特利加压素联合白蛋白比较米多君和奥曲肽联合白蛋白治疗肝肾综合征:一项随机试验

<正>肝肾综合征(HRS)是肝硬化的严重并发症,未经治疗其病死率较高。特利加压素联合白蛋白可有效地逆转HRS,由于特利加压素在美国未获批准,因此米多君和奥曲肽联合白蛋白作为一种替代治疗用于HRS。为了比较特利加压素联合白蛋白与米多君和奥曲肽联合白蛋白治疗HRS的疗效,Cavallin等进行了一项随机对照试验。随机分配27例患者接受特利加压素联合白蛋白治疗(TERLI组),22例患者接受米多君和奥曲肽联合白蛋白治疗(MID/OCT组)。TERLI组给予静脉滴注特利加压素,起始剂量为3 mg/24 h,如无应答则逐步     

特利加压素与去甲肾上腺素在肝肾综合征治疗中的比较

目的 比较去甲肾上腺素与特利加压索在肝肾综合征(HRS)治疗中的效果.方法 59例Ⅰ型HRS患者中,20例接受去甲肾上腺素治疗,6～16 mg/d,治疗至肾功能逆转,最多15 d;16例接受特利加压素治疗,0.5～2 mg/4h,治疗至肾功能逆转,最多15 d;23例为安慰剂治疗(对照组).所有患者均用白蛋白10 g/d治疗.观察患者治疗前后肝功能、肾功能、电解质、存活时间.统计学处理采用t检验和X2检验.结果 治疗15d后,20例接受去甲肾上腺素治疗的HRS患者,12例肾功能逆转(60％);16例接受特利加压素治疗患者,14例肾功能逆转(87.5％);对照组23例病情较治疗前恶化;特利加压素组与其他两组比较,差异有统计学意义(P＜0.05).去甲肾上腺素组、特利加压素组和对照组的综合应答率分别为80％、100％和17.4％,差异有统计学意义(P＜0.05).结论 特利加压素、去甲肾上腺素是治疗HRS的有效药物,特利加压素疗效更佳,两者远期疗效尚不确定.     

肝硬化并发肝肾综合征患者预后影响因素分析

目的 探讨肝硬化基础上并发肝肾综合征(HRS)患者的预后影响因素.方法 选取2019年1月至2019年12月山西医科大学附属白求恩医院收治的97例HRS患者,分为存活组与死亡组,采用多因素logistic回归分析影响患者住院28 d预后的因素.结果 住院期间HRS生存24例,死亡73例.死亡组的丙氨酸氨基转移酶、血清总...     

特利加压素治疗肝硬化食管胃底静脉曲张出血患者发生低钠血症的临床特征和危险因素

目的探讨特利加压素治疗肝硬化静脉曲张出血过程中,发生低钠血症的患者临床特征及危险因素。方法收集2013年1月1日至2016年12月31日因肝硬化急性静脉曲张出血在上海中医药大学附属普陀医院感染科住院接受特利加压素治疗的患者(特利加压素组),同时入选同期因肝硬化静脉曲张出血住院接受奥曲肽治疗的患者作为对照(奥曲肽组),对其临床表现、实验室检查等资料进行回顾性分析。结果纳入研究患者共107例,特利加压素组患者41例,血钠水平从(138.6±6.4)mmol/L降低至(127±7.8)mmol/L,血钠下降值为(11.9±9.4)mmol/L。其中39例(95.1%)出现血钠水平下降,20例(48.8%)出现显著血钠下降(≥10mmol/L),包括5例(5/20,25%)患者出现神经系统症状,2例患者因血钠迅速上升而出现渗透性脱髓鞘综合征。奥曲肽组患者66例,其中26例(39.4%)出现血钠水平下降,3例(4.5%)出现显著血钠下降,血钠下降值为(0.7±4.0)mmol/L。多因素分析发现,较高基线的血钠水平和白蛋白水平是发生显著低钠血症的独立危险因素。死亡率与低钠血症发生无关。结论特利加压素治疗肝硬化静脉曲张出血过程中发生低钠血症比较普遍,尤其是基线血钠和白蛋白水平较高的患者,需要加强监测。     

特利加压素联合白蛋白治疗肝肾综合征效果的预测因素

肝肾综合征(HRS)是终末期肝病的严重并发症,主要发生于有明显循环功能障碍的晚期肝硬化患者,预后较差。目前首选的药物治疗方案是特利加压素联合白蛋白治疗。关于特利加压素联合白蛋白治疗效果的预测因素的研究较多,但尚未有相关综合报道。从HRS的发病机制和药物作用机制方面回顾了这一疾病的最新研究进展,从基线资料、治疗后变化及治疗方案等方面对特利加压素联合白蛋白治疗效果的预测因素的研究进展进行了综述,指出早期识别有助于预测治疗反应的因素具有重要的临床意义。     

肝硬化并脑出血患者预后危险因素分析

目的探讨肝硬化并脑出血患者的预后和病死率,分析影响预后的危险因素。方法收集2008年12月至2018年7月解放军总医院第五医学中心收治的51例肝硬化并脑出血患者临床资料。根据出院情况将患者分为死亡组和好转组,对两组患者的临床特征进行比较,并探讨与预后相关的危险因素。结果 51例患者中,死亡31例,病死率为61%。单因素分析结果显示,死亡组与好转组患者的血肿面积分别为(57±28)mL、(25±11)mL,血小板分别为(31±27)×10~9/L、(62±21)×10~9/L,重度意识障碍分别为25例、5例,child评分C级为26例、8例,差异均有统计学意义(P0.05)。多因素分析结果显示,血小板计数为肝硬化并脑出血患者预后的独立危险因素(P0.05),血小板受试者工作特征曲线下面积为0.894(0.803～0.986),灵敏度和特异度分别为100%和77.4%,最大约登指数为0.774。结论血小板是肝硬化并脑出血患者预后的独立危险因素,与患者病死率呈正相关。肝硬化病因与并发脑出血有关,与预后无关。     

特利加压素治疗发生低钠血症的危险因素分析

目的:探讨特利加压素在肝硬化食管胃底静脉曲张破裂出血治疗过程中出现低钠血症的危险因素。方法:纳入2013年1月至2016年12月间我院32例因肝硬化食管胃底静脉曲张破裂出血而应用特利加压素的患者,收集临床资料,分析在特利加压素使用过程中低钠血症的发生率及危险因素。结果:应用特例加压素后,患者血钠水平从(136.91±4.11)mmol/L下降至(127.59±10.01)mmol/L(P0.001)。其中16例(50.0%)未出现血钠下降(血钠下降≤5 mmol/L)、4例(12.5%)血钠下降5~10 mmol/L、12例(37.5%)血钠下降10 mmol/L,其血钠水平分别从(135.00±3.98)、(138.50±3.11)、(138.91±3.55)mmol/L下降至(134.06±4.12)、(131.25±4.03)、(117.75±9.14)mmol/L。血钠下降的程度和血肌酐、终末期肝病模型(MELD)分数、初始钠水平、特利加压素总剂量有差异。经过Logstic回归分析显示,初始钠水平[比值比(OR)=1.797,95%可信区间(CI)为1.079~2.992,P=0.02]、特利加压素总剂量(OR=1.105,95%CI为1.003~1.218,P=0.04)是血钠下降的危险因素。结论 :特利加压素应用过程中低钠血症的发生率并不低,而初始钠水平越高、特利加压素总剂量越大,越容易出现低钠血症。     

特利加压素联合生长抑素治疗肝硬化食管胃底静脉曲张破裂出血疗效观察

目的 观察特利加压素联合生长抑素治疗肝硬化并发食管胃底静脉曲张破裂出血（EGVB）患者的临床疗效及不良反应。方法 67例肝硬化并发EGVB患者被随机分为两组,32例对照组在对症支持治疗的基础上加用生长抑素治疗,35例观察组在对照组治疗基础上加用特利加压素联合生长抑素治疗。结果 观察组患者28例（80.0%）止血,3例（8.6%）再出血,4例（11.4%）,对照组则分别为21例（65.6%）、7例（21.9%）和8例（25.0%,P<0.05）;观察组输血量为（3.8±2.2） U,对照组则为（5.9±2.7） U。结论 特利加压素联合生长抑素治疗肝硬化并发EGVB患者疗效优于单用生长抑素,且具有较好的安全性。     

肝肾综合征、MELD评分和肝移植:一个具有临床实践意义的话题

肝肾综合征(HRS)是肝硬化的一种严重并发症,预后往往很差。能够及时做出诊断并迅速开始使用特利加压素和白蛋白进行治疗至关重要,这样就可以改善预后。本文讨论了应用MELD评分预测HRS3个月病死率及其对优先选择肝移植方针的深远影响,而且还分析了药物治疗反应对MELD评分的影响及其可能延迟肝移植时间的效应,提出一种方法可以克服特利加压素和白蛋白对治疗应答者优先选择肝移植政策的矛     

特利加压素与托拉塞米治疗失代偿期肝硬化并发肝肾综合征患者疗效比较

目的 比较特利加压素与托拉塞米治疗失代偿期肝硬化并发肝肾综合征（HRS）患者的临床疗效。方法 在62例失代偿期肝硬化并发HRS患者中,30例接受托拉塞米治疗,32例在此基础上加用特利加压素治疗,两组均应用7 d。结果 特利加压素治疗患者腹胀、恶心、呕吐、乏力、纳差及腹水较托拉塞米治疗患者明显好转（P<0.05）;托拉塞米治疗患者治疗后尿量（938.4±281.9 ml/24 h）较治疗前（721.0±225.7 ml/24 h）明显增多（P<0.05）,但血尿素氮（18.2±6.5 mmol/L 对 16.1±5.7 mmol/L）、血清肌酐（235.4±86.9μmol/L 对217.2±75.1μmol/L）及腹围（95.2±5.4 cm对 94.3±5.3 cm）等指标变化无显著性差异（P>0.05）;特利加压素治疗患者治疗后尿量（2161.0±693.6 ml/24 h）、血尿素氮（10.4±4.2 mmol/L）、血清肌酐（128.6±64.2μmol/L）及腹围（90.5±4.6 cm）等指标较治疗前（分别为730.6±228.5ml/24 h, 18.0±6.1 mmol/L,238.1±87.7μmol/L和95.1±5.7 cm）明显改善（P<0.05）,且尿量增多（730.6±228.5ml/24 h）,较托拉塞米组患者治疗后（938.4±281.9 ml/24 h）更为显著（P<0.05）;在观察30 d内,特利加压素治疗患者病死率（37.5%）明显低于托拉塞米组（63.3%,P<0.05）。结论 特利加压素可明显改善失代偿期肝硬化并发HRS患者的临床症状及肾功能指标,降低近期病死率。     

Ⅰ型肝肾综合征的临床分析

目的探讨Ⅰ型肝肾综合征的发病原因、诱因及临床指标变化,以提高对该病的整体认知水平。方法回顾性查阅我院2000年至今收治的Ⅰ型HRS住院患者病例29例,分析其基础疾病及病因;发生肝肾综合征的诱因;肝肾功能及凝血象变化;CTP及MELD肝功能分级;尿量变化及生存率等。结果Ⅰ型HRS主要发生于晚期肝硬化和重症肝炎患者。易出现腹水、肝性脑病、感染及消化道出血等并发症。Child-Pugh评分多在B级和C级,以C级为主（82．76％）。MELD评分中有27例在20分以上（93．1％）,多数位于20～40分之间。Child-Pugh评分B级和C级间的MELD评分存在显著性差异。其尿量逐渐减少,甚至无尿。29例患者中21例在住院期间死亡,8例自动出院。结论Ⅰ型HRS患者死亡率极高,应争取早发现、早诊断、早治疗,以改善预后。     

老年糖尿病患者并发新型冠状病毒肺炎预后及其相关因素分析

目的分析老年糖尿病患者并发新型冠状病毒肺炎(COVID-19)的临床特征及其预后相关因素,为早期防治提供参考依据。 方法以2020年2月4日至2020年4月16日确诊的COVID-19 3 733例中伴有糖尿病的老年患者227例作为分析对象,采集患者一般资料、基础疾病、临床特征、实验室结果等信息,采用SPSS 23.0进行数据描述和分析。 结果227例老年糖尿病患者并发COVID-19被纳入分析,住院期间死亡16例,病死率为7.0%(16/227);单因素和多因素Logistic回归分析结果提示：肺部疾病、血糖、白细胞、中性粒细胞、肌酐、CKMB和呼吸困难是老年糖尿病并发COVID-19预后危险因素;采用这些因素预测老年糖尿病并发COVID-19死亡的ROC曲线下面积(AUC)为96.0%(95CI：91.0%~100.0%)。 结论老年人群中,糖尿病患者并发COVID-19的患者其预后风险较高,采用血糖和白细胞等因素预测COVID-19的预后具有临床意义。     

Clinical course,predictive factors and prognosis in patients with cirrhosis and type 1 hepatorenal syndrome treated with Terlipressin: a retrospective analysis

BACKGROUND AND AIM: Terlipressin has been proposed to treat renal failure in patients with type 1 hepatorenal syndrome (HRS). However, the predictive factors for improved renal function and survival are unknown in patients with type 1 HRS treated with terlipressin. The aim of the present retrospective study was to investigate the predictive factors and prognosis of patients with type 1 HRS treated with terlipressin. METHODS: The clinical charts of 18 consecutive patients with cirrhosis and type 1 HRS treated with terlipressin were studied. The predictive factors for improved renal function and survival were identified using univariate analyses. RESULTS: Improved renal function, indicated by a significant decrease in serum creatinine (61 +/- 4%), occurred in 11 (60%) patients. The only predictive factor for improved renal function was a Child-Pugh's score < or =13 at the time of diagnosis of HRS (P = 0.02). Fifteen patients (83%) died at 45 days and the median survival was 24 days. Of the three patients who survived, two underwent successful orthotopic liver transplantation. Three predictive factors for survival were identified: absence of a precipitating factor for HRS (P = 0.012); improved renal function during terlipressin therapy (P = 0.05); and a dose of terlipressin > or =3 mg/day (P = 0.04). CONCLUSIONS: In patients with type 1 HRS treated with terlipressin, patients with improved renal function had less severe cirrhosis (Child-Pugh >10 but < or =13) than patients without. The predictive factors for survival were the absence of a precipitating factor for HRS, the terlipressin-induced improvement in renal function and a dose of terlipressin of at least 3 mg/day. These findings suggest that a randomized controlled trial investigating the effect of terlipressin on survival in patients with type 1 HRS should be performed.     

Increased risk and case fatality rate of pyogenic liver abscess in patients with liver cirrhosis: a nationwide study in Denmark

BACKGROUND: Patients with liver cirrhosis are at increased risk of serious bacterial infections carrying a high case fatality rate. Case reports have suggested an association between liver cirrhosis and pyogenic liver abscess. AIMS: To estimate the risk and case fatality rate of pyogenic liver abscess in Danish patients with liver cirrhosis compared with the background population. METHODS: Identification of all patients with liver cirrhosis and pyogenic liver abscess over a 17 year period in the National Registry of Patients. Information on death was obtained from the Danish Central Person Registry. RESULTS: We identified 22 764 patients with liver cirrhosis and 665 patients with pyogenic liver abscess, of whom 21 were cirrhotics and 644 were non-cirrhotics. The crude incidence rate of liver abscess in cirrhotics was 23.3 (95% CI 14.4-35.6) per 100 000 person years. The age adjusted risk of liver abscess was increased 15-fold in patients with cirrhosis compared with the background population. The 30 day case fatality rates in patients with liver abscess and cirrhosis were 38.5% (13.9-68.4) in alcoholic cirrhosis and 62.5% (24.5-91.5) in non-alcoholic cirrhosis compared with 26.9% (23.5-30.5) in liver abscess patients from the background population. After adjustment for sex, age, and comorbidity, the relative risk of death was increased more than fourfold in alcoholic cirrhosis and non-alcoholic cirrhosis compared with the background population. CONCLUSIONS: Liver cirrhosis is a strong risk factor for pyogenic liver abscess associated with a poor prognosis.     

Risk and case fatality rate of meningitis in patients with liver cirrhosis

Bacterial infections are major causes of morbidity and death in patients with liver cirrhosis. The risk of bacterial meningitis in these patients is unknown, however. In this study on a nation-wide cohort of 22,743 patients with liver cirrhosis in Denmark an incidence rate of bacterial meningitis of 54.4 per 100,000 was found [95% confidence interval (CI) 40.3-71.9]. The highest incidence rate was found in patients with alcoholic cirrhosis, 65.3 per 100,000 person-years (95% CI 46.2-89.6), compared with 34.6 per 100,000 person-years (95% CI 17.3-61.9) in patients with non-alcoholic cirrhosis. The 30-d case fatality rate was 53.1% (95% CI 38.3-67.5), and high age and alcoholic cirrhosis were associated with the highest case fatality rates. The main bacterial pathogens were pneumococci and unspecified bacteria. These findings suggest that patients with liver cirrhosis are at increased risk of bacterial meningitis with a poor prognosis.     

Incidence and characteristics of type 2 hepatorenal syndrome in patients with cirrhosis and refractory ascites

BACKGROUND AND AIM: Type 2 hepatorenal syndrome (HRS) is a well described progressive impairment of renal function in patients with cirrhosis but its natural history, especially in patients with refractory ascites, is not well known. The aim of this study was to assess the incidence, predictive factors and outcome of type 2 HRS in patients with cirrhosis and refractory ascites. PATIENTS AND METHODS: Thirty patients with refractory ascites were followed-up for 17.5 +/- 26.3 months. The clinical characteristics, biological findings and outcome were analysed. The occurrence of renal dysfunction, and type 2 HRS in particular, was systematically analysed. RESULTS: Twenty-five patients (83.3%) developed renal dysfunction. Type 2 HRS was diagnosed in 16 patients (53.3%). Patients with type 2 HRS were older than patients without (64.8 +/- 9.1 yr vs 52.8 +/- 9.0 yr ; p < 0.001). All the others studied variables were similar between type 2 HRS and non-type 2 HRS patients. There was no significant difference in the overall probability of survival between these 2 groups. CONCLUSIONS: In patients with cirrhosis and refractory ascites, the development of type 2 HRS is frequent but does not occur in more severe liver disease and does not affect prognosis.     

广西461例青少年肝硬化临床特点和流行病学分析

目的探讨青少年肝硬化患者的临床特点和流行病学特征。方法收集广西地区1995年～2004年12所三甲医院的461例30岁以下肝硬化患者资料进行回顾性分析。结果80．04％患者为男性;2000年～2004年青少年肝硬化构成比较1994年～1999年明显降低;10年内平均住院费用、每日平均费用均有进行性增加趋势,平均住院日逐渐下降;64．86％（299／461）肝硬化病因是乙型肝炎,HBeAg阴性占81．96％（245／299）;24．08％病例发生上消化道出血,14．75％发生感染,3．69％发生肝性脑病,1．74％发生肝肾综合征,死亡组较非死亡组肝性脑病和肝。肾综合征发生率高。结论广西近10年青少年肝硬化所占比例有所下降,HBeAg阴性乙肝后肝硬化是广西青少年肝硬化主要类型,上消化道出血是最常见死因,青少年肝硬化死亡病例中肝性脑病和肝肾综合征发生率高。     

特利加压素治疗肝肾综合征的疗效、预后及相关影响因素

目的观察特利加压素治疗肝肾综合征的疗效、预后,并分析相关的影响因素及临床意义。方法回顾性分析2012年1月至2014年12月第二军医大学附属长海医院使用特利加压素治疗的肝肾综合征患者,收集治疗前及治疗后的数据,观察特利加压素的疗效及预后。根据疗效的差异和预后的不同通过单因素分析筛选可能的影响因素,进一步采用Logistic回归和ROC分析验证。结果共收集到使用特利加压素治疗肝肾综合征患者96例,特利加压素的总体有效率为43.8%,肝肾综合征I型患者有效率为32.8%,肝肾综合征Ⅱ型患者的有效率为65.6%;MELD-Na评分,基线的内生肌酐清除率,是否合并感染是特利加压素疗效的影响因素;MELD-Na评分,总胆红素和特利加压素是否有效是预后的影响因素。结论特利加压素治疗肝肾综合征疗效确切,应尽早开始治疗,对于MELD-Na评分较高的患者可能疗效较差。     

脑血管意外预后危险因素的病例—对照研究

目的 为探讨影响脑血管意外预后的有关因素,以住院病死病例作为病例组;存活病人为对照组。对华西医科大学附属第一医院神经内科的1990年至1996年297例患者作了回顾性的分析和研究。方法 全部病例资料应用国际临床流行病脑卒中协作组调查表,逐项记录,特别是对影响预后的有关重要因素如:病程、病情程度、神智状态、病型、年龄、合并症、并存症以及即往史和住院治疗等作了详细统计。并用双输法建立相关的数据库,资料分析处理采用x~2检验,非条件Logistic多元回归分析,并在STATA 5.0软件包上运行。结果 全部297例患者中,死亡者31例(10.4％),存活者266例。脑梗塞型179例(60％)。病例组中神智和语言障碍程度明显严重于对照组,并发高血压的比例亦高;但糖尿病及心脏病变致心律失常者,两组无差异。多因素分析链激酶类药和中西结合治疗有保护性作用(OR<1)。结论 提示住院患者脑卒中的病死率与年龄、梗塞类型、精神状态、高血压等有关。在常规治疗的基础上,中西医结合用药及溶栓抗凝药STK疗效较好。     

Prognostic factors for patients with cirrhosis and kidney dysfunction in the era of MELD: results of a prospective study.

BACKGROUND/AIM: Hepatorenal syndrome (HRS) is associated with a poor prognosis. The incidence and prognostic impact of kidney dysfunction due to other causes in cirrhotic patients are less well known. The current study prospectively evaluated the incidence and the prognostic relevance of different etiologies of kidney failure in cirrhotic patients. METHODS: Eighty-eight consecutive patients with cirrhosis and serum creatinine > or =1.5 mg/dl were enrolled. The etiologies of kidney dysfunction were analyzed, and prognostic factors including Model for End-Stage Liver Disease (MELD) score were evaluated in a multivariate Cox model. RESULTS: HRS was present in 35 (40%) patients (15 HRS 1, 20 HRS 2), followed by renal parenchymal disease (23%), drug-induced kidney dysfunction (19%) and prerenal failure due to bleeding or infections (15%). HRS patients had a significantly higher MELD score and shorter survival. In addition to the MELD score, only HRS 1 was independently predictive for survival. HRS 2 patients had a similar outcome as patients with non-HRS kidney dysfunction. CONCLUSIONS: In patients with cirrhosis and renal failure, hepatorenal syndrome is associated with a worse prognosis than kidney dysfunction due to other conditions but only HRS type 1 has independent prognostic relevance in addition to the MELD score in these patients.