Reply to "Six-minute walking test performance is associated with survival in cirrhotic patients" to the editor

Use of the six-minute walk test has been proposed as a prognostic marker in liver cirrhosis. In the Letter to the Editor presented here, the authors highlight some important points, which were raised after the article was published in the November issue of the World Journal of Hepatology.     

六分钟步行试验对于慢性心力衰竭患者的临床应用

目的 探讨六分钟步行试验（6MWT）对于慢性心力衰竭（CHF）患者的心功能评估作用：采用6MWT定量研究CHF患者运动前后心率、血压的变化。方法218例受试对象按年龄段及美国纽约心脏病学会分级（NYHA分级）分别进行6MWT,同时记录六分钟步行距离（6MWD）及运动前后的血压和心率。结果不同年龄段组6MWD与NYHA分级呈高度负相关关系（P〈0．01）。正常对照组与NYHAI级组6MWD没有差别（P〉0．05）,其余各组均有显著差异（P〈0．01）;各年龄段组NYHA分级与心率变化值呈正相关关系,与收缩压变化值呈负相关关系（P〈0．01）。结论6MWT更适合评价轻、中度慢性心力衰竭患者的心功能;根据运动前后心率、血压的变化,6MWT可以为CHF患者运动锻炼提供指导。     

Portal hypertensive colopathy is associated with portal hypertension severity in cirrhotic patients

AIM： To assess the prevalence of portal hypertension （PH） related colorectal lesions in liver transplant candidates, and to evaluate its association with the severity of PH. METHODS： Between October 2004 and December 2005, colonoscopy was performed in 92 cirrhotic liver transplant candidates. We described the lesions resulting from colorectal PH and their association with the grade of PH in 77 patients who underwent measurement of hepatic venous pressure gradient （HVPG）. RESULTS： Mean age was 55 years and 80.7% of patients were men. The main etiology of cirrhosis wasalcoholism （45.5%）. Portal hypertensive colopathy （PHC） was found in 23.9%, colonic varices in 7.6% and polyps in 38% of patients （adenomatous type 65.2%）. One asymptomatic patient had a well-differentiated adenocarcinoma. The manifestations of colorectal PH were not associated with the etiology of liver disease or with the Child-Pugh grade. Ninety percent of patients with colopathy presented with gastroesophageal varices （GEV）, and 27.5% of patients with GEV presented with colopathy （P = 0.12）. A relationship between higher values of HVPG and presence of colopathy was observed （19.9：1：6.2 mmHg vs 16.8 ± 5.4 mmHg, P = 0.045）, but not with the grade of colopathy （P = 0.13）. Preneoplastic polyps and neoplasm （P = 0.02） and spontaneous bacterial peritonitis （P = 0.006） were more prevalent in patients with colopathy. We did not observe any association between previous β-blocker therapy and the presence of colorectal portal hypertensive vasculopathy. CONCLUSION： PHC is common in cirrhotic liver transplant candidates and is associated with higher portal pressure.     

肝硬化患者的胆囊结石发生率及其与肝功能分级的关系

目的研究肝硬化患者胆囊结石的发生率与肝功能分级的关系。方法回顾性分析195例肝硬化患者的临床资料,以同期230例健康体检者为对照组。结果肝硬化患者的胆囊结石发病率明显高于健康对照组（43．1％比6．1％,P〈0．01）,且胆囊结石发病率与肝功能损害程度呈正相关,Child—PughB级和C级患者的胆囊结石发病率显著高于A级患者（A级25．5％比B级52．4％比C级44．7％,P〈0．01）。不同病因的肝硬化患者的胆囊结石发病率差异无统计学意义。胆囊结石为肝硬化患者合并急性胆囊炎、急性胰腺炎的主要原因（54．8％）,经积极抗炎、利胆等对症治疗后大部分患者症状好转。结论肝硬化患者的胆囊结石发病率明显增加,并与肝脏疾病的进展呈正相关。     

肝硬化患者口服葡萄糖耐量试验临床意义及研究进展

肝脏和骨骼肌维持糖代谢。随着慢性肝病进展为肝硬化,肝功能恶化会导致糖代谢异常。因此,肝硬化患者常常伴有糖耐量异常和胰岛素抵抗,早期以餐后高血糖和高胰岛素血症为特征。一般而言,即使应用传统的空腹血糖或糖化血红蛋白水平标准,肝硬化伴有糖代谢异常患者往往被低估,因为他们中的多数表现出较低的空腹血糖水平或糖化血红蛋白水平,掩盖了其糖耐量减低的实情。因此,推荐使用口服葡萄糖耐量试验来评估出现空腹血糖正常的餐后高血糖患者。     

应用健康评价系统对205例肝硬化患者 病死率的预测

目的了解急性生理、年龄及慢性健康评价系统（acutephysiology,ageandchronichealthevaluation,APACHEⅢ）评分对肝硬化患者死亡危险预测的准确性。方法分别记录205例患者入院第一天的APACHEⅢ评分及Child-Pugh评分,应用判别分析比较两者预测的准确性。结果50例死亡。上消化道出血、肝性脑病、肝肾综合征、原发性肝癌和自发性腹膜炎等并发症的发生率分别为15.6%、10.6%、8.8%、8.8%和4.8%;主要死因为上消化道出血、肝肾综合征、肝功能衰竭、自发性腹膜炎。分别占40%、34%、20%、6%。生存组的APACHEⅢ评分及Child评分分别为19.3±8.6和7.4±1.8,显著低于死亡组（47.9±20.1,10.6±2.4）,APACHE评分系统对住院患者死亡的预测准确率为82.3%,显著高于Child评分系统(72.7%),其敏感性为67%,特异性为91%。综合凝血酶原时间延长时间及腹水指标,其预测准确率可提高至88.2%。结论对于肝硬化患者预后的评价,APACHEⅢ评分是一个较Child评分准确率高的预测系统,值得临床推广应用。     

N-糖基化修饰蛋白gp73与肝硬化患者Child-Pugh的关系

目的评价N-糖基化修饰蛋白gp73的血清水平与肝硬化患者Child-Pugh之间的关系及其可能的临床意义。方法所观察的患者均为2009年1月~2010年10月在北京地坛医院门诊及住院肝硬化患者,所有患者均为HBsAg阳性。观察患者共610例,其中男性患者448例,年龄17~82岁,平均48岁;女性患者162例,年龄18~76岁,平均55岁。入组肝硬化患者的Child-Pugh分级主要依据血清白蛋白、总胆红素、凝血酶原活动度、腹水及肝性脑病评价等5项指标。血清gp73浓度采用ELISA法检测。结果伴随肝功能衰退,血清gp73水平也相应升高。血清gp73水平Child-Pugh为C级的患者（255.78 ng/mL±100.89 ng/mL）显著高于B级（203.30 ng/mL±99.15 ng/mL）和A级的患者（125.28 ng/mL±67.05 ng/mL）。血清gp73与白蛋白之间呈显著负相关（r=-0.52,P〈0.0001）。结论 HBV感染肝硬化患者血清gp73水平随肝功能恶化而升高。     

Six-minute walk test distance and resting oxygen saturations but not functional class predict outcome in adult patients with Eisenmenger syndrome

Background

Eisenmenger syndrome (ES) represents the extreme manifestation of pulmonary arterial hypertension in patients with congenital heart disease, associated with significant exercise intolerance and mortality. Even though of six-minute-walk-test (6MWT) is routinely used in these patients, little is known about its prognostic value in comparison to functional class.

Methods and results

We included 210 adult patients with ES who underwent a total of 822 6MWTs. Median walking distance (6MWD) was 330 m [IQR 260–395], oxygen saturation (SO₂) at baseline 86% [IQR 82–91%] and SO₂ at peak-exercise 69% [IQR 60–80%]. In patients commenced on advanced therapy for pulmonary hypertension, but not in the reminder, there was a significant improvement in walking distance (297 ± 97 m vs. 325 ± 87 m,P = 0.0019), SO₂ at rest (84.9 ± 7.1 vs. 86.8 ± 5.9%,P = 0.003), SO₂ at peak exercise (69.1 ± 12.7 vs. 72.3 ± 12.2%,P = 0.04) and NYHA functional class (P = 0.0047).During a follow up of 3.3 years, 29 patients died. On time-dependent Cox analysis, 6MWD (HR 0.94 per 10 m, 95%CI: 0.91–0.97,P < 0.001) and baseline SO₂ (HR 0.90, 95%CI:0.86–0.94,P < 0.0001) were predictors of death. In contrast, age, functional class, peak-exercise SO₂ and SO₂ change were not related to mortality. A three-fold increased risk of death was identified in patients not reaching a 6MWD of 350 m or with baseline SO₂ below 85%.

Conclusions

The 6MWD and resting SO₂, but not functional class were predictive of outcome in this contemporary cohort of Eisenmenger patients and should be incorporated in both risk stratification and management algorithms for these patients.     

肝硬化食管静脉曲张出血患者硬化治疗的生存分析

目的 研究肝硬化食管静脉曲张出血（CEVB）硬化治疗的各种因素对预后生存的影响,并进行定量分析,建立生存模型,估计生存率。方法 对我院1987年4月至2000年6月间670例CEVB硬化治疗患者的29项预后因子及生存期的随访资料采用Kaplan-Meier法进行生存率的估计,以Cox比例风险模型进行危险因素分析。结果 Cox模型分析结果为肝功能Child分级与曲张静脉转归是2个显著影响预后生存的因素。1、3、5年生存率分别是93.29%、85.24%、74.27%。肝功能Child分级为A、B、C级者,1年生存率分别是98.88%、95.97%、82.32%,5年生存率分别是91.42%、78.35%、49.48%,其生存曲线有明显差异。食管曲张静脉转归分为消失、基本消失、Ⅰ度、Ⅱ度、Ⅲ度,其1年生存率分别是96.08%、93.94%、85.84%、85.00%、53.85%,5年生存率分别是81.45%、67.76%、72.89%、61.59%、35.90%,生存曲线有明显差异,其Cox模型单因素和多因素分析P值分别为0.000和0.020。但5条曲线在50个月时有聚合趋势,可能说明硬化治疗静脉曲张改善保持时间约为4年。肝功能Child C级时静脉曲张转归为消失和基本消失者,其1年生存率均为88.24%,2年生存率为77.98%-83.63%,仍高于总体肝功能Child C级时的生存率。结论 CEVB的硬化治疗是一种有效的急诊止血和防止再出血的治疗方法,在肝功能Child C级时也能改善预后,所以应积极实施,并且4年左右重复硬化治疗可显著提高生存率。     

食管曲张静脉压力是预测肝硬化曲张静脉破裂出血的主要危险因素

目的:前瞻性研究影响肝硬化食管曲张静脉破裂出血的主要危险因素.方法:随访未发生过食管曲张静脉出血的57例肝硬化患者1年.采用内镜下无创性食管曲张静脉气囊测压仪检测曲张静脉压,研究终点为出现食管曲张静脉出血.研究食管曲张静脉内镜下表现、食管曲张静脉压力、肝功能分级、肝硬化病因及腹水指标与食管曲张静脉破裂出血的关系.结果:1年内34例(59.6%)患者发生首次食管曲张静脉破裂出血.单因素分析显示,食管曲张静脉压力(P=0.001)、曲张静脉直径(P=0.006)、内镜下红色征(P=0.012)与出血风险有关.进一步的多因素Logistic回归分析显示,食管曲张静脉压力是预测首次出血最主要的危险因子(OR=2.817,P=0.003),其受试者工作曲线(ROC)下面积为0.98.预测出血的食管曲张静脉压力截值为25.3 mm Hg(1 mm Hg=0.133 kPa),其敏感性与特异性均为91%.结论:食管曲张静脉压力是预测食管曲张静脉破裂出血的主要危险因素.     

Prognostic value of (13)C-phenylalanine breath test on predicting survival in patients with chronic liver failure

AIM: To evaluate the prognostic value of percentage of 13C-phenylalanine oxidation (13C-PheOx) obtained by 13C-phenylalanine breath test (13C-PheBT) on the survival of patients with chronic liver failure. METHODS: The hepatic function was determined by standard liver blood tests and the percentage of 13C-PheOx in 118 chronic liver failure patients. The follow-up period was of 64 mo. Survival analysis was performed by the Kaplan-Meier method and variables that were significant (P < 0.10) in univariate analysis and subsequently introduced in a multivariate analysis according to the hazard model proposed by Cox. RESULTS: Forty-one patients died due to progressive liver failure during the follow-up period. The probability of survival at 12, 24, 36, 48 and 64 mo was 0.88, 0.78, 0.66, 0.57 and 0.19, respectively. Multivariate analysis demonstrated that Child-Pugh classes, age, creatinine and the percentage of 13C-PheOx (HR 0.338, 95% CI: 0.150-0.762, P = 0.009) were independent predictors of survival. When Child-Pugh classes were replaced by all the parameters of the score, only albumin, bilirubin, creatinine, age and the percentage of 13C-PheOx (HR 0.449, 95% CI: 0.206-0.979, P = 0.034) were found to be independent predictors of survival.CONCLUSION: Percentage of 13C-PheOx obtained by 13C-PheBT is a strong predictor of survival in patients with chronic liver disease.     

心力衰竭患者脑钠素水平与6 min步行试验相关性研究

目的探讨心力衰竭(心衰)患者血浆脑钠素(BNP)水平与6 min步行试验的相关性,进一步说明BNP测定对心衰的重要性.方法随机选择106例住院心衰患者及65例无器质性心脏病患者作为研究对象.入院当日采集血标本以备血浆BNP、血糖、血脂等检查,并于当日完成6 min步行试验.采用ELISA法测定血浆BNP水平.血浆BNP水平与6 min步行距离的相关性采用SPSS for Windows V10.0软件包分析.结果随着心衰程度的加重,血浆BNP水平逐渐升高,与6 min步行距离具有良好的相关性(r=-0.804,P＜0.01).结论血浆BNP水平可以判断心衰患者的严重程度,与6 min步行试验相比,具有更广泛的临床应用价值.     

Perioperative risk assessment for patients with cirrhosis and liver disease

Patients with cirrhosis are at an increased risk of complications of operative procedures. There is a growing understanding of the nature of the risks that cirrhotic patients experience, as well as more precise and objective tools to gauge the patients at risk for surgical complications. Surgical procedures that are common and high risk for patients with cirrhosis are cardiac surgery, cholecystectomy and hepatic resections, as well as other abdominal surgeries and orthopedic surgeries. The physicians who care for patients with cirrhosis who require a surgical procedure can apply an understanding of the type of surgery anticipated with knowledge of the severity of the patient’s liver disease to predict those patients at risk for operative morbidity and mortality. A sound knowledge of the specific operative risks faced by patients with cirrhosis should prompt the clinician to take steps to prevent these complications.     

血浆降钙素原测定在肝硬化伴自发性细菌性腹膜炎患者中的临床应用

目的　探讨血浆降钙素原 (procalcitonin ,PCT)对肝硬化伴自发性细菌性腹膜炎 (spontaneousbacterialperitonitis ,SBP)的诊断价值及与临床病程和预后的关系。方法　采用金标层析法测定 112例肝硬化腹水患者 (单纯腹水 5 1例 ,合并SBP 6 1例 )血浆PCT水平。结果　肝硬化腹水患者血浆PCT水平均显著高于正常 ,以 10ng/mL为阳性判断值时 ,SBP组阳性检出率显著高于无SBP组(P <0 0 0 1) ,且与培养是否阳性无关。最初三天血浆PCT水平变化与临床结局密切相关。结论　血浆PCT测定对肝硬化伴SBP的早期快速诊断及预后判断等有重要价值。