南方医科大学学报

南方医科大学学报 ›› 2023, Vol. 43 ›› Issue (12): 2043-2052.doi: 10.12122/j.issn.1673-4254.2023.12.08

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肝硬化可疑自发性细菌性腹膜炎患者的预后及发生死亡的危险因素

唐 巧，周 超，张 宁，何召云，张晶晶，付双楠，李 昕，刘鹏程，张田义，张 瑾，宫 嫚   

  1. 南方医科大学中医药学院，广东 广州 510515；解放军总医院第五医学中心中医肝病科，北京 100039
  • 出版日期:2023-12-20 发布日期:2023-12-29

Prognosis and risk factors for mortality in cirrhotic patients with probable spontaneous bacterial peritonitis

TANG Qiao, ZHOU Chao, ZHANG Ning, HE Zhaoyun, ZHANG Jingjing, FU Shuangnan, LI Xin, LIU Pengcheng, ZHANG Tianyi, ZHANG Jin, GONG Man   

  1. School of Traditional Chinese Medicine, Southern Medical University, Guangzhou 510515, China; Department of Traditional Chinese Medicine Liver Disease, 5th Medical Center of Chinese PLA General Hospital, Bejing 100039, China
  • Online:2023-12-20 Published:2023-12-29

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摘要： 目的 探讨肝硬化可疑自发性细菌性腹膜炎（SBP）患者临床特征及预后情况，并分析其预后的影响因素。方法 回顾性收集解放军总医院第五医学中心2021年6月~2022年5月收治的323例肝硬化失代偿期合并腹水住院患者的临床资料，根据腹水多形核细胞计数（PMN）、常规腹水细菌培养结果及是否伴可疑SBP表现，将患者分为SBP组（腹水PMN计数≥250个/mm3）（n=115）、细菌性腹水（BA）组（PMN计数<250个/mm3且腹水细菌培养阳性，n=52）、可疑SBP组（PMN<250个/mm3，常规腹水细菌培养结果阴性，伴可疑SBP表现，n=67）及无感染组（PMN<250个/mm3，常规腹水细菌培养结果阴性，无可疑SBP表现，n=89）。比较各组间的一般特征、临床资料、实验室指标及90 d生存状态的差异，进而通过多因素Cox回归模型分析及1∶1倾向性评分匹配（PSM）控制混杂因素分析可疑SBP对肝硬化腹水患者90 d生存状态的影响，同时分析影响可疑SBP组生存状态的影响因素。结果 可疑SBP组90 d病死率与SBP组（43.28% vs 46.95%, Log-rank P=0.121）及BA组（43.28% vs 48.07%, Log-rank P=0.805）差异无统计学意义，显著高于无感染组（43.28% vs 11.23%, Log-rank P<0.001）；经PSM得到临床特征相似的可疑SBP组与无感染组各46例，可疑SBP组病死率 PSM前（43.28% vs 11.23%, Log-rank P<0.001）、PSM后（34.78% vs 15.21%, Log-rank P=0.038）均显著高于无感染组。Cox多因素回归分析结果显示，可疑SBP为肝硬化腹水患者死亡危险因素之一（HR=1.539, 95% CI=1.048~2.261, P=0.028）。终末期肝病模型评分>15（HR=1.943, 95% CI: 1.118~3.377, P=0.018）及降钙素原>0.48 ng/mL（HR=1.989, 95% CI: 1.111~3.560, P=0.021）是可疑SBP患者90 d预后的独立影响因素。结论 可疑SBP患者预后差，应进一步优化其临床管理路径，重点关注患者终末期肝病模型评分及降钙素原水平。

关键词: 肝硬化；自发性细菌性腹膜炎；预后；危险因素；倾向性评分匹配

Abstract: Objective To investigate the survival outcomes and risk factors for mortality in cirrhotic patients with probable spontaneous bacterial peritonitis (SBP). Methods We retrospectively analyzed the clinical data of 323 cirrhotic patients with ascites admitted from June 2021 to May 2022, including 115 patients with SBP [ascites polymorphonuclear leucocyte (PMN) count ≥250/mm3], 52 patients with bacterascites (PMN count <250/mm3 with positive microbiological finding in ascites), 67 patients with probable SBP (PMN count <250/mm3 with negative microbiological finding in ascites but clinical symptoms of SBP) and 89 patients without infection (PMN count <250/mm3 with negative microbiological finding without clinical symptoms of SBP). The clinical characteristics, laboratory data and 90-day mortality of the patients were compared among the 4 groups. Cox proportional hazard model and propensity score matching (PSM) in a 1∶1 ratio were used to analyze the risk factors for mortality in patients with probable SBP. Results The patients with probable SBP had a 90-day mortality rate of 43.28%, similar to those of patients with SBP (46.95%, P=0.121) and bacterascites (48.07%, P=0.805) but significantly higher than that of non-infected patients (11.23%, P<0.001). In the 46 pairs of patients matched using PSM, the 90-day mortality rates were higher in probable SBP group than in non-infected group both before (43.28% vs 11.23%, P<0.001) and after PSM (34.78% vs 15.21% , P=0.038). Cox regression analysis indicated that probable SBP was an independent predictor of 90-day mortality in cirrhotic patients with ascites (HR=1.539, 95% CI: 1.048-2.261, P=0.028). A Model for End-Stage Liver Disease (MELD) score >15 (HR=1.943, 95% CI: 1.118-3.377, P=0.018) and procalcitonin level >0.48 ng/mL (HR=1.989, 95% CI: 1.111-3.560, P=0.021) at diagnostic paracentesis were both independent risk factors for 90-day mortality in patients with probable SBP. Conclusion Cirrhotic patients with probable SBP have poor survival outcomes, and their management should be further optimized based on their MELD score and procalcitonin level.

Key words: liver cirrhosis; spontaneous bacterial peritonitis; prognosis; risk factors; propensity score matching