塞组治疗前后血红蛋白差异无统计学意义(均P>0.05)。在肝功能方面, 治疗后肝移植和单纯栓塞组均较治疗前明显改善, 差异有统计学意义(均P<0.001), 且前者改善优于后者(P<0.001);TIPS联合栓塞组与保守治疗组治疗前后差异无统计学意义(均P>0.05)。对于Child-Pugh C级患者, 肝移植组和单纯栓塞组生存率优于TIPS联合栓塞组与保守治疗组, 差异有统计学意义(Log-rank χ^(2)=27.260, P<0.001)。通过生存分析发现, 整体患者入肝血流组预后优于无明显血流组, 且两组均优于出肝血流组(Log-rank χ^(2)=15.570, P<0.001);保守治疗组入肝血流患者预后优于无明显血流患者和出肝血流患者(Log-rank χ^(2)=16.290, P<0.001)。结论 SSRS可通过影响门静脉血流而影响肝功能, 治疗应根据患者症状、分流道直径、肝功能、门静脉血流状态选择个体化方案。

Objective To investigate the clinical characteristics of spontaneous splenorenal shunt(SSRS)in cirrhosis and evaluate the outcomes associated with different treatment modalities.Methods This was a retrospective cohort study.Clinical data from 452 cirrhotic patients with SSRS treated at the First Affiliated Hospital of Zhengzhou University between June 2015 and June 2022 were analyzed.Patients were categorized into four groups based on treatment received:conservative treatment(284 cases),embolization alone(53 cases),transjugular intrahepatic portosystemic shunt(TIPS)combined with embolization(71 cases),and liver transplantation(44 cases).The changes of blood ammonia,hemoglobin,and liver function before and after treatment,as well as their differences and survival rates among four groups were compared,and the relationship between portal vein flow status and its relationship with prognosis were explored using color ultrasound.Wilcoxon rank-sum test was used for intra group comparison of continuous variables,while Kruskal-Wallis test was used for inter group comparison,and Chi-square test or Fisher's exact test was used for categorical data.The overall survival was described by Kaplan-Meier survival analysis and Log-rank test was compared between the four groups.Results The diameter of SSRS correlated positively with blood ammonia levels(R=0.521,P<0.001)and negatively with portal vein diameter(R=-0.308,P<0.001).Post-treatment,blood ammonia levels decreased significantly in the liver transplantation group,embolization alone group,and conservative treatment group(all P<0.05),with no statistically significant difference between liver transplantation and embolization alone groups(P=0.376),but both were superior to conservative treatment(all P<0.001).Hemoglobin levels increased in the liver transplantation group(P=0.003)and decreased in the conservative treatment group(P<0.001),with statistically significant differences.There was no statistically significant difference in hemoglobin level before and after treatment between the embolilation alone group and the TIPS combined with embolilation group(P>0.05).Liver function significantly improved in the liver transplantation and embolization alone groups post-treatment(both P<0.001),with liver transplantation showing superior improvement(P<0.001).There was no statistically significant difference between the TIPS combined embolization group and the conservative treatment group before and after treatment(P>0.05).Survival analysis indicated that for Child-Pugh grade C patients,liver transplantation and embolization alone provided better survival outcomes compared to TIPS combined with embolization and conservative treatment(Log-rankχ^(2)=27.260,P<0.001).Overall survival were better in patients with in-hepatic flow compared to those with no significant flow and out-hepatic flow for the whole(Log-rankχ^(2)=15.570,P<0.001)and the conservative treatment group(Log-rankχ^(2)=16.290,P<0.001).Conclusion SSRS influences liver function through its impact on portal blood flow.Treatment strategies should be tailored based on symptoms,shunt diameter,liver function,and portal blood flow status.