糖皮质激素治疗乙肝病毒相关慢加急性肝衰竭前期及早期的疗效观察

摘要

目的:探讨糖皮质激素治疗乙肝病-毒(HBV)相关慢加急性肝衰竭前期及早期的临床疗效及安全性.方法:回顾性研究2014年12月至2017年8月湖北医药学院附属太和医院感染科收治的HBV相关慢加急性肝衰竭前期或早期患者65例,根据治疗期间是否使用糖皮质激素,而分为治疗组(30例使用激素)及对照组(35例不使用激素).所有患者均使用恩替卡韦或替诺福韦抗病毒、常规护肝药物及对症治疗,治疗组患者在此基础上加用注射用甲泼尼龙琥珀酸钠40mg/d静脉滴注或地塞米松针剂5mg/d灌肠治疗,使用时间为7d.观察两组患者治疗前后的临床症状、血清总胆红素(TBil)、凝血酶原活动度(PTA)、4周生存率及并发症等情况.结果:激素使用1周时,患者血清TBil显著下降(由201.5±87.3 μmol/L下降至135.4±58.9 μmol/L),PTA迅速回升[由(42.8±12.2)％回升至(64.0±17.1)％].治疗组患者临床症状、生化指标的改善比例和速率明显优于对照组;患者感染及肝性脑病的发生率降低,且不影响患者病毒学应答.值得注意的是,激素治疗显著降低肝衰竭前期患者进展为肝衰竭的发生率(7.7％ VS73.3％;P ＜0.01);而且,治疗组患者4周生存率明显高于对照组(96.7％ vs 77.1％;P＜0.05).治疗期间,患者未出现明显糖皮质激素使用后的不良反应.结论:对HBV相关慢加急性肝衰竭前期及早期患者使用糖皮质激素干预治疗,有助于促进患者肝功能恢复,减少并发症发生,改善预后,提高生存率,且具有较高的安全性.%Objective:To investigate the efficacy and safety of glucocorticoids in treatment of patients with HBV-associated acute-on-chronic liver failure (HBV-ACLF) in the early stage and in pre-ACLF.Methods:Sixty-five patients with HBV-ACLF in the early stage or preACLF admitted in the department of infectious diseases of Taihe Hospital,Hubei University of Medicine,from Dec 2014 to Aug 2017,were enrolled in this retrospective study.All the patients received standard medical treatment including energy supplements and antiviral therapy using Entecavir or Tenofovir disoproxil,in which 30 patients received glucocorticoids treatment were assigned to treatment group,and the rest 35 patients were set as control group.A 7-day glucocorticoids regimen were applied with Methylprednisolone Sodium Succinate intravenously at the dose of 40mg per day or with Dexamethasone Sodium Phosphate at the dose of 5mg per day via retention enema.All the data including the clinical symptoms,liver function biochemical indexes,4 weeks survival rates and complications were retrieved from the electronic medical record system of Taihe Hospital.Results:After 1 week treatment with glucocorticoids,the total bilirubin was decreased from 201.5 ± 87.3moL/L to 35.4 ±58.9mol/L and the prothrombin activity was raised from 42.8 ± 12.2％ to 64.0 ± 17.1％ in the treatment group.The improvement rates of clinical symptoms and biochemical indexes were significantly higher in patients in the treatment group than those in control group,and the incidences of infection and hepatic encephalopathy were reduced significantly in patients received glucocorticoids treatment.It is noteworthy that glucocorticoids treatment can not only significantly raise the survival rates of patients with HBV-ACLF (96.7％ vs 77.1％;P ＜ 0.05),but also protect most patients with pre-ACLF from acute deterioration,much less patients with pre-ACLF developed ACLF in treatment group (7.7％) than in control group (73.3％) (P ＜ 0.01).During the treatment,there were no remarkable glucocorticoid-associated adverse event or side effect.Conclusion:The glucocorticoids treatment is effective and safe for patients with HBV-ACLF in the early stage and pre-ACLF,protecting liver function from deterioration,reducing complications,and improving the outcomes.