慢加急性乙型肝炎肝衰竭临床特征及血浆置换治疗对其预后的影响

doi:10.3969/j.issn.1672-5069.2016.02.016

摘要/Abstract

摘要： 目的探讨乙型肝炎相关的慢加急性肝衰竭患者的临床特征,以及血浆置换（PE）对慢加急性肝衰竭治疗的疗效。方法按肝衰竭诊疗指南的诊断标准,收集2012年5月至2014年2月我科诊治的52例乙型肝炎相关慢加急性肝衰竭患者的住院临床资料。使用德国BE公司血液凝固分析仪检测凝血功能指标;使用美国 Beckman LH750 血球分析仪检测血细胞计数;使用日立7600全自动生化分析仪检测血清生化指标。结果16例死亡患者入院时凝血酶原时间（PT）为（48.8±11.7）s、活化部分凝血酶时间（APTT）为（65.8±19.0）s、凝血酶原时间国际标准化比率（INR）为（2.4±1.0）、血氨为（100.1±74.7）μmol/L,均显著高于36例生存患者[分别为（42.7±14.0）s、（48.0±11.4）s、（1.7±0.4）和（47.9±21.5）μmol/L,P<0.05];死亡组入院时凝血酶原活动度（PTA）为（31.8±12.9）%、血小板计数为（85.6±61.3）×10⁹/L、白蛋白为（29.2±4.1）g/L、血钾为（3.8±0.5）mmol/L,均显著低于生存组[分别为（47.9±21.2）%、（133.4±50.7）×10⁹/L、（32.8±4.7）g/L、（4.1±0.6）mmol/L,P<0.05];死亡组发生肝性脑病、腹水、自发性腹膜炎、电解质紊乱和发生2个以上并发症所占比例（分别为37.5%、68.75%、25%、62.5%、62.5%）显著高于生存组（分别为2.8%、30.35%、2.8%、11.11%、11.11%,P<0.05）;患者在接受PE治疗后PTA[（44.8±23.5）%]、白细胞计数[（8.0±3.6×10⁹）/L]、白蛋白[（36.4±3.6）g/L]、血尿素氮[（7.1±4.6）mmol/L]较治疗前显著升高[分别为（36.6±14.6）%、（5.9±2.8×10⁹）/L、（33.7±4.1）g/L、（5.4±3.8）mmol/L,P<0.05],红细胞计数[（3.9±0.7×10⁹）/L]、血红蛋白[（119.5±18.2）g/L]、ALT为[（100.6±67.9）U/L]、AST[（120.0±62.8）U/L]、总胆红素[（335.7±121.3）μmol/L]、间接胆红素[（226.3±77.9）μmol/L]较治疗前显著降低[分别为（4.2±0.8×10⁹）/L、（130.6±23.8）g/L、（300.0±302.3）U/L、（227.2±174.6）U/L,（410.8±129.8）μmol/L,（290.4±100.5）μmol/L,P<0.05]。结论凝血酶原时间、血小板和白蛋白是判断乙型肝炎相关的慢加急性肝衰竭患者预后的敏感的实验室指标,发生并发症的患者预后差,PE治疗可暂时改善患者的凝血功能及肝功能指标,却对其生存无影响。

关键词: 慢加急性肝衰竭, 乙型肝炎, 并发症, 血浆置换, 预后

Abstract: Objective To investigate the clinical characteristics of patients with hepatitis B-induced acute-on-chronic liver failure（ACLF） and the effects of plasma exchanges（PE） on their prognosis. MethodsAccording to the guideline for diagnosis and treatment of liver failure,the clinical data of 52 patients with hepatitis B related ACLF were collected. The relationship between the laboratory indexes at admission and the prognosis of patients, and the effects of complications on the prognosis were analyzed. In addition,the laboratory indexes before and after PE were also explored to evaluate its efficacy. ResultsSerum levels of PT,APTT,INR and blood ammonia at admission in dead patients were significantly higher than those in survived cases[（48.8±11.7） s vs.（42.7±14.0） s,（65.8±19.0） s vs.（48.0±11.4） s,（2.4±1.0） vs.（1.7±0.4）,（100.1±74.7） μmol/L vs. （47.9±21.5） μmol/L,respectively,P<0.05 for all],while serum levels of PTA,PLT,ALB and potassium at admission in dead cases were significantly lower than those in survived cases [（31.8±12.9） % vs. （47.9±21.2）%, （85.6±61.3）×10⁹/L vs.（133.4±50.7）×10⁹/L,（29.2±4.1） g/L vs.（32.8±4.7） g/L,（3.8±0.5） μmol/L vs.（4.1±0.6） μmol/L,respectively,P<0.05 for all];the hepatic encephalopathy,ascites,spontaneous peritonitis,electrolyte disorder and more than one of them in dead patients were higher than in survived cases（37.5% vs. 2.8%, 68.7% vs. 30.3%,25.0% vs. 2.8%, 62.5% vs. 11.1%,62.5% vs. 11.1%, respectively,P<0.05 for all）;Lab indexes like PTA,WBC,ALB and Urea after the PE were significantly higher than those before treatment [（44.8±23.5） % vs. （36.6±14.6）%,（8.0±3.6）×10⁹/L vs. （5.9±2.8）×10⁹/L,（36.4±3.6） g/L vs. （33.7±4.1）g/L,（7.1±4.6） mmol/L vs. （5.4±3.8） mmol/L, respectively,P<0.05 for all];RBC,Hb,ALT,AST,TBIL and DBIL after the PE were remarkably lower than those before treatment [（3.9±0.7） ×10⁹/L vs. （4.2±0.8）×10⁹/L,（119.5±18.2） g/L vs. （130.6±23.8） g/L,（100.6±67.9） U/L vs. （300.0±302.3） U/L,（120.0±62.8） U/L vs. （227.2±174.6） U/L,（335.7±121.3） μmol/L vs. （410.8±129.8） μmol/L,（226.3±77.9） μmol/L vs. （290.4±100.5） μmol/L,respectively,P<0.05 for all）. Conclusion PT,PLT and ALB are sensitive laboratory indexes for the prediction of the prognosis in patients with hepatitis B related ACLF,and patients with complications have poor prognosis. PE could temporarily improve the blood coagulation function and the liver function,but has no influence on the survival in the patients with hepatitis B related ACLF.

Key words: Acute-on-chronic liver failure, Hepatitis B, Complications, Plasma exchanges, Prognosis

刘菲菲, 吴吉圆, 张海月, 张冬琴, 龚作炯. 慢加急性乙型肝炎肝衰竭临床特征及血浆置换治疗对其预后的影响[J]. 实用肝脏病杂志, 2016, 19(2): 188-191.

Liu Feifei, Wu Jiyuan, Zhang Haiyue. Clinical characteristics of patients with hepatitis B-induced acute-on-chronic liver failure and the effects of plasma exchanges on their prognosis[J]. JOURNAL OF PRACTICAL HEPATOLOGY, 2016, 19(2): 188-191.

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