脓毒症患者发生急性肝功能障碍诱因的多因素回归分析

目的运用多因素回归分析,明确脓毒症患者发生急性肝功能障碍（AHD）的诱因,为脓毒症患者AHD的防治提供参考依据。方法回顾性分析我院2008年9月—2015年9月收治的395例脓毒症患者临床资料,按照其AHD发生情况分为AHD组与非AHD组,分析脓毒症患者AHD发生率,运用多因素Logistic回归分析,了解脓毒症患者发生AHD的危险因素,分析诱因,提出防治策略。结果 395例患者中,共确诊AHD患者85例,AHD发生率21.5%,患者AHD发病时间为入院后1.9~127.5 h,平均（62.9±14.1）h,其病死率为38.8%（33/85）,显著高于非AHD患者的6.1%（19/310）,差异有统计学意义（P〈0.05）。多因素回归分析结果显示,年龄≥75岁、酒精成瘾史、合并糖尿病、合并慢性心功能不全、APACHEⅡ评分≥20分是影响脓毒症患者发生AHD的独立危险因素,差异有统计学意义（P〈0.05）。结论脓毒症患者发生AHD的诱因包括高龄、酗酒、合并糖尿病、合并慢性心功能不全及APACHEⅡ评分≥20分等,针对存在上述诱因的脓毒症患者实施全面监测及干预是降低病死率、改善预后的关键。

脓毒症患者并发急性肝功能障碍的危险因素分析

目的从合并症中筛选脓毒症患者并发急性肝功能障碍（AHD）的危险因素,为临床早期识别高危患者提供依据。方法对惠州市中心人民医院2007年1月~2013年12月收治的286例脓毒症患者资料进行回顾性分析,根据患者是否发生AHD分成两组AHD组（62例）和非AHD组（224例）,应用多因素Logistic回归模型筛选脓毒症患者并发AHD的危险因素。结果 286例脓毒症患者中有62例发生AHD,发生率为21.68%;AHD组30 d住院病死率明显高于非AHD组[38.71%（24/62）比6.82%（15/224）,P〈0.01]。Logistic回归分析显示,高龄（OR=1.589,95%CI 1.416~1.833,P=0.003）﹑慢性饮酒（OR=0.906,95%CI 0.509~1.612,P=0.038）﹑糖尿病史（OR=1.477,95%CI 1.265~1.858,P=0.014）﹑慢性心功能不全（OR=1.485,95%CI 1.271~1.868,P=0.015）﹑急性生理学与慢性健康状况评分Ⅲ（APACHE-Ⅲ）（OR=1.505,95%CI 1.281~1.916,P=0.023）是脓毒症患者并发AHD的高危因素。ROC曲线分析显示该模型有较高的判别AHD患者的能力,AUC为0.73（95%CI 0.68~0.91,P〈0.01）。结论高龄、慢性饮酒、糖尿病史、慢性心功能不全和APACHE-Ⅲ评分是脓毒症患者并发急性肝功能障碍的危险因素。

急性肝功能障碍患者血清骨桥蛋白水平

Objective. Fulminant hepatic failure (FHF) is a clinical syndrome of sudden and severe liver dysfunction accompanied by encephalopathy in a previously healthy person. In FHF, hepatocytes are severely damaged and ordinary liver regeneration is impaired. We demonstrated that the expression of osteopontin (OPN), a multifunctional cytokine, was up-regulated in mouse oval cell (a stem-cell progenitor) induction models. Material and methods. Based on this finding, serum OPN levels were examined in 43 patients with FHF and in 45 patients with acute self-limited hepatitis (AH). To determine the cellular source of OPN, the expression of OPN was studied in a liver specimen derived from an FHF patient. Results. The mean OPN level of patients with FHF was 2.80±0.48 ng/ml (log10,±SD), which was significantly higher than that of the patientswith AH (2.42±0.39 ng/ml) (p = 0.003, unpaired t-test). Patients with elevated serum OPN levels had a significantly poorer prognosis than patients whose serum OPN levels were not elevated. In the FHF patient’s liver, OPN protein was expressed not only in inflammatory cells but also in regenerating hepatocytes and bile ductular structures. Conclusions. Our current study indicates that serum OPN levels increased in patients with FHF and that OPN might play an important role in liver regeneration due to activation of hepatic stem cells.

脓毒症诱发急性肝功能障碍患者的危险因素和临床特征分析

目的探讨脓毒症诱发急性肝功能障碍患者的发生率、危险因素和临床特征。方法对160例脓毒症患者，收集个人和临床资料，以是否发生急性肝功能障碍分为脓毒症组和肝功能障碍组。采用Logistic回归分析阐明脓毒症诱发急性肝功能障碍可能的危险因素；比较两组生化指标、血浆内皮素-1（ET-1）、脓毒症相关器官衰竭（SOFA）评分的关系。结果在160例脓毒症患者中，出现急性肝功能障碍的患者25例，发生率15．6％。Logistic回归分析显示，长期饮酒（OR=4．102，95％CI1．288-13．063）、心功能不全史（OR=4．109，95％CI1．352—12．493）以及低血压（OR=5．833，95％CI1．712-19．868）为脓毒症诱发急性肝功能障碍的危险因素；除氧合指数（PaO：／FiO2）、血小板（PLA）、格拉斯哥昏迷评分（GCS）外，肝功能障碍组患者的总胆红素（‰）、直接胆红素（D）、肌酐（Cre）、血糖波动范围（R）、动脉血乳酸（Lac）、血浆ET-1、SOFA评分都高于脓毒症组；肝功能障碍组病死率高于脓毒症组。结论长期饮酒、心功能不全史以及低血压为脓毒症诱发急性肝功能障碍的危险因素；肝功能障碍组具有较高的动脉Lac、血浆ET-1和SOFA评分，预示预后不良。

创伤后肝细胞凋亡与坏死的检测及其意义

目的 探讨严重创伤后肝细胞凋亡及坏死在急性肝功能障碍发病机制中的作用。方法复制多发性骨折合并休克的大鼠创伤模型,采用 Annexin－V－Flous、碘化丙锭(propidium iodid,PI)双标法经流式细胞仪检测创伤后各时间点肝细胞凋亡与坏死的数量变化,结合光镜、电镜和电泳观察细胞凋亡与坏死,并与肝功能变化相比较。结果创伤后早期肝细胞即发生凋亡和坏死,坏死肝细胞的数量进行性升高,与肝功能变化显著呈正相关;凋亡肝细胞在创伤后3h达高峰,部分凋亡肝细胞发生继发性坏死,其数量与肝功能变化显著正相关。结论肝细胞坏死与凋亡是严重创伤后肝功能损害的重要原因,坏死肝细胞是肝功能损害的直接因素,凋亡肝细胞通过发生继发性坏死加重肝功能损害。

A Molecular Adsorbent Recycling System in Treating Posthepatectomy Acute Hepatic Failure Patients with Hepatocellular Carcinoma:a Bridge to Liver Transplantation

OBJECTIVE To evaluate the effect and safety of a Molecular Adsorbent Recycling System (MARS) in treating posthepatoectomy hepatic failure (AHF) patients surgically treated for primary hepatocellular carcinoma (HCC). METHODS 12 AHF patients induced by resection of HCC were treated with MARS before orthotopic liver transplantation (OLT). Their vital signs, urine volume, APACHEⅢand Glasgow scores were monitored. Routine laboratory blood tests, measurements of coagulatory function, liver and kidney function, serum ammonia, lactic acid and blood gas were conducted before and after treatment with MARS. All of the patients were followed up for a period of 6 months after OLT for prognosis and complication assessment. RESULTS Each patient was treated with MARS for 2-5 times (average of 3.6) with a length of 8-24 h each time. Their mean arterial blood pressure and urine volume were improved, APACHEⅢand Glasgow scores were better. Liver function was improved with the following alterations before and after treatment with MARS: serum ammonia (127.1±21.4 umol/L vs. 77.4±19.7 umol/L, P<0.05), lactic acid (6.53±0.45 mmol/L vs. 3.75±0.40 mmol/L, P<0.05) and total bilirubin (452.3±153.7 umol/L vs. 230.9±115.2 umol/L, P<0.05). However, there was no significant change in platelet count (44.25±3.60×109/L vs. 43.19±8.26×109/L, P>0.05) on international normalized ratio (INR) (2.74±0.50 us. 2.82±0.60, P>0.05), which showed the safety of MARS. For all patients no serious adverse effects occurred during the treatment with MARS. CONCLUSION MARS is effective and safe for treatment of AHF patients with HCC, especially as a bridge to OLT when a donor organ is not available.

重视儿科重症监护病房危重噬血细胞综合征的诊断与救治

噬血细胞综合征（hemophagocyticsyndrome，HPS）又称噬血细胞淋巴组织细胞增生症（hemophagocyticlymphohistiocytosis，HLH），表现为急性发病，以发热、肝脾肿大、全血细胞减少、急性肝功能障碍、凝血功能异常以及中枢神经系统损害表现为特征，实验室检查血清铁蛋白显著增高，骨髓检查可见噬血细胞，经常在短时间内发展为多器官功能障碍综合征（multipleorgandysfunctionsyndrome，MODS），病死率高[1]。

儿童噬血细胞综合征的特征与救治

噬血细胞综合征（hemophagocytic syndmme，HPS）主要表现为急性发病，进展迅速，以发热、肝脾肿大、全血细胞减少、急性肝功能障碍、凝血功能异常以及中枢神经系统损害为特征，实验室检查显示血清铁蛋白显著增高，骨髓检查可见吞噬血细胞现象。HPS与败血症容易混淆，抗感染效果不佳，病死率极高，是危重症之一。随着对HPS认识的深入，儿科重症监护病房收治病例呈现增多趋势。本文就近年来对HPS的认识及救治策略进行讨论。