慢加急性肝衰竭发病诱因及其对预后的影响

目的探讨不同发病诱因所致慢加急性肝衰竭(ACLF)患者的预后差异和近10年发病诱因的变迁。方法回顾性收集2008年1月-2017年12月西安交通大学第一附属医院和西安市第八医医院住院治疗的537例ACLF患者的临床资料,包括年龄、性别、病因、发病诱因、转归(好转/死亡),并计算28 d病死率。计量资料2组间比较采用t检验;计数资料2组间比较采用χ2检验。Cox回归分析评价不同诱因对28 d病死率的影响。结果537例患者中HBV相关ACLF 511例(95.16%)、HCV相关ACLF 3例(0.56%)、酒精性肝炎相关肝衰竭2例(0.37%)、未分型18例(3.35%)、HBV/HCV重叠感染1例(0.19%),原发性胆汁性肝硬化相关ACLF 2例(0.37%)。537例ACLF患者中,34.8%无发病诱因,17.1%未规范治疗,16.0%为HBV-ACLF停用核苷类似物(NAS),9.7%饮酒,6.9%合并感染,手术和应用肝损药物分别占3%。手术、感染、停用NAS诱发的ACLF 28 d病死率与无诱因患者相比,差异均有统计学意义(χ2值分别为8.553、11.351、4.274,P值均<0.05)。手术[风险比(HR)及95%可信区间(95%):2.132(1.240~3.664)]、感染[HR及95%CI:1.942(1.262~2.989)]是诱发慢性肝病患者发生ACLF并死亡的独立危险因素(P值均<0.05)。后5年发病诱因与前5年发病诱因比较,药物诱发ACLF患者比例明显增高(χ2=6.365,P<0.05)。结论ACLF患者存在手术、感染、停用NAS诱因时,与无诱因患者比28 d病死率增高;手术和感染是ACLF患者死亡的独立危险因素;近5年药物诱发ACLF的比例明显增高。

Predisposing factors for acute-on-chronic liver failure and their influence on prognosis

Objective To investigate the prognosis of patients with acute-on-chronic liver failure(ACLF)caused by different predisposing factors and the change in these factors within the past 10 years.Methods A retrospective analysis was performed for the clinical data of 537 ACLF patients who were hospitalized and treated in The First Affiliated Hospital of Xi’an Jiantong University and Xi’an Eighth Hospital from January 2008 to December 2017,including age,sex,etiology,predisposing factors,and prognosis(improvement/death),and the 28-day mortality rate was calculated.The t-test was used for comparison of continuous data between two groups,and the chi-square test was used for comparison of categorical data between two groups.A Cox regression analysis was used to evaluate the influence of different predisposing factors on 28-day mortality rate.Results Among the 537 patients with ACLF,511(95.16%)had HBV-related ACLF,3(0.56%)had HCV-related ACLF,2(0.37%)had alcoholic hepatitis-related liver failure,18(3.35%)had an unclassified type,1(0.19%)had overlapping infection of HBV and HCV,and 2(0.37%)had ACLF associated with primary biliary cirrhosis.Among the 537 patients with ACLF,34.8%had no predisposing factors,17.1%did not receive standard treatment,16%had HBV-ACLF due to the withdrawal of nucleos(t)ide analogues(NAs),9.7%had alcohol consumption,6.9%had infections,3%had a history of surgery,and 3%had a history of medication causing liver injury.There was a significant difference in 28-day mortality rate between the patients without predisposing factors and those with the predisposing factor of surgery,infection,or withdrawal of NAs(χ2=8.553,11.351,and 4.274,all P<0.05).Surgery(hazard ratio[HR]=2.132,95%confidence interval[CI]:1.240-3.664,P=0.006)and infection(HR=1.942,95%CI:1.262-2.989,P=0.003)were independent risk factors for ACLF and death in patients with chronic liver diseases.As for the change in predisposing factors in the recent 10 years,the proportion of patients with drug-induced ACLF in the last five years was significantly higher than that in the first five years(χ2=6.365,P<0.05).Conclusion ACLF patients with the predisposing factors of surgery,infection,and withdrawal of NAs have a higher 28-day mortality rate than those without these predisposing factors.Surgery and infection are independent risk factors for death in patients with ACLF.There is an increase in the proportion of patients with drug-induced ACLF in the recent 5 years.