Viasus Diego, Garcia-Vidal Carolina, Castellote Jose, Adamuz Jordi, Verdaguer Ricard, Dorca Jordi, Manresa Frederic, Gudiol Francesc, Carratalà Jordi
From Departments of Infectious Diseases (DV, CG, JA, FG, J. Carratalà), Hepatology and Liver Transplant (J. Castellote), Microbiology (RV), and Respiratory Medicine (JD, FM), Hospital Universitari de Bellvitge, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), University of Barcelona. L'Hospitalet de Llobregat, Barcelona, Spain.
Medicine (Baltimore). 2011 Mar;90(2):110-118. doi: 10.1097/MD.0b013e318210504c.
We performed an observational analysis of a prospective cohort of nonimmunocompromised hospitalized adults with community-acquired pneumonia (CAP) to determine the epidemiology, clinical features, and outcomes of patients with liver cirrhosis. We also analyzed the prognostic value of several severity scores. Of 3420 CAP episodes, 90 occurred in patients with liver cirrhosis. The median value of the Model for End-Stage Liver Disease (MELD) was 14 (range, 6-36). On the Child-Pugh (CP) score, 56% of patients were defined as grade B and 22% as grade C. Patients with liver cirrhosis were younger (61.8 vs. 66.8 yr; p = 0.001) than patients without cirrhosis, more frequently presented impaired consciousness at admission (33% vs. 14%; p < 0.001) and septic shock (13% vs. 6%; p = 0.011), and were more commonly classified in high-risk Pneumonia Severity Index (PSI) classes (classes IV-V) (74% vs. 58%; p = 0.002). Streptococcus pneumoniae (47% vs. 33%; p = 0.009) and Pseudomonas aeruginosa (4.4% vs. 0.9%; p = 0.001) were more frequently documented in patients with cirrhosis. Bacteremia was also more common in these patients (22% vs. 13%; p = 0.023). Areas under the curve (AUCs) from disease-specific scores (MELD, CP, PSI, and CURB-65 [confusion, urea, respiratory rate, blood pressure, and age ≥65 yr]) were comparable in predicting severe disease (30-d mortality and intensive care unit [ICU] admission). A new score based on MELD, multilobar pneumonia, and septic shock at admission (MELD-CAP) had an AUC of 0.945 (95% confidence interval [CI], 0.872-0.983) for predicting severe disease and was significantly different from other scores. Early (5.6% vs. 2.1%; p = 0.048) and overall (14.4% vs. 7.4%; p < 0.024) mortality rates were higher in cirrhotic patients than in patients without cirrhosis. Factors associated with mortality were impaired consciousness, multilobar pneumonia, ascites, acute renal failure, bacteremia, ICU admission, and MELD score. Among the severity scores, MELD-CAP was the only score associated with severe disease (odds ratio [OR], 1.33; 95% CI, 1.09-1.52) and mortality (OR, 1.21; 95% CI, 1.03-1.42). In conclusion, CAP in patients with liver cirrhosis presents a distinctive clinical picture and is associated with higher mortality than is found in patients without cirrhosis. The severity of hepatic dysfunction plays an important role in the development of adverse events. Cirrhosis-specific scores may be useful for predicting and stratifying cirrhotic patients with CAP who have a high risk of severe disease.
我们对一组前瞻性队列中未免疫受损的社区获得性肺炎（CAP）住院成年患者进行了观察性分析，以确定肝硬化患者的流行病学、临床特征及预后。我们还分析了几种严重程度评分的预后价值。在3420例CAP发作中，90例发生在肝硬化患者中。终末期肝病模型（MELD）的中位数为14（范围6 - 36）。根据Child-Pugh（CP）评分，56%的患者被定义为B级，22%为C级。肝硬化患者比无肝硬化患者更年轻（61.8岁对66.8岁；p = 0.001），入院时意识障碍更常见（33%对14%；p < 0.001）以及感染性休克更常见（13%对6%；p = 0.011），并且更常被归类于肺炎严重程度指数（PSI）的高危类别（IV - V级）（74%对58%；p = 0.002）。肺炎链球菌（47%对33%；p = 0.009）和铜绿假单胞菌（4.4%对0.9%；p = 0.001）在肝硬化患者中更常被检出。这些患者中菌血症也更常见（22%对13%；p = 0.023）。疾病特异性评分（MELD、CP、PSI和CURB - 65[意识模糊、尿素、呼吸频率、血压及年龄≥65岁]）的曲线下面积（AUC）在预测严重疾病（30天死亡率和重症监护病房[ICU]入院）方面相当。基于MELD、多叶肺炎及入院时感染性休克的新评分（MELD - CAP）在预测严重疾病方面的AUC为0.945（95%置信区间[CI]，0.872 - 0.983），且与其他评分有显著差异。肝硬化患者的早期死亡率（5.6%对2.1%；p = 0.048）和总体死亡率（14.4%对7.4%；p < 0.024）高于无肝硬化患者。与死亡率相关的因素有意识障碍、多叶肺炎、腹水、急性肾衰竭、菌血症、ICU入院及MELD评分。在严重程度评分中，MELD - CAP是唯一与严重疾病（比值比[OR]，1.33；95% CI，1.09 - 1.52）和死亡率（OR，1.21；95% CI，1.03 - 1.42）相关的评分。总之，肝硬化患者的CAP呈现出独特的临床特征，且与无肝硬化患者相比死亡率更高。肝功能障碍的严重程度在不良事件的发生中起重要作用。肝硬化特异性评分可能有助于预测和分层有严重疾病高风险的肝硬化CAP患者。
