摘要
目的比较单纯血浆置换术(plasma exchange,PE)、双重血浆分子吸附术(dual plasma molecular adsorption system,DPMAS)及DPMAS+PE治疗慢加急性肝衰竭的疗效。方法以2019年1月至2020年12月桂林市第三人民医院住院的140例慢加急性肝衰竭患者为研究对象,在常规检查、内科综合治疗的基础上,按随机数字表法分为PE组、DPMAS组和DPMAS+PE组,3组患者均每隔3~4 d行1次治疗。测定治疗前、治疗后2周、4周患者的肝功能[丙氨酸氨基转移酶(alanine transaminase,ALT)、天门冬氨酸氨基转移酶(aspartate transaminase,AST)、球蛋白(globulin,GLB)、总胆红素(total bilirubin,TBil)、碱性磷酸酶(alkaline phosphatase,ALP)]、凝血酶原时间(prothrombin time,PT)、血常规[白细胞(white blood cell,WBC),血红蛋白(hemoglobin,HGB),血小板(platelet,PLT)]及血氨,观察治疗前和治疗后2周、4周3组患者的临床症状和体征,观察8周、12周时治疗有效率及24周、48周的生存率。结果PE组、DPMAS组和DPMAS+PE组治疗2周时分别死亡1例、2例、1例,治疗4周时分别死亡1例、1例、2例。死因为消化道出血、肝性脑病及呼吸循环衰竭等并发症,死亡患者退出研究。①治疗2周、4周时DPMAS+PE组患者乏力、食欲不振等临床症状体征改善的比例较PE组和DPMAS组显著提高(P均<0.05)。②治疗8周时PE组、DPMAS组和DPMAS+PE组临床有效率分别为60.8%(28/46)、58.6%(27/46)和85.3%(41/48),差异具有统计学意义(χ^(2)=9.668,P=0.008),其中DPMAS+PE组显著高于PE组和DPMAS组(χ^(2)=7.250,P=0.007;χ^(2)=8.382,P=0.004)。治疗12周时PE组、DPMAS组和DPMAS+PE组患者的临床有效率分别为73.8%(34/46)、69.4%(32/46)和93.7%(45/48),差异具有统计学意义(χ^(2)=9.570,P=0.008),其中DPMAS+PE组显著高于PE组和DPMAS(χ^(2)=6.892,P=0.009;χ^(2)=9.274,P=0.002)。③治疗24周时PE组、DPMAS组和DPMAS+PE组患者的生存率分别为65%(30/46)、61%(28/46)、83%(40/48),差异有统计学意义(χ^(2)=6.390,P=0.041),DPMAS+PE组显著高于PE组和DPMAS组(χ^(2)=4.055,P=0.044;χ^(2)=5.924,P=0.015)。治疗48周时PE组、DPMAS组和DPMAS+PE组患者的生存率分别为61%(28/46)、54%(25/46)、79%(38/48),差异具有统计学意义(χ^(2)=6.873,P=0.032),DPMAS+PE组显著高于PE组和DPMAS组(χ^(2)=3.760,P=0.043;χ^(2)=6.546,P=0.011)。④治疗2周、4周时3组患者ALT、AST、TBil、ALP、PT、HGB和血氨水平较治疗前显著降低,GLB、WBC水平水平显著升高(P均<0.05)。治疗前、治疗2周、4周时3组患者上述指标差异均无统计学意义(P均>0.05)。⑤治疗8周和12周,3组患者MELD评分均显著低于治疗前[PE组:(22.7±2.1)分vs(21.5±3.6)分vs(33.5±5.5)分;DPMAS组:(24.7±5.1)分vs(23.5±3.7)分vs(34.6±5.9)分;DPMAS+PE组:(18.2±4.3)分vs(16.33±3.4)分vs(32.7±4.2)分],且DPMAS+PE组均显著低于PE组和DPMAS组(P均<0.05)。⑥PE组、DPMAS组、DPMAS+PE组不良反应发生率分别为58.7%(27/46)、4.3%(2/46)、10.4%(5/48),差异有统计学意义(χ^(2)=44.59,P<0.001),DPMAS组和DPMAS+PE组不良反应发生率均显著低于PE组(χ^(2)=31.47,P<0.001;χ^(2)=24.38,P<0.001)。结论DPMAS+PE可有效改善患者的临床症状及体征,具有较好的临床预后及远期生存率。与单纯PE相比,DPMAS+PE治疗可减少血浆使用量,不良反应发生率较低。
Objective To investigate the clinical efficacy of plasma exchange(PE),double plasma molecular adsorption system(DPMAS)and DPMAS+PE in treatment of patients with acute-on-chronic liver failure.Methods A total of 140 patients with acute-on-chronic liver failure in the Third People’s Hospital of Guilin from January 2019 to December 2020 were collected.On the basis of routine examination and comprehensive medical treatment,the patients were randomly divided into PE group,DPMAS group and DPMAS+PE group according to random number table method.All three groups were treated once every 3 to 4 days.The liver function indexes[alanine transaminase(ALT),aspartate transaminase(AST),globulin(GLB),total bilirubin(TBil),alkaline phosphatase(ALP)],prothrombin time(PT),white blood cell(WBC),hemoglobin(HGB),platelet (PLT)and blood ammonia were measured before treatment,2 weeks and 4 weeks after treatment,and the evolution of clinical symptoms were observed before treatment and 2 and 4 weeks after treatment.The effective rate(8 weeks and 12 weeks after treatment)and survival rate(24 weeks and 48 weeks after treatment)were also observed.Results For patients in PE group,DPMAS group and DPMAS+PE group,there were 1 case,2 cases and 1 case died after 2 weeks of treatment,respectively;and 1 case,1 case and 2 cases died after 4 weeks of treatment,respectively.The causes of death were complications such as gastrointestinal hemorrhage,hepatic encephalopathy,and respiratory and circulatory failure.Dead patients withdrew from the study.①After 2 weeks and 4 weeks treatment,the proportion of clinical symptoms improvement such as fatigue and poor appetite in DPMAS+PE group were significantly higher than that in PE group and DPMAS group(all P<0.05).②At 8 weeks of treatment,the clinical effective rate of PE group,DPMAS group and DPMAS+PE group were 60.8%(28/46),58.6%(27/46)and 85.3%(41/48),respectively,the difference was statistically significant(χ^(2)=9.668,P=0.008).The clinical effective rate of DPMAS+PE group was significantly higher than that of PE group and DPMAS group(χ^(2)=7.250,P=0.007;χ^(2)=8.382,P=0.004).At 12 weeks of treatment,the clinical effective rate of PE group,DPMAS group and DPMAS+PE group were 73.8%(34/46),69.4%(32/46)and 93.7%(45/48),respectively,the difference was statistically significant(χ^(2)=9.570,P=0.008).The clinical effective rate of DPMAS+PE group was significantly higher than that of PE group and DPMAS group(χ^(2)=6.892,P=0.009;χ^(2)=9.274,P=0.002).③At 24 weeks of treatment,the survival rates of patients in PE group,DPMAS group and DPMAS+PE group were 65%(30/46),61%(28/46)and 83%(40/48),respectively,the difference was statistically significant(χ^(2)=6.390,P=0.041).The survival rate of patients in DPMAS+PE group was significantly higher than that of PE group and DPMAS group(χ^(2)=4.055,P=0.044;χ^(2)=5.924,P=0.015).At 48 weeks of treatment,the survival rates of patients in PE group,DPMAS group and DPMAS+PE group were 61%(28/46),54%(25/46)and 79%(38/48),respectively,the difference was statistically significant(χ^(2)=6.873,P=0.032).The survival rate of patients in DPMAS+PE group was significantly higher than that of PE group and DPMAS group(χ^(2)=3.760,P=0.043;χ^(2)=6.546,P=0.011).④At 2 weeks and 4 weeks of treatment,the levels of ALT,AST,TBil,ALP,PT and blood ammonia of patients in three groups reduced significantly and levels of GLB and WBC increased significantly compared with before treatment(all P<0.05).There were no statistically significant differences in the above indexes among the three groups before treatment,2 weeks and 4 weeks after treatment(all P>0.05).⑤After 8 weeks and 12 weeks of treatment,the MELD scores in all three groups were significantly lower than that of before treatment[PE group:(22.7±2.1)points vs(21.5±3.6)points vs(33.5±5.5)points;DPMAS group:(24.7±5.1)points vs(23.5±3.7)points vs(34.6±5.9)points;DPMAS+PE group:(18.2±4.3)points vs(16.33±3.4)points vs(32.7±4.2)points],and MELD score in DPMAS+PE groups were significantly lower than that of PE and DPMAS group(all P<0.05).⑥The incidence of adverse reactions in PE group,DPMAS group and DPMAS+PE group were 58.7%(27/46)、4.3%(2/46)、10.4%(5/48),respectively,the difference was statistically significant(χ^(2)=44.59,P<0.001).The incidence of adverse reactions in DPMAS+PE group and DPMAS group were significantly lower than that of PE group(χ^(2)=31.47,P<0.001;χ^(2)=24.38,P<0.001).Conclusions DPMAS+PE can effectively improve the clinical symptoms and signs of patients with acute-on-chronic liver failure,and has a good clinical prognosis and long-term survival rate.Compared with PE,DPMAS+PE treatment can reduce plasma usage and has a lower incidence of adverse reactions.
作者
蔡毅峰
王朝辉
程书权
Cai Yifeng;Wang Zhaohui;Cheng Shuquan(Department of Gastroenterology,Guilin Hospital,XiangyaⅡHospital,Central South University,Guilin 541001,Guangxi Zhuang Autonomous Region,China;Department of Hepatology,Qingdao Sixth People’s Hospital,Qingdao 266033,Shandong Province,China;Department of Hepatology,the Third People’s Hospital of Guilin,Guilin 541001,Guangxi Zhuang Autonomous Region,China)
出处
《中国肝脏病杂志（电子版）》
CAS
2023年第1期46-55,共10页
Chinese Journal of Liver Diseases：Electronic Version
基金
桂林市科学研究与技术开发计划项目(20140120-9-1)。
关键词
肝衰竭
慢加急性
人工肝治疗
血浆置换术
双重血浆分子吸附术
Liver failure,acute-on-chronic
Artificial liver therapy
Plasma replacement
Dual plasma molecular adsorption
作者简介
通讯作者:蔡毅峰,Email:caiyifenggx@126.com。
