白蛋白用于自发性细菌性腹膜炎：护理差异、差距及结局
Albumin for Spontaneous Bacterial Peritonitis: Care Variation, Disparities, and Outcomes.
作者信息
Serper Marina, Pulaski Marya E, Zhang Siqi, Taddei Tamar H, Kaplan David E, Mahmud Nadim
机构信息
Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA.
Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
出版信息
Am J Gastroenterol. 2024 Nov 12. doi: 10.14309/ajg.0000000000003190.
INTRODUCTION
Intravenous albumin reduces mortality in spontaneous bacterial peritonitis (SBP). We sought to characterize albumin use for SBP over time and investigate patient-level and hospital-level factors associated with use.
METHODS
A retrospective cohort study in the Veterans Health Administration between 2008 and 2021 evaluated trends and patient-level, practice-level, and facility-level factors associated with use among patients with cirrhosis hospitalized for SBP confirmed with ascitic fluid criteria.
RESULTS
Among 3,871 veterans with SBP, 803 (20.7%) did not receive albumin, 1,119 (28.9%) received albumin but not per guidelines, and 1,949 (50.3%) received albumin per guidelines; use increased from 66% in 2008 to 88% in 2022. Veterans who identified as Black compared with White were less likely to receive guideline-recommended albumin (Odds ratio [OR] 0.76, 95% confidence interval [CI] 0.59-0.98) in all analyses. Guideline-recommended albumin was more likely to be administered to veterans with Child-Turcotte-Pugh class B (OR 1.39, 95% CI 1.17-1.64) and C (OR 2.21, 95% CI 1.61-3.04) compared with Child-Turcotte-Pugh A; and acute kidney injury Stage 1 (OR 1.48, 95% CI 1.22-1.79), Stage 2 (OR 2.17, 95% CI 1.62-2.91), and Stage 3 (OR 1.68, 95% CI 1.18-2.40) compared with no acute kidney injury. gastroenterology/hepatology consultation (OR 1.60, 95% CI 1.29-1.99), nephrology consultation (OR 1.60, 95% CI 1.23-2.07), and having both gastroenterology/hepatology and nephrology consultations (OR 2.17, 95% CI 1.60-2.96) were associated with higher albumin administration. In exploratory analyses accounting for interactions between model for end-stage liver disease sodium and albumin, guideline-recommended albumin was associated with lower in-hospital mortality (HR 0.90, 95% CI 0.85-0.96).
DISCUSSION
Future studies should investigate optimizing albumin use for SBP to reduce the variability and mitigate healthcare disparities.
引言
静脉注射白蛋白可降低自发性细菌性腹膜炎（SBP）的死亡率。我们试图描述白蛋白在SBP治疗中的使用情况随时间的变化，并调查与使用相关的患者层面和医院层面因素。
方法
一项在退伍军人健康管理局进行的回顾性队列研究，对2008年至2021年间因腹水标准确诊为SBP而住院的肝硬化患者进行评估，分析白蛋白使用的趋势以及患者层面、实践层面和机构层面与使用相关的因素。
结果
在3871例患有SBP的退伍军人中，803例（20.7%）未接受白蛋白治疗，1119例（28.9%）接受了白蛋白治疗但未遵循指南，1949例（50.3%）遵循指南接受了白蛋白治疗；使用率从2008年的66%上升至2022年的88%。在所有分析中，与白人退伍军人相比，黑人退伍军人接受指南推荐白蛋白的可能性较小（比值比[OR]0.76，95%置信区间[CI]0.59 - 0.98）。与Child-Turcotte-Pugh A级患者相比，Child-Turcotte-Pugh B级（OR 1.39，95% CI 1.17 - 1.64）和C级（OR 2.21，95% CI 1.61 - 3.04）的退伍军人更有可能接受指南推荐的白蛋白治疗；与无急性肾损伤的患者相比，急性肾损伤1期（OR 1.48，95% CI 1.22 - 1.79）、2期（OR 2.17，95% CI 1.62 - 2.91）和3期（OR 1.68，95% CI 1.18 - 2.40）的患者接受指南推荐白蛋白治疗的可能性更大。接受胃肠病学/肝病学会诊（OR 1.60，95% CI 1.29 - 1.99）、肾脏病学会诊（OR 1.60，95% CI 1.23 - 2.07）以及同时接受胃肠病学/肝病学和肾脏病学会诊（OR 2.17，95% CI 1.60 - 2.96）与更高的白蛋白给药率相关。在探索性分析中，考虑到终末期肝病钠模型与白蛋白之间的相互作用，遵循指南推荐的白蛋白与较低的住院死亡率相关（风险比[HR]0.90，95% CI 0.85 - 0.96）。
讨论
未来的研究应调查如何优化SBP患者白蛋白的使用，以减少差异并减轻医疗保健方面的不平等现象。
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