肝硬化患者肝性脑病发生风险的回顾性研究
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摘要
目的探讨肝硬化患者发生肝性脑病的危险因素。方法选取本院2016年6月至2018年6月确诊为肝性脑病的188例肝硬化患者作为病例组,且以1∶1的比例采用随机数字表抽取同期188例肝硬化无肝性脑病患者作为对照组,分析两组肝硬化患者发生肝性脑病的危险因素。结果单因素分析发现两组病因、肝性脑病病史、肝衰竭、高蛋白饮食、腹膜炎、败/脓毒血症、碱中毒、低氯血症、低钠血症、总胆红素(TBil)、直接胆红素(DBil)、国际化标准比值(INR)、终末期肝病模型(model for end stage liver disease,MELD)评分等比较,差异具有统计学意义(P<0.05)。多因素分析发现肝性脑病病史、高蛋白饮食、碱中毒、MELD评分是肝硬化患者发生肝性脑病的独立危险因素(P<0.05),前白蛋白是其保护性因素(P<0.05)。结论肝功能严重损害、肝性脑病病史、高蛋白饮食及碱中毒等危险因素可增加肝硬化患者肝性脑病发生风险,应及时进行评估与管理。
Objective To explore the risk factors associated with hepatic encephalopathy in patients with cirrhosis. Methods A total of 188 cirrhotic patients diagnosed with hepatic encephalopathy admitted in our hospital during June 2016 and June 2018 were enrolled and assigned into case group, another 188 cirrhotic patients without hepatic encephalopathy were subjected at a ratio of 1∶1 and assigned into the control group. The risk factors for hepatic encephalopathy were analyzed based on the clinical data of the 2 groups of patients. Results Univariate analysis found that there were significant differences among cause of disease, history of hepatic encephalopathy, liver failure, high protein diet, peritonitis, sepsis, alkalosis, hypochloremia, hyponatremia, total bilirubin, direct bilirubin, international normalized ratio, and model for end stage liver disease(MELD) score(P<0.05). And multivariate analysis, alkalosis indicated that history of hepatic encephalopathy, high protein diet, alkalosis, and MELD score were independent risk factors for the hepatic encephalopathy, but prealbumin was a protective factor(P<0.05). Conclusion Serious liver damage, history of hepatic encephalopathy, high protein diet, and alkalosis can increase the risk of hepatic encephalopathy in cirrhotic patients, and they should be evaluated and managed timely.
Objective To explore the risk factors associated with hepatic encephalopathy in patients with cirrhosis. Methods A total of 188 cirrhotic patients diagnosed with hepatic encephalopathy admitted in our hospital during June 2016 and June 2018 were enrolled and assigned into case group, another 188 cirrhotic patients without hepatic encephalopathy were subjected at a ratio of 1∶1 and assigned into the control group. The risk factors for hepatic encephalopathy were analyzed based on the clinical data of the 2 groups of patients. Results Univariate analysis found that there were significant differences among cause of disease, history of hepatic encephalopathy, liver failure, high protein diet, peritonitis, sepsis, alkalosis, hypochloremia, hyponatremia, total bilirubin, direct bilirubin, international normalized ratio, and model for end stage liver disease(MELD) score(P<0.05). And multivariate analysis, alkalosis indicated that history of hepatic encephalopathy, high protein diet, alkalosis, and MELD score were independent risk factors for the hepatic encephalopathy, but prealbumin was a protective factor(P<0.05). Conclusion Serious liver damage, history of hepatic encephalopathy, high protein diet, and alkalosis can increase the risk of hepatic encephalopathy in cirrhotic patients, and they should be evaluated and managed timely.
引文
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[8] 陈新,李慧,孙艳辉.肝硬化患者肝性脑病发生的影响因素分析[J].胃肠病学和肝病学杂志,2015,24(11):1327-1330.DOI:10.3969/j.issn.1006-5709.2015.11.013.CHEN X,LI H,SUN Y H.Influence factors of the occurrence of hepatic encephalopathy in patients with liver cirrhosis[J].Chin J Gastroenterol Hepatol,2015,24(11):1327-1330.DOI:10.3969/j.issn.1006-5709.2015.11.013.
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[11] 肝衰竭诊治指南(2012年版)[J].中华肝脏病杂志,2013,21(3):177-183.DOI:10.3760/cma.j.issn.1007-3418.2013.03.006.Diagnostic and treatment guidelines for liver failure (2012 version)[J].Chin J Hepatol,2013,21(3):177-183.DOI:10.3760/cma.j.issn.1007-3418.2013.03.006.
[12] REINTAM BLASER A,MALBRAIN M L,STARKOPF J,et al.Gastrointestinal function in intensive care patients:terminology,definitions and management.Recommendations of the ESICM working group on abdominal problems[J].Intens Care Med,2012,38(3):384-394.DOI:10.1007/s00134-011-2459-y.
[13] 翟永贞,岳阳阳,丁德平,等.血清前白蛋白联合终末期肝病模型评分评估失代偿期肝硬化患者预后的临床价值[J].中华肝脏病杂志,2017,25(7):533-535.DOI:10.3760/cma.j.issn.1007-3418.2017.07.012.ZHAI Y Z,YUE Y Y,DING D P,et al.The value of serum prealbumin combined with MELD score in predicting the prognosis of patients with decompensated cirrhosis[J].Chin J Hepatol,2017,25(7):533-535.DOI:10.3760/cma.j.issn.1007-3418.2017.07.012.
[14] SAAB S.Evaluation of the impact of rehospitalization in the management of hepatic encephalopathy[J].Int J Gen Med,2015,8:165-173.DOI:10.2147/IJGM.S81878.
[15] BALE A,PAI C G,SHETTY S,et al.Prevalence of and factors associated with minimal hepatic encephalopathy in patients with cirrhosis of liver[J].J Clin Exp Hepatol,2018,8(2):156-161.DOI:10.1016/j.jceh.2017.06.005.
[16] 侯玉丽,高梦丹,郭鸿雁,等.白蛋白-胆红素指数与血氨联合检测对肝硬化并发肝性脑病的诊断价值评估[J].中华医学杂志,2018,98(2):127-131.DOI:10.3760/cma.j.issn.0376-2491.2018.02.011.HOU Y L,GAO M D,GUO H Y,et al.Diagnostic value of albumin-bilirubin grade combined with serum ammonia in cirrhosis with hepatic encephalopathy[J].Natl Med J China,2018,98(2):127-131.DOI:10.3760/cma.j.issn.0376-2491.2018.02.011.
[17] CHANEY A,WERNER K T,KIPPLE T.Primary care management of hepatic encephalopathy:A common cirrhosis complication[J].J Nurs Prac,2015,11(3):300-306.DOI:10.1016/j.nurpra.2014.11.005.
[18] YOSHIMURA E,ICHIKAWA T,MIYAAKI H,et al.Screening for minimal hepatic encephalopathy in patients with cirrhosis by cirrhosis-related symptoms and a history of overt hepatic encephalopathy[J].Biomed Rep,2016,5(2):193-198.DOI:10.3892/br.2016.702.
[19] RIGGIO O,AMODIO P,FARCOMENI A,et al.A model for predicting development of overt hepatic encephalopathy in patients with cirrhosis[J].Clin Gastroenterol Hepatol,2015,13(7):1346-1352.DOI:10.1016/j.cgh.2014.12.025.
[20] LUO L,FU S Y ,ZHANG Y Z,et al.Early diet intervention to reduce the incidence of hepatic encephalopathy in cirrhosis patients:post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) findings[J].Asia Pac J Clin Nutr,2016,25(3):497-503.DOI:10.6133/apjcn.092015.14.
[21] 李倩倩,牛小霞,徐碧海,等.肝硬化失代偿期患者主要照顾者对延续性护理需求的质性研究[J].解放军护理杂志,2018,35(1):25-28.DOI:10.3969/j.issn.1008-9993.2018.01.005.LI Q Q,NIU X X,XU B H,et al.The qualitative study of continuity care needs of the family caregivers of the patients with decompensated live cirrhosis[J].Nurs J Chin PLA,2018,35(1):25-28.DOI:10.3969/j.issn.1008-9993.2018.01.005.
[22] MEENA R K,SUNDARMURTHY G,KARTHIK P,et al.Constipation and upper gastrointestinal bleed:Leading precipitating factors of hepatic encephalopathy in Indian cirrhotic patients[J].Indian J Med Special,2018,9(4):192-194.DOI:10.1016/j.injms.2018.06.002.
[2] BAJAJ J S,WADE J B,GIBSON D P,et al.The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers[J].Am J Gastroenterol,2011,106(9):1646-1653.DOI:10.1038/ajg.2011.157.
[3] 樊慧丽,朱迎,董丽.专科品质指标对失代偿期乙肝肝硬化患者护理品质的影响[J].齐鲁护理杂志,2018,24(13):51-53.DOI:10.3969/j.issn.1006-7256.2018.13.017.FAN H L,ZHU Y,DONG L.Effect of specialist quality indicators on nursing quality of decompensated patients with hepatitis B cirrhosis[J].J Qilu Nursing,2018,24(13):51-53.DOI:10.3969/j.issn.1006-7256.2018.13.017.
[4] 黄慧懿,钱湘云,陈璇,等.赋能教育理念在乙型肝炎肝硬化失代偿患者健康教育中的应用[J].中华现代护理杂志,2018,24(29):3527-3531.DOI:10.3760/cma.j.issn.1674-2907.2018.29.012.HUANG H Y,QIAN X Y,CHEN X,et al.Application of empowerment education concept in the health education for decompensated patients with hepatitis B cirrhosis[J].Chin J Mod Nurs,2018,24(29):3527-3531.DOI:10.3760/cma.j.issn.1674-2907.2018.29.012.
[5] 许芳,吴海珍.个体化疾病管理干预对肝硬化失代偿期患者服药信念和依从性的影响[J].中华现代护理杂志,2018,24(12):1457-1460.DOI:10.3760/cma.j.issn.1674-2907.2018.12.024.XU F,WU H Z.Effect of individualized disease management intervention on the medication beliefs and compliance among patients with decompensated cirrhosis[J].Chin J Mod Nurs,2018,24(12):1457-1460.DOI:10.3760/cma.j.issn.1674-2907.2018.12.024.
[6] 中华医学会肝病学分会,徐小元,段钟平.肝硬化肝性脑病诊疗指南[J].中华肝脏病杂志,2018,26(10):721-736.DOI:10.3760/cma.j.issn.1007-3418.2018.10.001.Chinese Society of Hepatology of Chinese Medical Association,XU X P,DUAN Z P.Guidelines for the diagnosis and management of hepatic encephalopathy in cirrhosis[J].Chin J Hepatol,2018,26(10):721-736.DOI:10.3760/cma.j.issn.1007-3418.2018.10.001.
[7] PANTHAM G,POST A,VENKAT D,et al.A new look at precipitants of overt hepatic encephalopathy in cirrhosis[J].Dig Dis Sci,2017,62(8):2166-2173.DOI:10.1007/s10620-017-4630-y.
[8] 陈新,李慧,孙艳辉.肝硬化患者肝性脑病发生的影响因素分析[J].胃肠病学和肝病学杂志,2015,24(11):1327-1330.DOI:10.3969/j.issn.1006-5709.2015.11.013.CHEN X,LI H,SUN Y H.Influence factors of the occurrence of hepatic encephalopathy in patients with liver cirrhosis[J].Chin J Gastroenterol Hepatol,2015,24(11):1327-1330.DOI:10.3969/j.issn.1006-5709.2015.11.013.
[9] 慢性乙型肝炎防治指南(2015更新版)[J].中华肝脏病杂志,2015,23(12):888-905.DOI:10.3760/cma.j.issn.1007-3418.2015.12.002.The guideline of prevention and treatment for chronic hepatitis B:a 2015 update[J].Chin J Hepatol,2015,23(12):888-905.DOI:10.3760/cma.j.issn.1007-3418.2015.12.002.
[10] 中华医学会消化病学分会,中华医学会肝病学分会,北京大学人民医院肝病科.中国肝性脑病诊治共识意见(2013年,重庆)[J].中华肝脏病杂志,2013,21(9):641-651.DOI:10.3760/cma.j.issn.1007-3418.2013.09.001.Chinese Society of Gastroenterology,Chinese Society of Hepatology,Department of hepatiolgy of People’s Hospital of Peking University.Consensus on the diagnosis and treatment of hepatic encephalopathy in China (Chongqing,2013)[J].Chin J Hepatol,2013,21(9):641-651.DOI:10.3760/cma.j.issn.1007-3418.2013.09.001.
[11] 肝衰竭诊治指南(2012年版)[J].中华肝脏病杂志,2013,21(3):177-183.DOI:10.3760/cma.j.issn.1007-3418.2013.03.006.Diagnostic and treatment guidelines for liver failure (2012 version)[J].Chin J Hepatol,2013,21(3):177-183.DOI:10.3760/cma.j.issn.1007-3418.2013.03.006.
[12] REINTAM BLASER A,MALBRAIN M L,STARKOPF J,et al.Gastrointestinal function in intensive care patients:terminology,definitions and management.Recommendations of the ESICM working group on abdominal problems[J].Intens Care Med,2012,38(3):384-394.DOI:10.1007/s00134-011-2459-y.
[13] 翟永贞,岳阳阳,丁德平,等.血清前白蛋白联合终末期肝病模型评分评估失代偿期肝硬化患者预后的临床价值[J].中华肝脏病杂志,2017,25(7):533-535.DOI:10.3760/cma.j.issn.1007-3418.2017.07.012.ZHAI Y Z,YUE Y Y,DING D P,et al.The value of serum prealbumin combined with MELD score in predicting the prognosis of patients with decompensated cirrhosis[J].Chin J Hepatol,2017,25(7):533-535.DOI:10.3760/cma.j.issn.1007-3418.2017.07.012.
[14] SAAB S.Evaluation of the impact of rehospitalization in the management of hepatic encephalopathy[J].Int J Gen Med,2015,8:165-173.DOI:10.2147/IJGM.S81878.
[15] BALE A,PAI C G,SHETTY S,et al.Prevalence of and factors associated with minimal hepatic encephalopathy in patients with cirrhosis of liver[J].J Clin Exp Hepatol,2018,8(2):156-161.DOI:10.1016/j.jceh.2017.06.005.
[16] 侯玉丽,高梦丹,郭鸿雁,等.白蛋白-胆红素指数与血氨联合检测对肝硬化并发肝性脑病的诊断价值评估[J].中华医学杂志,2018,98(2):127-131.DOI:10.3760/cma.j.issn.0376-2491.2018.02.011.HOU Y L,GAO M D,GUO H Y,et al.Diagnostic value of albumin-bilirubin grade combined with serum ammonia in cirrhosis with hepatic encephalopathy[J].Natl Med J China,2018,98(2):127-131.DOI:10.3760/cma.j.issn.0376-2491.2018.02.011.
[17] CHANEY A,WERNER K T,KIPPLE T.Primary care management of hepatic encephalopathy:A common cirrhosis complication[J].J Nurs Prac,2015,11(3):300-306.DOI:10.1016/j.nurpra.2014.11.005.
[18] YOSHIMURA E,ICHIKAWA T,MIYAAKI H,et al.Screening for minimal hepatic encephalopathy in patients with cirrhosis by cirrhosis-related symptoms and a history of overt hepatic encephalopathy[J].Biomed Rep,2016,5(2):193-198.DOI:10.3892/br.2016.702.
[19] RIGGIO O,AMODIO P,FARCOMENI A,et al.A model for predicting development of overt hepatic encephalopathy in patients with cirrhosis[J].Clin Gastroenterol Hepatol,2015,13(7):1346-1352.DOI:10.1016/j.cgh.2014.12.025.
[20] LUO L,FU S Y ,ZHANG Y Z,et al.Early diet intervention to reduce the incidence of hepatic encephalopathy in cirrhosis patients:post-Transjugular Intrahepatic Portosystemic Shunt (TIPS) findings[J].Asia Pac J Clin Nutr,2016,25(3):497-503.DOI:10.6133/apjcn.092015.14.
[21] 李倩倩,牛小霞,徐碧海,等.肝硬化失代偿期患者主要照顾者对延续性护理需求的质性研究[J].解放军护理杂志,2018,35(1):25-28.DOI:10.3969/j.issn.1008-9993.2018.01.005.LI Q Q,NIU X X,XU B H,et al.The qualitative study of continuity care needs of the family caregivers of the patients with decompensated live cirrhosis[J].Nurs J Chin PLA,2018,35(1):25-28.DOI:10.3969/j.issn.1008-9993.2018.01.005.
[22] MEENA R K,SUNDARMURTHY G,KARTHIK P,et al.Constipation and upper gastrointestinal bleed:Leading precipitating factors of hepatic encephalopathy in Indian cirrhotic patients[J].Indian J Med Special,2018,9(4):192-194.DOI:10.1016/j.injms.2018.06.002.