TIPS治疗自身免疫性肝病和乙型病毒肝炎所致肝硬化门静脉高压的疗效及因素分析

doi:10.3877/cma.j.issn.2095-5782.2025.03.008

目的

评估经颈静脉肝内门体分流术（Transjugular Intrahepatic Portosystemic Shunt，TIPS）治疗自身免疫性肝病（Autoimmune Liver Disease, AILD）对比乙型肝炎病毒（Hepatitis B Virus, HBV）所致肝硬化失代偿患者的预后差异及影响因素。

方法

回顾性分析2018年1月~2023年6月在南京医科大学第一附属医院接受TIPS治疗的470例患者，经过纳排分为AILD组（n=47）和HBV组（n=102）。收集患者基线资料、术前术后的门静脉压力及手术情况、术后上消化道再出血、支架失功、肝性脑病及生存预后相关资料，并进行分析。

结果

AILD组中位随访时间为614天，HBV组中位随访时间为854天； AILD组的3个月、6个月和1年死亡率分别为6.38%、21.27%和21.27%，HBV组分别为2.94%、3.92%和7.84%，AILD组的生存率低于HBV组（P=0.029）。单因素及多因素分析显示病因（HR=2.211, 95% CI： 1.111~4.401, P=0.024）、MELD评分（HR=1.009, 95% CI： 1.021~1.184, P=0.012）是死亡相关危险因素。再出血和显性肝性脑病的发生率在两组间无显著差异，但支架失功在AILD组中更为常见（P=0.056）。血清肌酐水平显性肝性脑病的独立危险因素（HR=1.004, 95% CI： 1.000~1.007, P=0.038）。

结论

AILD和HBV所致肝硬化失代偿患者行TIPS治疗后可有效降低门静脉压力、改善临床症状，AILD患者预后生存期较HBV患者短，但两组术后再出血和显性肝性脑病的发生率上无显著差异。

关键词: 肝硬化失代偿, 经颈静脉门体分流术, 自身免疫性肝病, 乙型肝炎病毒

Objective

To evaluate the prognostic differences and influencing factors of transjugular intrahepatic portosystemic shunt (TIPS) in decompensated cirrhosis caused by autoimmune liver disease (AILD) versus hepatitis B virus (HBV).

Methods

A retrospective analysis was conducted on 470 patients who received TIPS treatment at the First Affiliated Hospital of Nanjing Medical University from January 2018 to June 2023. Patients were divided into the AILD group (n=47) and the HBV group (n=102). Baseline data, preoperative and postoperative portal pressure, surgical conditions, postoperative upper gastrointestinal rebleeding, stent dysfunction, hepatic encephalopathy, and survival prognosis were collected and analyzed.

Results

The median follow-up time was 614 days for the AILD group and 854 days for the HBV group. The 3-month, 6-month, and 1-year mortality rates in the AILD group were 6.38%, 21.27%, and 21.27%, respectively, compared to 2.94%, 3.92%, and 7.84% in the HBV group. The survival rate in the AILD group was significantly lower than that in the HBV group (P=0.029). Univariate and multivariate analyses identified etiology (HR=2.211, 95% CI: 1.111~4.401, P=0.024) and MELD score (HR=1.009, 95% CI: 1.021~1.184, P=0.012) as risk factors for mortality. No significant differences were found between the two groups in terms of rebleeding and hepatic encephalopathy rates, but stent dysfunction was more common in the AILD group (P=0.056). Serum creatinine level was an independent risk factor for overt hepatic encephalopathy (HR=1.004, 95% CI: 1.000~1.007, P=0.038).

Conclusion

TIPS can effectively reduce portal pressure and improve clinical symptoms in patients with decompensated cirrhosis caused by both AILD and HBV. However, AILD patients have a shorter survival period compared to HBV patients, although there are no significant differences in postoperative rebleeding and overt hepatic encephalopathy between the two groups.

Key words: Decompensated Cirrhosis, Transjugular Intrahepatic Portosystemic Shunt, Autoimmune Liver Disease, Hepatitis B Virus

图1 流程图

表1 AILD 组和 HBV 组接受 TIPS 治疗的患者基线表

	AILD (n=47)	HBV (n=102)	P值
性别男	3 (6.38%)	73 (71.57%)	<0.001
年龄,>65岁	18(38.29%)	25(24.51%)	0.084
<65岁	29(61.71%)	77(75.49%)
TIPS适应症			0.577
顽固性腹水	7(14.89%)	19(18.63%)
急性/复发曲张静脉出血	40(85.11%)	83(81.34%)
实验室指标
ALT (U/L)	21.80(13.80~37.20)	24.00(16.85~35.88)	0.323
AST (U/L)	36.10(26.30~53.50)	32.35(23.13~49.63)	0.242
GGT (U/L)	48.00(33.70~109.10)	29.30(20.95~46.70)	<0.001
ALP (U/L)	117.00(71.00~183.00)	74.00(57.50~93.80)	<0.001
TB (μmol/L)	23.80(15.80~39.30)	23.25(17.45~34.00)	0.830
ALB (g/L)	30.73±4.67	31.44±4.79	0.399
Cr (μmol/L)	59.30(51.90~69.10)	64.30(54.15~80.25)	0.150
国际标准化比值INR	1.38±0.28	1.37±0.18	0.858
血钠 (mmol/L)	137.82±4.30	139.23±3.64	0.042
血钾 (mmol/L)	3.76±0.69	3.78±0.41	0.743
Child-Pugh 评分	7(6~9)	7(6~8)	0.603
Child-Pugh 分级			0.987
A	14 (29.79%)	30 (29.41%)
B	27 (57.45%)	58 (56.86%)
C	6 (12.77%)	14 (13.73%)
MELD 评分	12(9~14)	11.5(10~13)	0.952
MELD-Na 评分	13(10~16)	12(10~14)	0.499
TIPS前门静脉压力梯度(mm Hg)	22.02 ± 5.98	21.86 ± 6.42	0.876
TIPS后门静脉压力梯度(mm Hg)	12.79 ± 4.80	12.94 ± 4.85	0.871

表1 AILD 组和 HBV 组接受 TIPS 治疗的患者基线表

	AILD (n=47)	HBV (n=102)	P值
性别男	3 (6.38%)	73 (71.57%)	<0.001
年龄,>65岁	18(38.29%)	25(24.51%)	0.084
<65岁	29(61.71%)	77(75.49%)
TIPS适应症			0.577
顽固性腹水	7(14.89%)	19(18.63%)
急性/复发曲张静脉出血	40(85.11%)	83(81.34%)
实验室指标
ALT (U/L)	21.80(13.80~37.20)	24.00(16.85~35.88)	0.323
AST (U/L)	36.10(26.30~53.50)	32.35(23.13~49.63)	0.242
GGT (U/L)	48.00(33.70~109.10)	29.30(20.95~46.70)	<0.001
ALP (U/L)	117.00(71.00~183.00)	74.00(57.50~93.80)	<0.001
TB (μmol/L)	23.80(15.80~39.30)	23.25(17.45~34.00)	0.830
ALB (g/L)	30.73±4.67	31.44±4.79	0.399
Cr (μmol/L)	59.30(51.90~69.10)	64.30(54.15~80.25)	0.150
国际标准化比值INR	1.38±0.28	1.37±0.18	0.858
血钠 (mmol/L)	137.82±4.30	139.23±3.64	0.042
血钾 (mmol/L)	3.76±0.69	3.78±0.41	0.743
Child-Pugh 评分	7(6~9)	7(6~8)	0.603
Child-Pugh 分级			0.987
A	14 (29.79%)	30 (29.41%)
B	27 (57.45%)	58 (56.86%)
C	6 (12.77%)	14 (13.73%)
MELD 评分	12(9~14)	11.5(10~13)	0.952
MELD-Na 评分	13(10~16)	12(10~14)	0.499
TIPS前门静脉压力梯度(mm Hg)	22.02 ± 5.98	21.86 ± 6.42	0.876
TIPS后门静脉压力梯度(mm Hg)	12.79 ± 4.80	12.94 ± 4.85	0.871

表2 AILD 组和 HBV 组 TIPS 术后观察指标的比较

	AILD (n=47)	HBV (n=102)	χ² Value	P Value
TIPS支架失功率 [n (%)]	5(10.64%)	2(1.96%)	3.65	0.056
上消化道再出血率 [n (%)]	7(14.89%)	13(12.75%)	0.01	0.921
显性脑病发生率 [n (%)]	13(27.66%)	18(17.65%)	1.39	0.237
疾病相关病死率 [n (%)]	18(38.30%)	20(19.61%)	4.97	0.026

表2 AILD 组和 HBV 组 TIPS 术后观察指标的比较

	AILD (n=47)	HBV (n=102)	χ² Value	P Value
TIPS支架失功率 [n (%)]	5(10.64%)	2(1.96%)	3.65	0.056
上消化道再出血率 [n (%)]	7(14.89%)	13(12.75%)	0.01	0.921
显性脑病发生率 [n (%)]	13(27.66%)	18(17.65%)	1.39	0.237
疾病相关病死率 [n (%)]	18(38.30%)	20(19.61%)	4.97	0.026

图2 AILD 组和 HBV 组临床结果的 Kaplan-Meier 分析。a 存活累积发生率（log-rank test, P=0.029）；b累积再出血率（log-rank test, P=0.1112）；c 累积显性肝性脑病 (log-rank test, P=0.1031)。

表3 TIPS治疗预后危险因素分析

	单因素分析		多因素分析
	HR (95% CI)	P Value	HR (95% CI)	P Value
死亡率
病因 (AILD vs. HBV)	2.051(1.061~3.964)	0.033	2.211(1.111~4.401)	0.024
TIPS适应症	1.371(0.624~3.009)	0.423
年龄	1.003(0.972~1.034)	0.865
Child-Pugh 评分	1.068(0.885~1.289)	0.492
MELD 评分	1.104(1.027~1.187)	0.008	1.009(1.021~1.184)	0.012
MELD-Na 评分	1.088(1.026~1.154)	0.005
TB	1.017(1.006~1.029)	0.003
GGT	0.999(0.993~1.005)	0.687
ALP	1.000(0.996~1.004)	0.924
再出血
病因 (AILD vs. HBV)	1.300(0.516~3.279)	0.578
显性肝性脑病
病因 (AILD vs. HBV)	1.795(0.879~3.668)	0.108
Child-Pugh 评分	1.207(1.003~1.452)	0.046
MELD-Na 评分	1.076(0.999~1.159)	0.054
术前门静脉压力梯度	1.039(1.001~1.078)	0.043
ALP	1.004(1.001~1.007)	0.013
Cr	1.002(1.000~1.004)	0.032	1.004(1.000~1.007)	0.038

表3 TIPS治疗预后危险因素分析

	单因素分析		多因素分析
	HR (95% CI)	P Value	HR (95% CI)	P Value
死亡率
病因 (AILD vs. HBV)	2.051(1.061~3.964)	0.033	2.211(1.111~4.401)	0.024
TIPS适应症	1.371(0.624~3.009)	0.423
年龄	1.003(0.972~1.034)	0.865
Child-Pugh 评分	1.068(0.885~1.289)	0.492
MELD 评分	1.104(1.027~1.187)	0.008	1.009(1.021~1.184)	0.012
MELD-Na 评分	1.088(1.026~1.154)	0.005
TB	1.017(1.006~1.029)	0.003
GGT	0.999(0.993~1.005)	0.687
ALP	1.000(0.996~1.004)	0.924
再出血
病因 (AILD vs. HBV)	1.300(0.516~3.279)	0.578
显性肝性脑病
病因 (AILD vs. HBV)	1.795(0.879~3.668)	0.108
Child-Pugh 评分	1.207(1.003~1.452)	0.046
MELD-Na 评分	1.076(0.999~1.159)	0.054
术前门静脉压力梯度	1.039(1.001~1.078)	0.043
ALP	1.004(1.001~1.007)	0.013
Cr	1.002(1.000~1.004)	0.032	1.004(1.000~1.007)	0.038

[1]	Trivedi PJ, Hirschfield GM. Recent advances in clinical practice: epidemiology of autoimmune liver diseases[J]. Gut, 2021,70(10):1989-2003.
[2]	Chang C, Tanaka A, Gershwin ME. Unmet needs in autoimmune liver diseases[J]. J Dig Dis, 2019, 20(7):327-330.
[3]	Aitcheson G, Cezar C, John I, et al. Update on the evaluation and management of portal hypertension[J]. Gastroenterol Hepatol (NY), 2021,17(12):569-578.
[4]	Hu YF, Li SX, Liu HL, et al. Precirrhotic primary biliary cholangitis with portal hypertension: bile duct injury correlate[J]. Gut Liver, 2024, 18(5):867-876.
[5]	Vizzutti F, Schepis F, Arena U, et al. Transjugular intrahepatic portosystemic shunt (TIPS): current indications and strategies to improve the outcomes[J]. Intern Emerg Med, 2020, 15(1): 37-48.doi: 10.1007/s11739-019-02252-8
[6]	Terrault NA, Lok ASF, McMahon BJ, et al. Update on Prevention, Diagnosis, and Treatment of Chronic Hepatitis B: AASLD 2018 Hepatitis B Guidance[J]. Clinical Liver Disease, 2018, 12(1): 33-34.doi: 10.1002/cld.728
[7]	谭绪, 党富涛, 付海艳, 朱艳平, 唐映梅. 经颈静脉肝内门体分流术治疗原发性胆汁性胆管炎效果观察[J]. 山东医药, 2021, 61(1): 16-20.
[8]	张玮, 诸葛宇征, 张明, et al. 经颈静脉肝内门体分流术治疗原发性胆汁性肝硬化门静脉高压的效果及安全性[J]. 临床肝胆病杂志, 2016, 32(2): 259-263.
[9]	Wang C. Transjugular intrahepatic portosystemic shunt in patients with autoimmune hepatitis-induced cirrhosis and variceal bleeding. Abdominal Radiology[EB/OL]. Published online 2022.
[10]	Janik MK, Wunsch E, Milkiewicz P. Variants of autoimmune liver diseases: how to diagnose and treat them?[J]. Pol Arch Intern Med, 2023, 133(1):16408.
[11]	Ridola L, Faccioli J, Nardelli S, Gioia S, Riggio O. Hepatic encephalopathy: Diagnosis and management[J]. Journal of Translational Internal Medicine, 2020, 8(4): 210-219.doi: 10.2478/jtim-2020-0034
[12]	吴军政, 刘圣, 施海彬, et al. TIPS联合PTVE治疗自身免疫性肝硬化曲张静脉出血疗效分析[J]. 南京医科大学学报(自然科学版), 2022, 42(8): 1142-1146.
[13]	Liu SP, Bian ZH, Zhao ZB, et al. Animal Models of Autoimmune Liver Diseases: a Comprehensive Review[J]. Clinic Rev Allerg Immunol, 2020, 58(2): 252-271.doi: 10.1007/s12016-020-08778-6
[14]	Iwasa M, Sugimoto R, Mifuji-Moroka R, et al. Factors contributing to the development of overt encephalopathy in liver cirrhosis patients[J]. Metab Brain Dis, 2016, 31(5): 1151-1156.doi: 10.1007/s11011-016-9862-6
[15]	Lee HW, Lee JS, Ahn SH. Hepatitis B Virus Cure: Targets and Future Therapies[J]. Int J Mol Sci. Published online 2021.
[16]	童雅茹, 尹晓春, 张玮, 孙畅, 张明, 诸葛宇征. 经颈静脉肝内门体分流术治疗原发性胆汁性胆管炎伴门静脉高压的效果评估[J]. 临床肝胆病杂志, 2023, 39(2): 333-338.
[17]	Stockhoff L, Muellner‐Bucsics T, Markova AA, et al. Low Serum Cholinesterase Identifies Patients With Worse Outcome and Increased Mortality After TIPS[J]. Hepatol Commun, 2022, 6(3): 621-632.doi: 10.1002/hep4.1829
[18]	Nardelli S, Bellafante D, Ridola L, Faccioli J, Riggio O, Gioia S. Prevention of post-tips hepatic encephalopathy: The search of the ideal candidate[J]. Metab Brain Dis, 2023, 38(5): 1729-1736.doi: 10.1007/s11011-022-01131-0

[1]	黄春燕, 方敏, 朱渝, 万朝敏, 廖琼. 婴儿乙型肝炎合并丁型肝炎病毒感染的临床分析并文献复习[J/OL]. 中华妇幼临床医学杂志(电子版), 2024, 20(06): 675-684.
[2]	吴娟丽, 张域爽, 高涵, 张毅恒, 王磊, 曲云东, 李涛. 慢性乙型肝炎和乙型肝炎肝硬化患者核苷（酸）类似物完全病毒学应答后血清乙型肝炎病毒核糖核酸检测及影响因素[J/OL]. 中华实验和临床感染病杂志(电子版), 2024, 18(06): 343-349.
[3]	张小曼, 马筱秋, 许正锯, 张纯瑜, 何彩婷. 乙型肝炎病毒逆转录酶区耐药突变对血清乙型肝炎病毒表面抗原水平的影响[J/OL]. 中华实验和临床感染病杂志(电子版), 2023, 17(05): 324-332.
[4]	钱小梅, 罗洪, 李智慧, 周代君, 李东. 76例乙型肝炎肝硬化并发原发性肝癌的高危因素Logistic分析[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(03): 251-253.
[5]	吴方园, 孙霞, 林昌锋, 张震生. HBV相关肝硬化合并急性上消化道出血的危险因素分析[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(01): 45-47.
[6]	中华医学会器官移植学分会肝移植学组, 中国医师协会器官移植医师分会. 中国自身免疫性肝病肝移植受者免疫抑制方案应用指南[J/OL]. 中华移植杂志(电子版), 2025, 19(02): 76-85.
[7]	蔡艺丹, 方坚, 张志强, 陈莉, 张世安, 夏磊, 阮梅, 李东良. 经颈静脉肝内门体分流术对肝硬化门脉高压患者肠道菌群及肝功能的影响[J/OL]. 中华细胞与干细胞杂志(电子版), 2024, 14(05): 285-293.
[8]	林水荣, 宋子敏, 于玺, 李绍强, 华赟鹏, 沈顺利. 术前抗病毒治疗对HBV相关肝癌肝切除术后肝衰竭影响[J/OL]. 中华肝脏外科手术学电子杂志, 2025, 14(05): 700-706.
[9]	刘敏思, 李荣, 李媚. 基于GGT与Plt比值的模型在HBV相关肝细胞癌诊断中的作用[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 831-835.
[10]	孟涵钰, 曹瑞雪, 张杨杨, 辛萱, 毕利泉, 刘晓红. HBV感染相关肝细胞癌中MYCT1和FAS的表达及临床病理分析[J/OL]. 中华消化病与影像杂志(电子版), 2025, 15(04): 311-316.
[11]	方海丽, 王俊, 栾琳. HBV 相关慢加急性肝衰竭患者诱发肝性脑病风险列线图模型构建与验证应用[J/OL]. 中华消化病与影像杂志(电子版), 2025, 15(02): 144-148.
[12]	董佳, 王坤, 张莉. 预后营养指数结合免疫球蛋白、血糖及甲胎蛋白对HBV 相关慢加急性肝衰竭患者治疗后预后不良的预测价值[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 555-559.
[13]	胡静, 杨秀锦, 侯志云. HBV感染患者外周血ISGs表达水平变化及其与干扰素治疗疗效的关系[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(04): 343-347.
[14]	包萨础拉, 温都苏. HBV 功能性治愈的联合策略研究进展[J/OL]. 中华临床医师杂志(电子版), 2025, 19(03): 234-239.
[15]	刘春林, 刘畅, 赵东岩, 李端萍, 刘建梅, 罗秋林. 利用室内质控与能力验证数据评定HBV DNA和HCV RNA测量不确定度[J/OL]. 中华临床实验室管理电子杂志, 2024, 12(02): 91-96.

阅读次数

全文

摘要

选择文件类型/文献管理软件名称

选择包含的内容

Comparative efficacy of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in cirrhosis due to autoimmune liver disease and hepatitis B virus

模态框（Modal）标题

选择文件类型/文献管理软件名称

选择包含的内容

Comparative efficacy of transjugular intrahepatic portosystemic shunt in the treatment of portal hypertension in cirrhosis due to autoimmune liver disease and hepatitis B virus