肝硬化和无法控制的静脉曲张破裂出血的死亡率决定因素

StephenW

Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding

    Rahul Kumar
    Annarein J.C. Kerbert
    M. Faisal Sheikh
    Banwari Agarwal
    David Patch
    Rajiv Jalan
    Show all authors

Published:June 16, 2020DOI:https://doi.org/10.1016/j.jhep.2020.06.010

Highlights

    •
    Failure to control variceal bleeding in cirrhosis is associated with high mortality and frequently causes ACLF.
    •
    ACLF is the most important determinant of 42-day and 1-year mortality in cirrhotic patients with failure to control variceal bleeding.
    •
    Transjugular intrahepatic shunt insertion improves 42-day and 1-year survival in patients with ACLF secondary to failure to control variceal bleeding.

Background & Aims
Failure to control oesophago-gastric variceal bleeding (OGVB) and acute-on-chronic liver failure (ACLF) are both important prognostic factors in cirrhosis. The aims of this study were to determine whether ACLF and its severity define the risk of death in OGVB and whether insertion of rescue transjugular intrahepatic shunt (TIPS) improves survival in patients with failure to control OGVB and ACLF.
Methods
Data on 174 consecutive eligible patients, with failure to control OGVB between 2005 and 2015, were collected from a prospectively maintained intensive care unit registry. Rescue TIPS was defined as technically successful TIPS within 72 hours of presentation with failure to control OGVB. Cox-proportional hazards regression analyses were applied to explore the impact of ACLF and TIPS on survival in patients with failure to control OGVB.
Results
Patients with ACLF (n = 119) were significantly older, had organ failures and higher white cell count than patients with acute decompensation (AD, n = 55). Mortality at 42-days and 1-year was significantly higher in patients with ACLF (47.9% and 61.3%) than in those with AD (9.1% and 12.7%, p <0.001), whereas there was no difference in the number of endoscopies and transfusion requirements between these groups. TIPS was inserted in 78 patients (AD 21 [38.2%]; ACLF 57 [47.8%]; p = 0.41). In ACLF, rescue TIPS insertion was an independent favourable prognostic factor for 42-day mortality. In contrast, rescue TIPS did not impact on the outcome of patients with AD.
Conclusions
This study shows that in patients with failure to control OGVB, the presence and severity of ACLF determines the risk of 42-day and 1-year mortality. Rescue TIPS is associated with improved survival in patients with ACLF.
Lay summary
Variceal bleeding that is not controlled by initial endoscopy is associated with high risk of death. The results of this study showed that in the occurrence of failure of the liver and other organs defines the risk of death. In these patients, insertion of a shunt inside the liver to drain the portal vein improves survival.


Keywords

    Acute variceal bleeding
    Esophageal varices
    Acute-on-chronic liver failure
    ACLF
    Transjugular intrahepatic portosystemic shunt
    TIPS

StephenW

肝硬化和无法控制的静脉曲张破裂出血的死亡率决定因素

    拉胡尔·库马尔（Rahul Kumar）
    安纳琳（Annarein J.C. Kerbert）
    费萨尔·谢赫（M. Faisal Sheikh）
    班瓦里·阿加瓦尔
    大卫·帕奇
    拉吉夫·贾兰（Rajiv Jalan）
    显示所有作者

发布时间：2020年6月16日DOI：https：//doi.org/10.1016/j.jhep.2020.06.010

强调

    •
    肝硬化未能控制静脉曲张破裂出血与高死亡率相关，并经常引起ACLF。
    •
    ACLF是无法控制静脉曲张破裂出血的肝硬化患者中42天和1年死亡率的最重要决定因素。
    •
    经颈静脉肝内分流术可改善因未能控制静脉曲张破裂出血而继发的ACLF患者的42天和1年生存率。

背景与目标
无法控制食管胃静脉曲张破裂出血（OGVB）和慢性肝功能衰竭（ACLF）都是肝硬化的重要预后因素。这项研究的目的是确定ACLF及其严重程度是否确定了OGVB的死亡风险，以及插入急诊经颈静脉肝内分流（TIPS）是否能改善无法控制OGVB和ACLF的患者的生存率。
方法
从前瞻性维持的重症监护病房注册表中收集了2005年至2015年之间连续174例OGVB未能控制的合格患者的数据。救援性TIPS被定义为在演示后72小时内技术成功的TIPS，但无法控制OGVB。应用Cox比例风险回归分析来探讨ACLF和TIPS对无法控制OGVB的患者生存的影响。
结果
与急性代偿失调患者相比，ACLF患者（n = 119）年龄更大，器官衰竭且白细胞计数更高（AD，n = 55）。 ACLF患者（分别为47.9％和61.3％）在42天和1年时的死亡率显着高于AD患者（分别为9.1％和12.7％，p <0.001），但内镜检查的数量没有差异以及这些人群之间的输血要求。在78例患者中插入了TIPS（AD 21 [38.2％]； ACLF 57 [47.8％]； p = 0.41）。在ACLF中，抢救性TIPS插入是42天死亡率的独立有利预后因素。相反，抢救性TIPS对AD患者的预后没有影响。
结论
这项研究表明，在无法控制OGVB的患者中，ACLF的存在和严重程度决定了42天和1年死亡率的风险。抢救性TIPS与ACLF患者的生存改善有关。
放置摘要
初次内窥镜检查无法控制的静脉曲张破裂出血与高死亡风险相关。这项研究的结果表明，在发生肝脏和其他器官衰竭时定义了死亡风险。在这些患者中，在肝内插入分流器以引流门静脉可提高生存率。


关键词

    急性静脉曲张破裂出血
    食管静脉曲张
    慢性慢性肝功能衰竭
    ACLF
    经颈静脉肝内门体分流
    提示