钠和氯稳态紊乱可预测肝硬化稳定和危重症患者的结局。

Disturbances in sodium and chloride homeostasis predict outcome in stable and critically ill patients with cirrhosis.

机构信息

Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.

Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.

出版信息

Aliment Pharmacol Ther. 2023 Jul;58(1):71-79. doi: 10.1111/apt.17507. Epub 2023 Apr 4.

DOI:10.1111/apt.17507

PMID:37016513

Abstract

BACKGROUND

Hyponatremia has prognostic implications in patients with cirrhosis, and thus, has been incorporated in the 2016 MELD-UNOS update. Changes in serum chloride are commonly perceived as 'just' parallel to changes in serum sodium. However, these are less well studied in the context of cirrhosis.

AIMS

To investigate whether serum chloride independently predicts outcomes in patients with advanced chronic liver disease (ACLD) and stable clinical course or with critical illness.

METHODS

891 patients with ACLD (defined by hepatic venous pressure gradient [HVPG] ≥6 mm Hg) were followed after HVPG measurement between 2003 and 2020 (ACLD cohort). 181 critically ill patients with cirrhosis admitted to the ICU between 2004 and 2007 were recruited for the ICU cohort. Hypo-/hypernatremia (normal: 136-145 mmol/L) and hypo-/hyperchloremia (normal: 98-107 mmol/L) at baseline were assessed.

RESULTS

ACLD cohort: 68% of male patients with a median MELD (adjusted for Na) of 11 (9-17) were included (Child-Pugh-stages-A/B/C: 46%/38%/16%) and followed for a median of 60 months. Lower serum chloride (adjusted average HR per mmol/L: 0.965 [95% confidence interval (95% CI): 0.945-0.986], p = 0.001) showed a significant association with hepatic decompensation/liver-related mortality on multivariable Cox regression analysis adjusted for age, HVPG, albumin and MELD. In line, hypochloremia was significantly associated with hepatic decompensation/liver-related mortality (adjusted average HR: 1.656 [95% CI:1.267-2.163], p < 0.001). ICU cohort: 70% of patients were male, median MELD was 31(22-39) at ICU admission (92% with Child-Pugh-stage-C). After adjusting for hypo-/hypernatremia, MELD, and blood pH, hypochloremia remained independently associated with ICU-mortality (aOR Cl: 3.200 [95%CI: 1.209-8.829], p = 0.021).

CONCLUSION

Hypochloremia is associated with increased mortality in clinically stable and critically ill patients with cirrhosis independently of MELD including serum sodium.

摘要

背景

低钠血症对肝硬化患者具有预后意义，因此已被纳入 2016 年 MELD-UNOS 更新中。血清氯的变化通常被认为与血清钠的变化“仅仅”平行。然而，在肝硬化的背景下，这些变化研究得较少。

目的

研究血清氯是否可独立预测慢性肝损伤（ACLD）和稳定临床病程或危重症患者的结局。

方法

在 2003 年至 2020 年间测量 HVPG 后，对 891 名 HVPG≥6mmHg 的 ACLD 患者（定义为 HVPG≥6mmHg）进行了随访（ACLD 队列）。2004 年至 2007 年间，招募了 181 名因肝硬化住进 ICU 的危重症患者，纳入 ICU 队列。在基线时评估低钠血症/高钠血症（正常范围：136-145mmol/L）和低氯血症/高氯血症（正常范围：98-107mmol/L）。

结果

ACLD 队列：纳入了 68%的男性患者（中位 MELD（校正 Na）为 11（9-17））（Child-Pugh 分期-A/B/C：46%/38%/16%），中位随访时间为 60 个月。校正后的血清氯（每 mmol/L 的平均 HR：0.965 [95%CI：0.945-0.986]，p=0.001）与多变量 Cox 回归分析中调整后的年龄、HVPG、白蛋白和 MELD 后肝失代偿/肝相关死亡率显著相关。同样，低氯血症与肝失代偿/肝相关死亡率显著相关（调整后的平均 HR：1.656 [95%CI：1.267-2.163]，p<0.001）。ICU 队列：70%的患者为男性，ICU 入院时中位 MELD 为 31（22-39）（92%为 Child-Pugh 期 C）。在调整低钠血症/高钠血症、MELD 和血 pH 后，低氯血症与 ICU 死亡率独立相关（调整后的优势比 Cl：3.200 [95%CI：1.209-8.829]，p=0.021）。