PDF治疗过程中总胆红素反弹的危险因素分析

Analysis of risk factors for total bilirubin rebound in patients undergoing PDF support therapy

目的探讨慢加急性肝功能衰竭患者行血浆透析滤过治疗过程中与总胆红素反弹有关的危险因素。方法回顾性分析2021年1月-2023年1月本院重症医学科收治的79例慢加急性肝功能衰竭(乙型病毒性肝炎)患者的临床资料,所有患者进入ICU后均接受血浆透析滤过(Plasmadiafiltration,PDF)治疗,以患者住院期间总胆红素水平为研究焦点,根据入院后第一次PDF治疗前后24 h总胆红素水平的变化差异,将患者分为未反弹组(总胆红素水平较治疗前下降>20%)与反弹组(总胆红素水平较治疗前升高>20%)。记录并比较两组患者一般资料、SOFA评分、Child-pugh评分、是否合并感染、治疗后各实验室指标平均值、总住院时间、ICU住院时间及6个月生存率的差异。采用Spearman分析各指标与胆红素反弹的相关性。采用Logistic回归分析治疗过程中引起胆红素反弹的相关危险因素。采用试者工作特征曲线(Receiver operator characteristic curve,ROC曲线)评价各危险因素对胆红素反弹的预测价值。结果79例慢加急肝功能衰竭接受PDF治疗的患者中,有28例在第一次接受PDF治疗后总胆红素水平下降>20%,在后续治疗中逐渐下降至正常水平,有51例患者在第一次接受PDF治疗后,有胆红素反弹>20%现象的发生。通过对两组患者的临床资料进行分析发现,两组患者在PDF治疗前是否合并有糖尿病,、肝性脑病、腹水、感染差异具有统计学意义(P<0.05),治疗前SOFA评分、Child-pugh评分具有差异(P<0.05),治疗过程中WBC、PCT、ATⅢ、血氨、总胆红素平均水平的变化和6个月生存情况均具有明显差异(P<0.05)。经过Spearman分析得知,合并糖尿病及ATⅢ水平与胆红素反弹呈负相关(r均<0,P<0.05);合并肝性脑病、腹水、感染以及SOFA评分、Child-pugh评分、WBC、PCT、血氨水平与胆红素反弹呈正相关(r均>0,P<0.05)。多因素Logistic回归分析,结果显示Child-pugh高评分是胆红素反弹的独立危险因素(OR=10.490,95%CI为2.047~53.753,P=0.005)。ROC曲线分析显示:Child-pugh肝功能评分高低对肝功能衰竭患者PDF治疗后胆红素反弹具有一定预测价值,ROC曲线下面积AUC=0.931,95%CI为0.851~0.976,P<0.0001;当最佳截断值为10.5%时,其敏感度和特异度分别为94.12%和78.57%。结论Child-pugh评分越高,患者肝功能越差,若同时合并感染及多脏器功能不全行PDF治疗后胆红素反弹的风险越高。

Objective To investigate the risk factors related to total bilirubin rebound in patients with acute-on-chronic liver failure undergoing plasma diafiltration(PDF)support therapy.Methods A retrospective analysis was performed on the clinical data of 79 patients with acute-on-chronic liver failure(hepatitis B virus)who were admitted to the Department of Critical Care Medicine of our hospital from January 2021 to January 2023.All enrolled patients received PDF support therapy after entering the ICU.Focusing on the total bilirubin level during hospitalization,they were divided into two groups based on the difference of total bilirubin level 24 hours before and after the first PDF treatment after admission:non-rebound group(that is,after receiving PDF treatment,total bilirubin level decreased more than 20%compared with that before treatment)and rebound group(that is,total bilirubin level increased more than 20%compared with that before treatment).The differences between the two groups were recorded and compared in terms of general data,SOFA score,Child-Pugh score,presence of infection,laboratory indicators,total length of hospital stay,length of ICU stay,and 6-month survival rate.Spearman correlation analysis was utilized to analyze the correlation between each indicator and the bilirubin rebound.In addition,risk factors associated with bilirubin rebound during therapy were analyzed by Logistic regression.The predictive value of each risk factor to bilirubin rebound was evaluated by the receiver operating characteristic curve(ROC).Results Of the 79 patients with acute-on-chronic liver failure undergoing PDF support therapy,total bilirubin levels decreased more than 20%in 28 cases after the first PDF treatment,and gradually decreased to normal levels in subsequent treatment,while 51 cases had bilirubin rebound more than 20%after the first PDF treatment.The analysis of clinical data of the two groups revealed significant differences in diabetes,hepatic encephalopathy,ascites,infection,etc.,before therapy(P<0.05),as well as differences in SOFA score and Child-Pugh score before therapy(P<0.05).During therapy,the two groups showed significant differences in the changes of WBC,PCT,ATIII,blood ammonia,total bilirubin levels,and 6-month survival rate(P<0.05).Spearman correlation analysis showed that bilirubin rebound was negatively correlated with diabetes and ATIII levels(all r<0,P<0.05);while positively correlated with hepatic encephalopathy,ascites,infection,SOFA score,Child-Pugh score,WBC,PCT,and blood ammonia levels(all r>0,P<0.05).Furthermore,multivariate logistic regression analysis showed that a high Child-Pugh score was an independent risk factor(OR=10.490,[95%CI:2.047~53.753]P=0.005)for bilirubin rebound.ROC curve analysis showed that the Child-Pugh liver function score had a certain predictive value for bilirubin rebound in patients with liver failure after PDF support therapy,with an AUC=0.931,95%CI:0.851-0.976,P<0.0001;when the optimal cut-off value was 10.5,the sensitivity and specificity were 94.12%and 78.57%,respectively.Conclusions A higher Child-Pugh score indicates poorer liver function in patients,and likewise,a higher risk of bilirubin rebound after PDF treatment with concurrent infection and multiple organ dysfunction.