| Objective:Analysed the medical record of acute-on-chronic hepatitis B liver failure patients retrospectively, collected the baseline demographic, clinical, biochemical and virological features, the following issues were studied:(1) The influencing factors of hepatic encephalopathy on acute-on-chronic hepatitis B liver failure patients;(2) The influencing factors of spontaneous bacterial peritonitis on acute-on-chronic hepatitis B liver failure patients;(3) The influencing factors of hepatorenal syndrome on acute-on-chronic hepatitis B liver failure patients;(4) The influencing factors of pulmonary infection on acute-on-chronic hepatitis B liver failure patients;(5) The influencing factors of fungal infections on acute-on-chronic hepatitis B liver failure patients;(6) The influencing factors of upper gastrointestinal bleeding on acute-on-chronic hepatitis B liver failure patients;(7) The influencing factors of electrolyte imbalance on acute-on-chronic hepatitis B liver failure patients;(8) Developed the predictive model on the basic of dynamic change of index in acute-on-chronic hepatitis B liver failure patients. Method:(1) To study the influencing factors of the complications in acute-on-chronic hepatitis B liver failure patients:eight hundred and thirty acute-on-chronic hepatitis B liver failure patients were hospitalized in the department of liver diseases of Mengchao Hepatobiliary Hospital of Fujian Medical University during January2004to December2010, and the diagnosis acute-on-chronic hepatitis B liver failure was followed by The Prevention and Treatment Proposal of Liver Failure established in2012. Collected the baseline demographic, clinical, biochemical and virological features, inclued:gende, age(year), family history, whether hepatic encephalopathy occured or not, whether spontaneous bacterial peritonitis occured or not, whether hepatorenal syndrome occured or not, whether pulmonary infection occured or not, whether fungal infections occured or not, whether upper gastrointestinal bleeding occured or not, whether electrolyte imbalance occured or not, serum albumin (ALB)(g/1), serum globulin (GLB)(g/1), A/G ratio, serum total bilirubin (TBIL)(mol/L), serum direct bilirubin (DBIL)(mol/L), TBIL/DBIL ratio, serum alanine aminotransferase (ALT)(U/L), serum aspartate aminotransferase (AST)(U/L), ALT/AST ratio, serum gamma-glutamyl transferase (GGT)(U/L), serum alkaline phosphatase (ALP)(U/L), total serum cholesterol(CHO)(mmol/L), serum cholinesterase(CHE)(U/L), serum potassium(k+)(mmol/L), serum sodium (Na+)(mmol/L), serum creatinine (CR)(mol/L), prothrombin activity (PTA)(%), international normalized ratio (INR), surem alpha fetoprotein(AFP)(ng/ml), HBVDNA(IU/ml), hepatitis B e antigen(HBeAg) qualitative, white blood cell count (WBC)(*109/L), neutral granulocyte ratio(GR)(%), hemoglobin(Hb)(g/1), platelet count(PLT)(*109/L). For reducing the deviations, the measurement data inclued TBIL, DBIL, ALT, AST, CHE, PTA, AFP, HBVDNA were transformed logarithm with base10. Statistical analysis of data were performed by nonparametric test, Chi-square test, t test, etrietest,Ch-squaretest, and multiple binary logistic regression analysis using the SPSS v.13.0statistical package. Enumeration data were calculated as1or2,1stand for positive events.(2) Developed the predictive model on the basic of dynamic change of index in acute-on-chronic hepatitis B liver failure patients:seven hundred and fourteen acute-on-chronic hepatitis B liver failure patients were hospitalized more than seven days in the department of liver diseases of Mengchao Hepatobiliary Hospital of Fujian Medical University during January2004to December2010, and the diagnosis acute-on-chronic hepatitis B liver failure was followed by The Prevention and Treatment Proposal of Liver Failure established in2012. Collected the baseline and7th day’s demographic, clinical, biochemical and virological features, inclued:gende, age(year), family history, whether hepatic encephalopathy occured or not, whether spontaneous bacterial peritonitis occured or not, whether hepatorenal syndrome occured or not, whether pulmonary infection occured or not, whether fungal infections occured or not, whether upper gastrointestinal bleeding occured or not, whether electrolyte imbalance occured or not, ALB (g/1), serum globulin GLB (g/1), A/G ratio, TBIL (mol/L), DBIL(mol/L), TBIL/DBIL ratio, ALT (U/L), AST (U/L), ALT/AST ratio, GGT (U/L), ALP (U/L), CHO (mmol/L), CHE (U/L), k+(mmol/L), Na+(mmol/L), CR(mol/L), PTA (%), INR, AFP(ng/ml), HBVDNA(IU/ml), HBeAg qualitative, WBC (*109/L), GR(%), Hb (g/1), PLT(*109/L). For reducing the deviations, the measurement data inclued TBIL, DBIL, ALT, AST, CHE, PTA, AFP, HBVDNA were transformed to natural logarithm. Calculated the difference of measurement data between the baseline and7th day’s excerpt the AFP, HBVDNA.0stand for death,1stand for cansored events,1stand for male,2stand for female,1stand for HBeAg positive,2stand for HBeAg negative. Followed-up all the patients till the patients dead or the study finished on January10,2011. The survival time was from hospitalized day to the day that the patients were dead, Lost of follow up, accepted the liver transplant operation and were diagnosed as malignant tumor. All the patients were devided to two groups according to the ratio of85%to15%:607patients on the model developed group and107patients on the model validity group. COX proportional hazards regression analyses identified the influencing factors on the patients of model developed group, developed the statistical model. According to the model, calculated the scores of our model and Model for end-stage liver disease(MELD), evaluated the validity of the two model through the Receiver operating characteristic curve(ROC).Results:(1) The age of830acute-on-chronic hepatitis B liver failure patients were (40.7±12.1) years,721patients were male(86.9%),109patients were female (13.1%), Hepatic encephalopathy occured on278acute-on-chronic hepatitis B liver failure patients(33.5%),244patients of them were male(29.4%),34patients of them were female(4.1%), there was no significant difference between the male and female patients(x2=0.298,P=0.585). Among all the acute-on-chronic hepatitis B liver failure patients, the age of hepatic encephalopathy patients were42(17) years, the age of non-hepatic encephalopathy patients were38.5(14) years, there was significant difference between the two kinds of patients(Z=-4.46, P=0.000). The results of univariate analysis is that there was significant difference between hepatic encephalopathy patients and non-hepatic encephalopathy patients on the index of age, TBIL/DBIL ratio, CHO, Na+, PTA, INR, AFP, WBC, GR, PLT. The results of logistic is that age, TBIL/DBIL ratio, PTA, INR, AFP, WBC, GR, HBVDNA are the influencing factors of hepatic encephalopathy on acute-on-chronic hepatitis B liver failure patients.(2) Spontaneous bacterial peritonitis occured on593acute-on-chronic hepatitis B liver failure patients(71.4%),244patients of them were male(61.3%),34patients of them were female(11.1%), there was no significant difference between the male and female patients(x2=1.942,P=0.163). Among all the acute-on-chronic hepatitis B liver failure patients, the age of spontaneous bacterial peritonitis patients were40(16) years, the age of non-spontaneous bacterial peritonitis patients were37(13) years, there was significant difference between the two kinds of patients (Z=-4.46, P=0.000). The results of univariate analysis is that there was significant difference between spontaneous bacterial peritonitis patients and non-spontaneous bacterial peritonitis patients on the index of age, ALB, A/G, TBIL, DBIL, ALT, AST, ALT/AST ratio, GGT, ALP, CHO, CHE, K+, PTA, INR, WBC, GR, Hb, PLT, HBVDNA. The results of logistic is that CHE, Hb are the influencing factors of spontaneous bacterial peritonitis on acute-on-chronic hepatitis B liver failure patients.(3) Hepatorenal syndrome occured on90acute-on-chronic hepatitis B liver failure patients(10.84%),76patients of them were male(9.15%),14patients of them were female(9.15%), there was no significant difference between the male and female patients(x2=0.52,P=0.471). Among all the acute-on-chronic hepatitis B liver failure patients, the age of hepatorenal syndrome patients were45(15) years, the age of non-hepatorenal syndrome patients were39(15) years, there was significant difference between the two kinds of patients(Z=-4.46,P=0.000). The results of univariate analysis is that there was significant difference between hepatorenal syndrome patients and non-hepatorenal syndrome patients on the index of age, ALB, TBIL, DBIL, ALT, ALT/AST ratio, CHO, CHE, Na+, CR, PTA, INR, AFP, WBC, GR, Hb, PLT. The results of logistic is that age, CR, WBC are the influencing factors of hepatorenal syndrome on acute-on-chronic hepatitis B liver failure patients.(4) Pulmonary infection occured on138acute-on-chronic hepatitis B liver failure patients(16.6%),120patients of them were male(14.5%),18patients of them were female(2.1%), there was no significant difference between the male and female patients(x2=0.001,P=0.973). Among all the acute-on-chronic hepatitis B liver failure patients, the age of pulmonary infection patients were45(16) years, the age of non-pulmonary infection patients were39(15) years, there was significant difference between the two kinds of patients(Z=-4.854, P=0.000). The results of univariate analysis is that there was significant difference between pulmonary infection patients and non-pulmonary infection patients on the index of age, ALB, A/G, TBIL, TBIL/DBIL ratio, ALT, AST, ALT/AST ratio, CHO, CHE, K+, Na+, PTA, AFP, WBC, GR, Hb, PLT. The results of logistic is that age, AFP, WBC, Hb are the influencing factors of pulmonary infection on acute-on-chronic hepatitis B liver failure patients.(5) Fungal infections occured on68acute-on-chronic hepatitis B liver failure patients(8.2%),58patients of them were male(7.0%),10patients of them were female(1.2%), there was no significant difference between the male and female patients(x2=0.161,P=0.688). Among all the acute-on-chronic hepatitis B liver failure patients, the age of fungal infections patients were46.5(18) years, the age of non-fungal infections patients were39(15) years, there was significant difference between the two kinds of patients(Z=-4.424, P=0.000). The results of univariate analysis is that there was significant difference between fungal infections patients and non-fungal infections patients on the index of age, ALB, A/G, WBC, Hb, PLT. The results of logistic is that age, WBC are the influencing factors of fungal infections on acute-on-chronic hepatitis B liver failure patients.(6) Upper gastrointestinal bleeding occured on83acute-on-chronic hepatitis B liver failure patients(10.0%),70patients of them were male(8.4%),13patients of them were female(1.62%), there was no significant difference between the male and female patients(x2=0.518,P=0.472). Among all the acute-on-chronic hepatitis B liver failure patients, the age of upper gastrointestinal bleeding patients were42(19) years, the age of non-upper gastrointestinal bleeding patients were39(15) years, there was significant difference between the two kinds of patients(Z=-2.317, P=0.021). The results of univariate analysis is that there was significant difference between upper gastrointestinal bleeding patients and non-upper gastrointestinal bleeding patients on the index of age, GGT, ALP, CHO, CHE, Na+, CR, PTA, INR, WBC, Hb, PLT. The results of logistic is that age, PTA, Hb are the influencing factors of upper gastrointestinal bleeding on acute-on-chronic hepatitis B liver failure patients.(7) Electrolyte imbalance occured on570acute-on-chronic hepatitis B liver failure patients(68.68%),490patients of them were male(59.04%),80patients of them were female(9.64%), there was no significant difference between the male and female patients(χ2=1.299, P=0.254). Among all the acute-on-chronic hepatitis B liver failure patients, the age of electrolyte imbalance patients were40(15) years, the age of non-electrolyte imbalance patients were37(15) years, there was significant difference between the two kinds of patients(Z=-3.785, P=0.000). The results of univariate analysis is that there was significant difference between electrolyte imbalance patients and non-electrolyte imbalance patients on the index of age, ALB, A/G ratio, TBIL, DBIL, ALT, ALT/AST ratio, CHO, CHE, K+, Na+, PTA, INR, AFP, WBC, GR, Hb. The results of logistic is that ALB, ALT/AST ratio, K+, Na+,AFP are the influencing factors of electrolyte imbalance on acute-on-chronic hepatitis B liver failure patients.(8) The age of714acute-on-chronic hepatitis B liver failure patients were39(15) years,622patients were male(87.1%),92patients were female(12.9%); The age of model developed patients were38(14) years,93patients were male(86.9%),14patients were female(13.1%). Till the follow-up finished, there were193patients died among714acute-on-chronic hepatitis B liver failure patients(27.0%), there were521patients lost of follow up, survived or accept the liver transplant operation(73.0%); there were162patients died among model developed patients(26.7%), there were445patients lost of follow up, survived or accept the liver transplant operation(73.3%); there were31patients died among714acute-on-chronic hepatitis B liver failure patients(29.0%), there were76patients lost of follow up, survived or accept the liver transplant operation(71%). The median follow-up time was334days, and the longest follow-up time was2558days. The results of the COX proportional hazards regression analyses is that ALB, ALT/AST ratio, PTA, AFP, HBVDNA, GR, ACR, ΔPTA, ΔGR, ΔPLT are the influencing factors of prognosis in acute-on-chronic hepatitis B liver failure patients. The personal prognosis index(PI):PI=0.052*ALB(g/l)-0.203*(ALT/AST)-1.189*LN(PTA%)-0.161*LN[AFP(ng/ml)]-0.06*LN[HBVDNA(IU/ml)]+0.036*(GR%)-0.003*ΔCR(μmol/l)+1.119*ΔLN (PTA%)-0.028*(ΔGR%)+0.005*Δ[PLT(*109/l)]The results of ROC is that the area under curve(AUC) of our model is79.1%, P=0.000, meanwhile the AUC of MELD is57.9%, P=0.199. The optimal cutoff of our model was-4.98, the sensitivity was80.6%, the specificity was72.4%.Conclusion:(1) The risk factors of hepatic encephalopathy in acute-on-chronic hepatitis B liver failure patients is higher age, higher TBIL/DBIL ratio, lower PTA, higher INR, lower AFP, higher WBC, higher GR, higher HBVDNA.(2) The risk factors of spontaneous bacterial peritonitis in acute-on-chronic hepatitis B liver failure patients is lower CHE, lower Hb.(3) The risk factors of hepatorenal syndrome in acute-on-chronic hepatitis B liver failure patients is higher age, higher Cr, higher WBC.(4) The risk factors of pulmonary infection in acute-on-chronic hepatitis B liver failure patients is higher age, lower AFP, higher WBC, lower Hb.(5) The risk factors of fungal infections in acute-on-chronic hepatitis B liver failure patients is higher age, higher WBC.(6) The risk factors of upper gastrointestinal bleeding in acute-on-chronic hepatitis B liver failure patients is higher age, lower PTA, lower Hb.(7) The risk factors of electrolyte imbalance in acute-on-chronic hepatitis B liver failure patients is lower ALB, lower ALT/AST ratio, lower K+, lower Na+, lower AFP.(8) The influencing factors of the prognosis in acute-on-chronic hepatitis B liver failure patients is ALB, ALT/AST ratio, PTA, AFP, HBVDNA, GR, ACR, APTA, AGR, ΔPLT. Our model was validated, if the PI of patients is more than-4.98, his prognosis will be bad. |
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