摘要
目的 探讨肌肉减少症预测经颈静脉肝内门体分流术(TIPS)后肝性脑病发生的临床价值.方法 回顾性分析2018年1月1日至2020年1月1日在北京世纪坛医院接受TIPS治疗的284例肝硬化门静脉高压症伴食管胃底静脉曲张破裂出血患者临床资料.根据骨骼肌质量指数(SMI)诊断,将患者分为肌肉减少症组(n=61)和非肌肉减少症组(n=223).采用倾向性评分匹配(PSM)分析法,对非肌肉减少症组中61例患者与肌肉减少症组患者进行对比研究.TIPS后每6个月1次随访2年,统计分析患者各项实验室检查结果和临床终点事件.采用Kaplan-Meier法及Cox回归多因素分析确定两组肝性脑病、非肝移植生存率的预测因素.结果 PSM对比分析后,两组患者年龄、性别、病因、肝肾功能、Child-Pugh评分和分级、终末期肝病模型(MELD)评分等临床基线特征比较差异无统计学意义(均P＞0.05).两组患者术前、术后门静脉压力梯度(PPG)比较差异无统计学意义(均P＞0.05).肌肉减少症组、非肌肉减少症组患者1、2年显性肝性脑病累积发生率分别为18.0％、34.4％,8.2％、16.4％,差异均有统计学意义(HR=2.16,95％CI=1.07～4.38,P=0.03).Cox多因素分析显示,年龄、分组是TIPS后显性肝性脑病发生的独立预测因素(均P＜0.05).两组TIPS后肝性脊髓病、支架狭窄及再出血率比较差异无统计学意义(均P＞0.05).随访期间,肌肉减少症组血氨值显著高于非肌肉减少症组(P--0.02).肌肉减少症组、非肌肉减少症组1、2年无肝移植累积存活率分别为96.7％、88.5％,98.4％、95.1％.Cox多因素分析显示,MELD评分与非肝移植生存率相关(P＜0.05).结论 肌肉减少症是TIPS后肝性脑病发生的重要预测因素.
Abstract
Objective To discuss the clinical value of sarcopenia in predicting hepatic encephalopathy after transjugular intrahepatic portosystemic shunt(TPIS).Methods The clinical data of 284 patients with cirrhotic portal hypertension complicated by esophageal and gastric varices rupture and bleeding,who received TIPS at the Beijing Shijitan Hospital of China between January 2018 and January 2020,were retrospectively analyzed.According to skeletal muscle mass index(SMI),the patients were divided into sarcopenia group(n=61)and non-sarcopenia group(n=223).Using propensity score matching(PSM)method,a comparison study between 61 patients in the non-sarcopenic group and 61 patients in the sarcopenia group was conducted.After TIPS,the patients were followed up once every 6 months for 2 years,and the results of various laboratory tests and clinical endpoint events were recorded.Kaplan-Meier method and Cox regression multivariate analysis were used to determine the predictors for hepatic encephalopathy and non-liver transplantation survival in both groups.Results After propensity score matching,there were no significant differences in age,gender,etiology,liver and kidney function,Child-Pugh score and grade,and Model of End-Stage Liver Disease(MELD)score between the sarcopenia group and the non-sarcopenia group(P＞0.05).In both groups,the postoperative portal vein pressure gradient(PPG)values were not significantly different from the preoperative PPG values(all P＞0.05).The postoperative one-year and 2-year incidence of overt hepatic encephalopathy in sarcopenia group was 18.0％and 34.4％respectively,which in the non-sarcopenia group was 8.2％and 16.4％respectively,the differences were statistically significant(HR=2.16,95％CI=1.07-4.38,P=0.03).Cox multivariate analysis showed that age and group were the independent predictors for post-TIPS overt hepatic encephalopathy(all P＜0.05).The differences in post-TIPS hepatic myelopathy,stent stenosis,and rebleeding rate between the two groups were not statistically significant(all P＞0.05).During the follow-up period,the blood ammonia level in the sarcopenia group was remarkably higher than that in the non-sarcopenia group(P=0.02).The postoperative one-year and 2-year cumulative survival rates without having liver transplantation in the sarcopenia group were 96.7％and 88.5％respectively,which in the non-sarcopenia group were 98.4％and 95.1％respectively.Cox multivariate analysis indicated that MELD score was well associated with non-liver transplantation survival rate(P＜0.05).Conclusion Sarcopenia is an important factor for the occurrence of hepatic encephalopathy after TIPS.(J Intervent Radiol,2024,33:419-424)
基金项目
国家自然科学基金(8187070452)
北京市教委科技发展计划一般项目(KM201810025028)
NETL
NSTL
万方数据