慢性乙型肝炎相关慢加急性肝功能衰竭患者肾上腺功能不全的临床观察

摘要

目的：研究慢性乙型肝炎慢加急性肝功能衰竭（ACLF）中肾上腺功能不全的发生率及肾上腺功能不全与疾病严重程度和预后的相关性。方法为单中心的观察性研究，纳入2013年3月至2014年11月入住中国人民解放军第三〇二医院的慢性乙型肝炎ACLF患者，排除合并感染及半年内应用皮质激素的患者。根据晨起皮质醇水平将患者分为肾上腺功能不全慢性乙型肝炎ACLF组（皮质醇＜276 nmol/L）和肾上腺功能正常慢性乙型肝炎ACLF组（皮质醇≥276 nmol/L），比较两组患者的血流动力学（SBP、ΔSBP、DBP、ΔDBP、HR和UO）、肝肾功能（ALT、AST、ALB、CHE、Scr和BUN）、凝血功能（PTA和INR）、MELD评分及预后。结果共纳入54例慢性乙型肝炎ACLF患者，其中肾上腺功能不全者27例（50%）。ACLF早期、中期和晚期肾上腺功能不全者分别为11例（55%）、13例（52%）和3例（33.3%），各期患者肾上腺功能不全的患病率差异无统计学意义（χ2=1.231，P =0.666）。肾上腺功能不全慢性乙型肝炎ACLF组与肾上腺功能正常慢性乙型肝炎ACLF组相比，血流动力学指标（SBP、ΔSBP、DBP、ΔDBP、HR和UO）无统计学差异（P均＞0.05），生物化学指标中，肾上腺功能不全慢性乙型肝炎ACLF组较肾上腺功能正常慢性乙型肝炎ACLF组的TBil [（314.5±146.0）µmol/Lvs （405.3±123.1）µmol/L]和ALB [（28.2±2.8）g/Lvs（30.3±3.1）g/L]降低，差异有统计学意义（P =0.011、0.017），其他指标（ALT、AST、CHE、PTA、INR、Scr、BUN）无统计学差异（P均＞0.05）。在MELD评分[（26.1±6.0）分vs（27.7±5.0）分）及预后风险方面（OR =0.862，95%CI：0.295～2.513）也无统计学差异（P值分别为0.288和1.000）。结论慢性乙型肝炎ACLF患者中肾上腺功能不全的发病率为50%，但肾上腺功能不全与血流动力学、肝病严重程度及预后无显著相关性。因此，以肾上腺功能不全作为慢性乙型肝炎ACLF的预后指标以及对肾上腺功能不全患者补充肾上腺皮质激素以纠正肾上腺功能不全从而达到改善肝脏功能及预后的设想仍需商榷。%Objective To explore the prevalence rate of adrenal insufifciency (AI) in patients with chronic hepatitis B patients with acute-on-chronic liver failure (ACLF) and the relationship between AI andACLF. MethodsThis is a observational single center study.Chronic hepatitis B patients with ACLF without bacterial infection and steroids use in half a year were enrolled and divided into AI group (serum cortisol< 276 nmol/L) and non-AI group (serum cortisol≥ 276 nmol/L) according to the serum cortisol concentration. The indexes of hemodynamics (SBP, ΔSBP, DBP, ΔDBP, HR and UO), hepatic and renal function (TBil, ALT, AST, ALB, CHE, Scr and BUN), coagulation function (PTa and INR), MELD score and outcomes between the two groups were compared. Results Total of 54 cases were enrolled in the trials and 27 cases (50%) of the patients were with AI. There were 11 cases (55%), 13 cases (52%) and 3 cases (33.3%) in early, middle and later stage of ACLF, respectively. The prevalence rates of AI among the three stages had no statistically signiifcant difference(χ2 = 1.231,P = 0.666). Between AI group and non-AI group, the indexes of hemodynamics (SBP,ΔSBP, DBP, ΔDBP, HR and UO) were with no statistically signiifcant difference(P> 0.05). The levels of TBil [(314.5 ± 146.0) µmol/Lvs (405.3 ± 123.1) µmol/L] and ALB [(28.2 ± 2.8)g/Lvs (30.3 ± 3.1) g/L] in AI group decreased signiifcantly (P = 0.011, 0.017), the difference in other indexes (ALT, AST, CHE, Scr, BUN, PTa, INR) were not statistically signiifcant. Finally, there was no signiifcant difference in MELD scores [(26.1 ± 6.0)vs (27.7 ± 5.0)] and prognostic risks (OR = 0.862, 95%CI: 0.295~2.513) between the two groups (P= 0.288, 1.000).Conclusions The prevalence rate of AI in chronic hepatitis B patients with ACLF was 50%, and AI in these patients had no relationship with hemodynamics, severe illness and prognosis, which did not support the hypothesis that chronic hepatitis B patients with ACLF complicated with AI could beneift in hepatic function and outcome from treatment of AI.