乙型肝炎病毒相关的慢加急性肝衰竭患者发生急性肾损伤的临床特点及预后研究  

Clinical features and prognosis of acute kidney injury in patients with acute on chronic liver failure associated with hepatitis B virus

作　　者：常敏 孙芳芳 路遥 郝红晓 张璐 刘如玉 申戈 吴淑玲 高媛娇 胡蕾苹 李明慧 黄容海[3] 谢尧 Chang Min;Sun Fangfang;Lu Yao;Hao Hongxiao;Zhang Lu;Liu Ruyu;Shen Ge;Wu Shuling;Gao Yuanjiao;Hu Leiping;Li Minghui;Huang Ronghai;Xie Yao(Department of Hepatology Division 2,Beijing Ditan Hospital,Capital Medical University,Beijing 100015,China;Department of Hepatology Division 2,Peking university Ditan Teaching Hospital,Beijing 100015,China;Department of General Surgery,Beijing Ditan Hospital,Capital Medical University)

机构地区：[1]首都医科大学附属北京地坛医院肝病二科,北京100015 [2]北京大学地坛医院教学医院肝病二科,北京100015 [3]首都医科大学附属北京地坛医院普外科,北京100015

出　　处：《中华实验和临床病毒学杂志》2021年第4期378-383,共6页Chinese Journal of Experimental and Clinical Virology

基　　金：国家科技重大专项(2018ZX10715-005-003-005);首都临床特色应用研究专项资助课题(Z151100004015122);北京市医院管理中心临床医学发展专项经费资助(XMLX 201706和XMLX 202127);北京市医院管理中心消化内科学科协同发展中心资助课题(XXZ0302和XXT28);北京市科技计划子课题(D161100002716002);北京地坛医院启航计划(DTQH201801)。

摘　　要：目的:总结乙型肝炎病毒(hepatitis B virus,HBV)相关的慢加急性肝衰竭(acute on chronic liver failure,ACLF)患者发生急性肾损伤(acute kidney injury,AKI)的临床特点和预后情况。方法:回顾性分析2010年9月至2019年9月住院治疗的HBV相关的ACLF基础上合并AKI的患者150例,总结患者的性别、发病年龄、实验室检查、Child-pugh分级、MELD评分,并随访患者的生存情况,分析患者的生存时间、影响预后的因素。结果:在发生AKI时,93%患者合并腹水,81%患者合并自发性腹膜炎,65%患者合并肝性脑病,58.7%患者合并肺部感染。AKI 1期90例(60.0%)、2期44例(29.3%)、3期16例(10.7%)。在诊断AKI时合并低钠血症患者,白蛋白水平更低(t=2.571,P=0.011),而尿素氮、血钾及白细胞水平更高(t=3.184,P=0.002;t=2.069,P=0.040;t=2.251,P=0.026)。74.7%患者在30天内死亡,90天生存率为16.7%。在诊断AKI时合并低钠血症患者30天或90天的死亡率均显著高于不合并低钠血症患者(χ^(2)=4.11,P=0.044;χ^(2)=3.901,P=0.0497)。Kaplan-Meier生存分析显示,发生AKI前尿酸异常、发生AKI时存在低钠血症、合并心或肺功能损伤、代谢性酸中毒、上消化道出血、肝性脑病等因素的患者,生存明显差。Cox回归分析显示,存在肝肾以外的脏器功能严重损伤、合并代谢性酸中毒以及高龄,是ACLF发生AKI患者死亡的独立危险因素,死亡风险增加约2~3倍。结论:HBV相关的ACLF患者在发生AKI时大多合并有腹水和自发性腹膜炎,AKI 1期患者多见。合并肝肾以外的脏器功能严重损伤、代谢性酸中毒以及高龄的患者死亡风险高。Objective To summarize the clinical features and prognosis of acute kidney injury in patients with HBV related acute on chronic liver failure(ACLF).Methods A total of 150 patients who developed acute kidney injury(AKI)in patients with HBV related ACLF from Sep.2010 to Sep.2019 were reviewed retrospectively,and the gender,age,laboratory examination,Child-pugh scores,and model for end-stage liver disease(MELD)were collected and the survival of the patients were followed up to analyze the prognosis.Results Ninety-three percent of the patients were complicated with ascites,81%with spontaneous peritonitis,65%with hepatic encephalopathy and 58.7%with pulmonary infection;60 patients(60.0%)were AKI stage 1,44 patients(29.3%)were AKI stage 2,16 patients(10.7%)were AKI stage 3.The patients with hyponatremia had lower albumin(t=2.571,P=0.011),higher blood urea nitrogen,serum potassium and white blood cell levels than those without hyponatremia(t=3.184,P=0.002;t=2.069,P=0.040;t=2.251,P=0.026);74.7%of the patients died within 30 days,and the 90 days survival rate was 16.7%.The 30 days and 90 days mortality of patients with hyponatremia was higher than that of patients without hyponatremia(χ^(2)=4.11,P=0.044;χ^(2)=3.901,P=0.0497).Kaplan-Meier analysis revealed that the patients who had abnormal uric acid pre-diagnosis of AKI,hyponatremia when diagnosis of AKI,organ damage other than liver and kidney,metabolic acidosis,upper gastrointestinal tract bleeding,hepatic encephalopathy had a poor survival.Cox regression analysis showed that other organ function damage other than liver and kidney,metabolic acidosis,and the old age,were independent risk factors of death.Conclusions Most of the AKI patients with HBV related ACLF had ascites and spontaneous bacterial peritonitis when AKI occurred,and AKI stage 1 was common.The mortality of patients with hyponatremia was high,and the risk of death was high in patients with severe organ damage other than liver and kidney,metabolic acidosis and the old age.

关 键 词：乙型肝炎病毒 慢加急性肝衰竭 急性肾损伤 预后 

分 类 号：R575.3[医药卫生—消化系统]