肝衰竭合并巨细胞病毒再激活患者的临床特征及预后分析

目的探讨肝衰竭患者巨细胞病毒(cytomegalovirus,CMV)再激活的临床特征及预后转归。方法纳入2016年1月至2019年6月于上海复旦大学附属华山医院感染科诊断为肝衰竭,并进行血清CMV DNA检测的住院患者共75例,根据CMV DNA检测结果分成CMV DNA阳性组和CMV DNA阴性组,比较两组的肝衰竭分类、糖皮质激素使用、T淋巴细胞亚群并进行预后评估。统计学方法采用曼-惠特尼U检验和χ²检验。结果75例肝衰竭患者中,CMV DNA阳性17例,CMV DNA阴性58例。17例CMV DNA阳性组患者中,急(亚急)性肝衰竭9例,使用糖皮质激素13例,占比分别高于CMV阴性组的20.7%(12/58)和20.7%(12/58),差异均有统计学意义(χ²=6.70、18.40,均P<0.05)。CMV DNA阳性组患者的CD3⁺T淋巴细胞、CD8⁺T淋巴细胞比例分别高于CMV DNA阴性组,CD4⁺T淋巴细胞比例、CD4⁺/CD8⁺T淋巴细胞比值和B淋巴细胞比例分别低于CMV DNA阴性组,差异均有统计学意义(U=274.50、165.50、273.00、185.00、189.00,均P<0.05)。急(亚急)性肝衰竭比值比(odds ratio,OR)=4.3,95%可信区间(confidence interval,CI)1.3~12.6]和使用糖皮质激素(OR=12.5,95%CI 3.4~38.3)是肝衰竭患者CMV再激活的危险因素。CMV DNA阴性组患者疾病好转率为56.9%(33/58),CMV DNA阳性组的17例患者中5例好转,两组差异有统计学意义(χ²=1.99,P=0.04)。结论糖皮质激素的使用增加了肝衰竭患者CMV再激活的风险,且CMV再激活肝衰竭患者存在免疫紊乱,严重影响其预后,因此应重视使用糖皮质激素肝衰竭患者的CMV DNA监测。

Clinical characteristics and prognosis analysis of cytomegalovirus reactivation in patients with liver failure

Objective To investigate the clinical characteristics and prognosis of cytomegalovirus(CMV)reactivation in patients with liver failure.Methods A total of 75 patients diagnosed with liver failure and tested for serum CMV DNA between January 2016 and June 2019 in Huashan Hospital,Fudan University were retrospectively analyzed.According to the CMV DNA test results,the patients were divided into CMV DNA positive group and CMV DNA negative group.The classification of liver failure,the use of glucocorticoids,the proportions of T lymphocyte subsets of the two groups were compared and the prognosis was evaluated.Mann-Whitney U test and chi-square test were used to analyze the data.Results Of the 75 patients with liver failure,17 were CMV DNA positive and 58 were CMV DNA negative.Among the 17 CMV DNA positive patients,nine were acute(subacute)liver failure,and 13 were treated with glucocorticoids,which were all significantly higher than those in the CMV negative group(20.7%(12/58)and 20.7%(12/58),respectively).The differences were both statistically significant(χ²=6.70 and 18.40,respectively,both P<0.05).The proportions of CD3⁺T lymphocytes and CD8⁺T lymphocytes in the CMV DNA positive group were both higher than those in the CMV DNA negative group,and the proportions of CD4⁺T lymphocytes,the ratio of CD4⁺/CD8⁺T lymphocytes and the proportion of B lymphocytes were all lower than those in the CMV DNA negative group.The differences were all statistically significant(U=274.50,165.50,273.00,185.00 and 189.00,respectively,all P<0.05).Acute(subacute)liver failure(odds ratio(OR)=4.3,95%confidence interval(CI)1.3-12.6)and glucocorticoid use(OR=12.5,95%CI 3.4-38.3)were risk factors for CMV reactivation in patients with liver failure.The disease improvement rate in the CMV DNA negative group was 56.9%(33/58),and five out of 17 patients improved in the CMV DNA positive group,with a statistically significant difference(χ²=1.99,P=0.04).Conclusions The use of glucocorticoids increases the risk of CMV reactivation in patients with liver failure,and CMV reactivation in patients with liver failure presents immune disorders which seriously affect their prognosis.Therefore,it is important to pay attention to CMV DNA monitoring in patients with liver failure using glucocorticoids.