双重血浆分子吸附系统模式治疗高原慢性肝衰竭患者的效果分析.docx

其他肝病l：10.12449/JCH20240119双重血浆分子吸附系统模式治疗高原慢性肝衰竭患者的效果分析王博文L彭梦佳L江历恒、方斐、王宇亮L沈元弟Y1西藏军区总医院重症医学中心，拉萨8500002海军特色医学中心急诊科，上海200000通信作者：沈元弟，dor-shen226（三）126.m（ORCID:0000-0001-8466-4266）摘要：目的比较世居高原和移居高原慢性肝衰竭患者接受双重血浆分子吸附系统模式（DPMAS）治疗后的临床特征和病死率。方法选取2016年1月2021年12月于西藏军区总医院重症监护室接受DPMAS治疗的63例慢性肝衰竭患者。根据患者的旅居史将患者分为世居高原组（。=29）和移居高原组（。=34）,对比两组患者的基线资料和接受DPMAS治疗前后的临床特征。符合正态分布的计量资料组间比较采用成组f检验；组内治疗前与治疗后比较应采用配对，检验.非正态分布计量资料组间比较采用Mann-WhitneyU检验；组内治疗前后比较应采用WiICoXon秩和检验。计数资料组间比较采用必检验。KaPlan-Meier法绘制生存曲线，死亡风险比较采用Log-rank检验结果移居高原组汉族比例明显多于世居高原组”=41.729,P<0.001）；世居高原组患者最近一次高原连续居住时间明显长于移居高原组（Z=3.364rP<0.001）；MELD评分、肝性脑病、肝肾综合征和消化道出血发生率均较世居高原组明显增高（Z=2.318,尤值分别为6.903、5.154、6.262,P值均<0.05）DPMAS治2且B三9PLTHGB.ALT、AST、Alb、TBikDBikLDH、Or、统（尸酸<0.05）.DPMAS治疗前，移居高原组ALT、AST、TBiI、DBiIxLDH、Cr、BUN和INR均较世居高原组高（尸值均0.05）,HGB较世居高原组低（P<0.05）;DPMAS治疗后，移居高原组患者PLT和HGB数量下降较世居高原组更为显著（尸值均<0.05）,但ALT、AST、TBiLDBikLDH、BUN和INR均仍较世居匐期高（P值均0.05）.世居高原组啪居高旌患者接受DPMAS治疗后60天病死率分别为52.5%（95%。：41.763.8）和81.3%（95%。：77.985.6）.相比于世居高原组.47,95%。：0.230.95）移居高者60EtZ硒（H8=2.14,95%。：1.064.32）明口（1.039）.结论与峥高原慢性肝衰竭患者相比，移居高原患者的肝功能损伤更重，DPMAS治疗后肝功能改善程度较弱，同时病死率更高。临床医护人员需要加强对移居高原慢性肝衰竭患者的重视，尽可能提高患者生存率.关键词：肝，AI；肝功育绩竭；高原病Clinicaleffectofdoubleplasmamolecularadsorptionsystemintreatmentofpatientswithchronicliverfailureinhigh-altitudeareasWANGBowen1lPENGMengjia1,JIANGUheng1lFANGFei1,WANGYuliang',SHENYuandi12.（1.CriticalCareMedicalCenter,GeneralHospitalofTibetMiIitaryCommand,Lhasa850000,China;2.DepartmentOfEmergency,PLANavyCharacteristicMedicalCenter,Shanghai200000,China）Correspondingauthor:SHENYuandi,dor_shen226（ORCID:0000-0001-8466-4266）Abstract:ObjectiveToinvestigatethedifferencesinclinicalfeaturesandmortalityratebetweennativepatientswithchronicliverfailure（CHF）andmigratedpatientswithCHFaftertreatmentwithdoubleplasmamolecularadsorptionsystem（DPMAS）inhigh-altitudeareas.MethodsAtotalof63patientswithCHFwhoreceivedDPMAStreatmentintheintensivecareunitofGeneralHospitalofTibetMilitaryCommandfromJanuary2016toDecember2021wereenrolled,andaccordingtotheirhistoryofresidenceinhigh-altitudeareas,theyweredividedintonativegroupwith29patientsandmigratedgroupwith34patients.ThetwogroupsweremparedintermsofbaselinedataandclinicalfeaturesbeforeandafterDPMAStreatment.Theindependent-samplesttestwasusedformparisonofrmallydistributedntinousdatabetweengroups,andthepairedMestwasusedforcomparisonbeforeandaftertreatmentwithineachgroup;theMann-WhitneyUtestwasusedforcomparisonofnon-nomallydistributedcontinuousdatabetweengroups,andtheWilcoxonsignedranksumtestwasusedformparisonbeforeandaftertreatmentwithineachgroup;thechi-squaretestwasusedforcomparisonofcategoricaldatabetweengroups.TheKaplan-Meiermethodwasusedtoplotsurvivalcurves,andtheLog-ranktestwasusedformparisonoftheriskofdeath.ResultsComparedwiththenativegroup,themigratedgrouphadasignificantlyhigherproportionofChineseHanpatients(2=41.729,P<0.001),andcomparedwiththemigratedgrouprthenativegrouphadasignificantlylongerdurationofthemostrecentntinousresidenceinhigh-altitudeareas(Z=3.364,P<0.00).Comparedwiththenativegroup,themigratedgrouphadsignificantlyhigherMELDsreandincidenceratesofhepaticencephalopathy,hepatorenalsyndrome,andgastrointestinalbleeding(Z=2.318,/=6.903,5.154,and6.262,allP<0.05).Bothgrpshadsignificantchangesinplateletnt(PLT),hemoglobinunt(HGB),alanineaminotransferase(ALT),aspartateaminotransferase(AST),albumin,totalbilirubin(TBiI),directbilirubin(DBiI),lactatedehydrogenase(LDH),creatinine(Cr),andinternationalnormalizedratio(INR)afterDPMAStreatment(all20.05).BeforeDPMAStreatment,comparedwithtenativegroup,themigratedgrouphadsignificantlyhigherlevelsofALT,AST,TBiI,DBiI,LDH,Cr,BUN,andINR(allP<0.05)andasignificantlylowerlevelofHGB(P<0.05);afterDPMAStreatment,comparedwiththenativegroup,themigratedgrouphadsignificantlygreaterreductionsinPLTandHGB(bothP<0.05)andstillsignificantlyhigherlevelsofALT,AST,TBiI,DBiI,LDH,BUN,andINR(allR<0.05).The60-daymortalityrateofpatientsafterDPMAStreatmentwas52.5%(95%confidenceintervalCl:41.763.8)inthenativegroupand81.3%(95%C:77.985.6)inthemigratedgrp.Comparedwiththenativegroup(hazardratioHR=0.47,95%C:0.230.95),themigratedgrouphadasignificantincreaseintheriskofdeathonday60(HR=2.14,95%C:1.064.32,P=0.039).ConclusionComparedwiththenativepatientswithCHFinhigh-altitudeareas,migratedpatientshaveahigherdegreeofliverimpairment,alowerdegreeofimprovementinliverfunctionafterDPMAStreatment,andahighermortalityrate.ClinicalmedicalstaffneedtopaymoreattentiontomigratedpatientswithCHF,soastoimprovetheirsurvivalrates.Keywords:Liver,Artificial;LiverFailure;AltitudeSickness慢性肝衰竭(ChroniCliverfailure,CHF)国g在各种原因导致的肝硬化的基础上，以反复出现腹水和肝性脑病为临床特点的严重肝功能失代偿综合征l1-2LCHF患者肝功能严重受损，体内积聚的胆红素和中大分子毒素引发的全身多脏器损伤是造成其高死亡率的重要因素之一【3”肝移植是CHF最重要的治疗方法，但是受到供体数量，医疗成本以及技术要求的限制，很难在临床上广泛开展15).人工肝通过体外循环装置，暂时性部分替代肝脏功能，从而达到协助治疗CHF的目的。人工肝在肝衰竭的治疗中已经取得了肯定的疗效61.目前临床上常用的人工肝模式包括血浆置换、血液灌流和双重血浆分附系统(doubleplasmamolecularabsorptionsystem,DPMAS)等a】。高原地区具有海拔高、气压低、氧含量低的气候特点。移居高原人群的血流动力学和心肝肺功能均会出现不同程度的生理改变以实现高原习服B.因此，对于移居