急性肝衰竭患者急性肾损伤的危险因素及预后
Risk factors and outcomes of acute kidney injury in patients with acute liver failure.
作者信息
Tujios Shannan R, Hynan Linda S, Vazquez Miguel A, Larson Anne M, Seremba Emmanuel, Sanders Corron M, Lee William M
机构信息
Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas.
Division of Biostatistics, University of Texas Southwestern Medical Center, Dallas, Texas.
出版信息
Clin Gastroenterol Hepatol. 2015 Feb;13(2):352-9. doi: 10.1016/j.cgh.2014.07.011. Epub 2014 Jul 11.
BACKGROUND & AIMS: Patients with acute liver failure (ALF) frequently develop renal dysfunction, yet its overall incidence and outcomes have not been fully assessed. We investigated the incidence of acute kidney injury (AKI) among patients with ALF, using defined criteria to identify risk factors and to evaluate its effect on overall outcomes.
METHODS
We performed a retrospective review of data from 1604 patients enrolled in the Acute Liver Failure Study Group, from 1998 through 2010. Patients were classified by the Acute Kidney Injury Network criteria, as well as for etiology of liver failure (acetaminophen-based, ischemic, and all others).
RESULTS
Seventy percent of patients with ALF developed AKI, and 30% received renal replacement therapy (RRT). Patients with severe AKI had higher international normalized ratio values than those without renal dysfunction (P < .001), and a higher proportion had advanced-grade coma (coma grades 3 or 4; P < .001) or presented with hypotension requiring vasopressor therapy (P < .001). A greater proportion of patients with acetaminophen-induced ALF had severe kidney injury than of patients with other etiologies of ALF; 34% required RRT, compared with 25% of patients with ALF not associated with acetaminophen or ischemia (P < .002). Of the patients with ALF who were alive at 3 weeks after study entry, significantly fewer with AKI survived for 1 year. Although AKI reduced the overall survival time, more than 50% of patients with acetaminophen-associated or ischemic ALF survived without liver transplantation (even with RRT), compared with 19% of patients with ALF attribute to other causes (P < .001). Only 4% of patients requiring RRT became dependent on dialysis.
CONCLUSIONS
Based on a retrospective analysis of data from more than 1600 patients, AKI is common in patients with ALF and affects short- and long-term outcomes, but rarely results in chronic kidney disease. Acetaminophen-induced kidney injury is frequent, but patients have better outcomes than those with other forms of ALF.
背景与目的
急性肝衰竭（ALF）患者常出现肾功能障碍，但其总体发病率及预后尚未得到充分评估。我们利用明确的标准来识别风险因素并评估其对总体预后的影响，对ALF患者中急性肾损伤（AKI）的发病率进行了调查。
方法
我们对1998年至2010年期间纳入急性肝衰竭研究组的1604例患者的数据进行了回顾性分析。根据急性肾损伤网络标准以及肝衰竭病因（对乙酰氨基酚所致、缺血性及其他所有病因）对患者进行分类。
结果
70%的ALF患者发生了AKI，30%接受了肾脏替代治疗（RRT）。重度AKI患者的国际标准化比值高于无肾功能障碍的患者（P < 0.001），且更高比例的患者出现高级别昏迷（昏迷分级为3级或4级；P < 0.001）或出现需要血管升压药治疗的低血压（P < 0.001）。与其他病因所致ALF患者相比，对乙酰氨基酚所致ALF患者中重度肾损伤的比例更高；34%的患者需要RRT，而与对乙酰氨基酚或缺血无关的ALF患者中这一比例为25%（P < 0.002）。在研究入组3周后仍存活的ALF患者中，发生AKI的患者存活1年的人数明显较少。虽然AKI缩短了总体生存时间，但与其他病因所致ALF患者中19%的生存率相比，对乙酰氨基酚相关性或缺血性ALF患者中超过50%的患者在未进行肝移植的情况下存活（即使接受了RRT）（P < 0.001）。需要RRT的患者中只有4%依赖透析。
结论
基于对1600多名患者数据的回顾性分析，AKI在ALF患者中很常见，会影响短期和长期预后，但很少导致慢性肾脏病。对乙酰氨基酚所致肾损伤很常见，但患者的预后优于其他形式的ALF患者。
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