Leithead J A, Ferguson J W, Bates C M, Davidson J S, Lee A, Bathgate A J, Hayes P C, Simpson K J
Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, 51, Little France Crescent, Edinburgh EH16 4SA, UK.
Gut. 2009 Mar;58(3):443-9. doi: 10.1136/gut.2008.154120. Epub 2008 Nov 10.
Although renal dysfunction is a common complication of acute liver failure (ALF) with significant prognostic implications, the pathophysiological mechanisms remain unclear. The current hypothesis suggests that the renal dysfunction may mirror the hepatorenal syndrome of cirrhosis. However, ALF has distinct clinical characteristics and the circulatory derangement may be more comparable with sepsis.
To examine the relationship between the systemic inflammatory response syndrome (SIRS) and renal dysfunction in ALF, and to identify additional risk factors for renal dysfunction.
A single-centre retrospective study of 308 patients with ALF was carried out. Renal dysfunction was defined according to the RIFLE criteria for acute kidney injury.
67% of patients developed renal dysfunction. On univariate analysis, renal dysfunction patients were more likely to be hypothermic (p = 0.010), had a faster heart rate (p<0.001), a higher white cell count (p = 0.001) and a lower PaCO(2) (p = 0.033). 78% of renal dysfunction patients and 53% of non-renal dysfunction patients had SIRS (p<0.001). On multivariate analysis, the risk factors for renal dysfunction were age (p = 0.024), fulfilled Kings College Hospital prognostic criteria (p<0.001), hypotension (p<0.001), paracetamol-induced ALF (p<0.001), infection (p = 0.077) and SIRS (p = 0.017). SIRS remained an independent predictor of renal dysfunction in the subgroup of patients with non-paracetamol-induced ALF (n = 91, p = 0.001). In contrast, in patients with paracetamol-induced ALF (n = 217), no relationship between SIRS and renal dysfunction was demonstrated (p = 0.373).
SIRS is strongly associated with the development of renal dysfunction in patients with non-paracetamol-induced ALF. It is proposed that the systemic inflammatory cascade plays a key role in its pathogenesis.
尽管肾功能不全是急性肝衰竭（ALF）的常见并发症，具有重要的预后意义，但其病理生理机制仍不清楚。目前的假说认为，肾功能不全可能反映了肝硬化的肝肾综合征。然而，ALF具有独特的临床特征，其循环紊乱可能与脓毒症更具可比性。
研究全身炎症反应综合征（SIRS）与ALF患者肾功能不全之间的关系，并确定肾功能不全的其他危险因素。
对308例ALF患者进行单中心回顾性研究。根据急性肾损伤的RIFLE标准定义肾功能不全。
67%的患者出现肾功能不全。单因素分析显示，肾功能不全患者更易出现体温过低（p = 0.010）、心率更快（p<0.001）、白细胞计数更高（p = 0.001）和动脉血二氧化碳分压更低（p = 0.033）。78%的肾功能不全患者和53%的非肾功能不全患者出现SIRS（p<0.001）。多因素分析显示，肾功能不全的危险因素包括年龄（p = 0.024）、符合国王学院医院预后标准（p<0.001）、低血压（p<0.001）、对乙酰氨基酚所致ALF（p<0.001）、感染（p = 0.077）和SIRS（p = 0.017）。在非对乙酰氨基酚所致ALF患者亚组（n = 91，p = 0.001）中，SIRS仍然是肾功能不全的独立预测因素。相反，在对乙酰氨基酚所致ALF患者（n = 217）中，未显示SIRS与肾功能不全之间存在关联（p = 0.373）。
SIRS与非对乙酰氨基酚所致ALF患者肾功能不全的发生密切相关。推测全身炎症级联反应在其发病机制中起关键作用。
