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中华介入放射学电子杂志 ›› 2018, Vol. 06 ›› Issue (01) : 40 -45. doi: 10.3877/cma.j.issn.2095-5782.2018.01.010

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血管介入

TIPS术后短期总胆红素显著升高的相关因素分析及其对生存预后的影响
陈斯良1, 胡朋1, 林志鹏1, 赵剑波1,†()   
  1. 1. 510515　广州，南方医科大学南方医院介入科
  • 收稿日期:2017-08-03 出版日期:2018-02-01
  • 通信作者: 赵剑波

Relevant factors analysis on significant increase of total bilirubin in short term after TIPS and its influence on survival prognosis

Siliang Chen1, Peng Hu1, Zhipeng Lin1, Jianbo Zhao1,†()   

  1. 1. Department of Interventional Radiology, Southern Medical University, Nanfang Hospital, Guangzhou 510515, China
  • Received:2017-08-03 Published:2018-02-01
  • Corresponding author: Jianbo Zhao
  • About author:
    Corresponding author: Zhao Jianbo, Email:
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陈斯良, 胡朋, 林志鹏, 赵剑波. TIPS术后短期总胆红素显著升高的相关因素分析及其对生存预后的影响[J]. 中华介入放射学电子杂志, 2018, 06(01): 40-45.

Siliang Chen, Peng Hu, Zhipeng Lin, Jianbo Zhao. Relevant factors analysis on significant increase of total bilirubin in short term after TIPS and its influence on survival prognosis[J]. Chinese Journal of Interventional Radiology(Electronic Edition), 2018, 06(01): 40-45.

目的：

探讨经颈静脉肝内门腔静脉分流术（TIPS）后短期总胆红素显著升高的相关因素，观察术后短期总胆红素显著升高对患者长期生存预后的影响。

方法：

选取2009年1月—2015年12月我院收治的因肝硬化门静脉高压失代偿接受TIPS治疗的患者202例。根据术后短期内是否出现总胆红素显著升高分为两组：A组为总胆红素未显著升高组106例，B组为总胆红素显著升高组96例。采用单因素分析及多元非条件Logistic回归模型分析TIPS术后短期总胆红素显著升高的相关影响因素，并通过长期随访对比分析两组患者术后的生存预后。

结果：

202例患者均成功建立肝内门腔支架分流道。门静脉压力从术前的（24.2±5.1）mmHg降至（14.6±4.3）mmHg，差异有统计学意义（t=17.33，P<0.01）。TIPS术前总胆红素为（23.27±18.67）μmol/L，术后2周升至（36.52±28.17）μmol/L，差异有统计学意义（t=6.461，P <0.01）。单因素分析显示B组患者的年龄、术前总胆红素、术前Child-Pugh评分、肝内支架分流道长度均高于A组（P<0.05）；两组的门静脉高压病因、门静脉穿刺位置、术后门静脉分支显影情况以及分流道支架类型比较差异也均有统计学意义。多元非条件Logistics回归分析显示术前总胆红素、术前Child-Pugh评分、肝内支架分流道长度及术后门静脉分支显影情况与术后短期内总胆红素显著升高有关。Kaplan-Meier分析显示TIPS术后A组的生存率高于B组，有统计学差异（χ2=4.528，P=0.033），术后两组的分流道累积通畅率及HE发生率无统计学差异。

结论：

术前总胆红素水平高、术前Child-Pugh评分高、肝内支架分流道长度长是TIPS术后短期总胆红素显著升高的危险因素，术后门静脉分支显影支数多是TIPS术后短期总胆红素显著升高的保护因素。术后短期总胆红素显著升高比未显著升高患者的长期累积生存率低。

关键词: 肝硬化门静脉高压, 经颈静脉肝内门腔分流术, 总胆红素, 相关因素, 生存预后
Objective:

To investigate the relevant factors of significant increase of total bilirubin in short term after transjugular intrahepatic portosystemic shut (TIPS) and the influence of survival prognosis.

Methods:

A retrospective review including 202 patients with cirrhotic portal hypertension undergoing TIPS from January 2009 to December 2015 was performed. All patients were divided into two groups: without significant increase of total bilirubin in short term (group A, n=106) and significant increase of total bilirubin in short term (group B, n=96) after TIPS. The relative factors affecting significant increase of total bilirubin in short term after TIPS were analyzed by single factor analysis and multivariate non conditional Logistics regression model, and the survival prognosis of the two groups were analyzed by long-term follow-up.

Results:

The intrahepatic shunts were established successfully in all patients. The preoperative portal venous pressure was (24.2±5.1) mmHg, while postoperative portal venous pressure was (14.6±4.3) mmHg, with statistical difference (t=17.33, P<0.01) . The preoperative total bilirubin was (23.27±18.67) μmol/L, while total bilirubin was (36.52±28.17) μmol/L two weeks after TIPS, with statistical difference (t=6.461, P<0.01) . Single variate analysis showed that age, preoperative total bilirubin, preoperative Child-Pugh score and length of intrahepatic stent in group B were all higher than those of group A (P<0.05) , and there were statistical differences in pathogenesis of portal hypertension, puncture sites of portal vein, postoperative development of portal branch and type of stent between two groups (P<0.05) . Multivariate logistic regression model showed that the sign of significant increase of total bilirubin in short term after TIPS related to preoperative total bilirubin, preoperative Child-Pugh score, length of intrahepatic stent and postoperative development of portal branch. Kaplan-Meier analysis showed that group A had higher survival rate than group B (χ2=4.528, P=0.033) , and there was no significant difference between two groups in shunt patency and HE.

Conclusions:

Preoperative higher total bilirubin, preoperative higher Child-Pugh score and longer intrahepatic stent are the independent risk factors for significant increase of total bilirubin in short term after TIPS, while postoperative more development of portal branch is the independent protective factor. Significant increase of total bilirubin in short term after TIPS might have lower survival rate.

Key words: Cirrhotic portal hypertension, Transjugular intrahepatic portosystemic shunt, Total bilirubin, Relevant factors, Survival prognosis
表1 A组和B组的临床资料比较
因素 A组(n=106) B组(n=96) 统计量 P值
年龄（岁） 47.9±12.5 53.6±11.7 t=2.137 0.034
术前总胆红素(μmol/L) 17.35±12.85 29.16±21.36 t=3.383 <0.01
术前Child-Pugh评分（分） 6.80±1.15 7.31±1.16 t=2.035 0.041
肝内支架分流道长度(cm) 5.63±1.54 6.44±2.19 t=2.232 0.022
门静脉高压病因（例） ? ? ? ?
? 病毒性肝炎 64(60.3) 76(79.2) ? ?
? 酒精性肝炎 19(17.9) 4(4.2) χ2=12.886 0.005
? 布加综合征 6(5.7) 7(7.3) ? ?
? 其他 17(16.1) 9(9.3) ? ?
门静脉穿刺位置（例） ? ? ? ?
? 主干或分叉 68(64.2) 66(68.8) ? ?
? 左支 22(20.7) 8(8.3) χ2=7.033 0.030
? 右支 16(15.1) 22(22.9) ? ?
术后门静脉分支显影情况（例） ? ? ? ?
? 无显影 15(14.2) 27(28.1) ? ?
? 1支显影 16(15.1) 15(15.6) χ2=6.400 0.041
? 2支显影 75(70.7) 54(56.3) ? ?
分流道支架类型（例） ? ? ? ?
? 单膜 47(44.3) 57(59.4) ? ?
? 复合支架 59(55.7) 39(40.6) χ2=4.559 0.033
表2 Logistic回归分析中分类变量的赋值表
因素 赋值说明
性别 女=0,男=1
门静脉高压病因 病毒性肝炎=0，酒精性肝炎=1，布加综合征=2，不明原因=3
门静脉高压主要症状 曲张静脉和（或）出血=0，顽固性腹水=1
术前肝性脑病 无=0,有=1
术前Child-Pugh分级 A级=0,B级=1，C级=2
门静脉血栓 无=0,分支=1，主干=2
门静脉穿刺位置 分叉或主干=0，左支=1，右支=2
术后门静脉分支显影情况 无显影=0，1支显影=1，2支显影=2
分流道支架类型 单膜=0，复合支架=1
表3 多元非条件Logistic回归分析结果
影响因素 β Wald χ2 P OR OR95%CI
术前总胆红素 2.167 27.863 0.001 10.414 6.217~15.351
术前Child-Pugh评分 1.712 7.876 0.008 5.744 2.433~8.926
肝内支架分流道长度 1.844 15.230 0.001 6.243 3.024~10.586
术后门静脉分支显影支数 -0.779 3.559 0.023 0.434 0.237~0.787
图1 Kaplan-Meier分析显示两组分流道累积通畅率差异无统计学意义（χ2=0.02，P=0.887）
图2 Kaplan-Meier分析显示两组未发生HE比例差异无统计学意义（χ2=0.016，P=0.898）
图3 Kaplan-Meier分析显示TIPS术后短期内总胆红素未显著升高组的生存率高于显著升高组（χ2=4.528，P=0.033）
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