肝硬化患者基于人群队列的肝性脑病的预后。

Outcomes after hepatic encephalopathy in population-based cohorts of patients with cirrhosis.

机构信息

Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA.

Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA.

出版信息

Aliment Pharmacol Ther. 2020 Jun;51(12):1397-1405. doi: 10.1111/apt.15749. Epub 2020 May 3.

DOI:10.1111/apt.15749

PMID:32363684

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC7266029/

Abstract

BACKGROUND

Hepatic encephalopathy is a devastating complication of cirrhosis.

AIM

To describe the outcomes after developing hepatic encephalopathy among contemporary, aging patients.

METHODS

We examined data for a 20% random sample of United States Medicare enrolees with cirrhosis and Part D prescription coverage from 2008 to 2014. Among 49 164 persons with hepatic encephalopathy, we evaluated the associations with transplant-free survival using Cox proportional hazard models with time-varying covariates (hazard ratios, HR) and incidence rate ratios (IRR) for healthcare utilisation measured in hospital-days and 30-day readmissions per person-year. We validated our findings in an external cohort of 2184 privately insured patients with complete laboratory values.

RESULTS

Hepatic encephalopathy was associated with median survivals of 0.95 and 2.5 years for those ≥65 or <65 years old and 1.1 versus 3.9 years for those with and without ascites. Non-alcoholic fatty-liver disease posed the highest adjusted risk of death among aetiologies, HR 1.07 95% CI (1.02, 1.12). Both gastroenterology consultation and rifaximin utilisation were associated with lower mortality, respective adjusted-HR 0.73 95% CI (0.67, 0.80) and 0.40 95% CI (0.39, 0.42). Thirty-day readmissions were fewer for patients seen by gastroenterologists (0.71 95% CI [0.57-0.88]) and taking rifaximin (0.18 95% CI [0.08-0.40]). Lactulose alone was associated with fewer hospital-days, IRR 0.31 95% CI (0.30-0.32), than rifaximin alone, 0.49 95% CI (0.45-0.53), but the optimal therapy combination was lactulose/rifaximin, IRR 0.28 95% CI (0.27-0.30). These findings were validated in the privately insured cohort adjusting for model for endstage liver disease-sodium score and serum albumin.

CONCLUSIONS

Hepatic encephalopathy remains morbid and associated with poor outcomes among contemporary patients. Gastroenterology consultation and combination lactulose-rifaximin are both associated with improved outcomes. These data inform the development of care coordination efforts for subjects with cirrhosis.

摘要

背景

肝性脑病是肝硬化的一种严重并发症。

目的

描述当代老年肝硬化患者发生肝性脑病后的结局。

方法

我们检查了 2008 年至 2014 年期间美国医疗保险参保者中肝硬化和处方药物覆盖人群的 20%随机样本数据。在 49164 例肝性脑病患者中，我们使用时变协变量的 Cox 比例风险模型（风险比，HR）和每患者人年的住院天数和 30 天再入院率评估了与无移植生存率的相关性。我们在一个包含 2184 名有完整实验室值的私人保险患者的外部队列中验证了我们的发现。

结果

对于≥65 岁和<65 岁的患者，肝性脑病的中位生存时间分别为 0.95 年和 2.5 年，对于有和无腹水的患者，中位生存时间分别为 1.1 年和 3.9 年。非酒精性脂肪性肝病是病因中调整后死亡风险最高的，HR 为 1.07（95%CI，1.02，1.12）。胃肠病学咨询和利福昔明的使用与较低的死亡率相关，调整后的 HR 分别为 0.73（95%CI，0.67，0.80）和 0.40（95%CI，0.39，0.42）。与接受胃肠病学咨询的患者相比，30 天再入院的患者更少（0.71，95%CI[0.57，0.88]），使用利福昔明的患者更少（0.18，95%CI[0.08，0.40]）。乳果糖单药治疗与更少的住院天数相关，IRR 为 0.31（95%CI，0.30-0.32），而利福昔明单药治疗为 0.49（95%CI，0.45-0.53），但最佳治疗联合是乳果糖/利福昔明，IRR 为 0.28（95%CI，0.27-0.30）。这些发现通过调整终末期肝病模型钠评分和血清白蛋白的模型在私人保险队列中得到了验证。