■尽管腹水是肝硬化中最常见的第一失代偿事件,作为单指标失代偿的腹水后的临床病程尚不明确。因此,这项多中心研究的目的是系统地研究腹水作为第一个失代偿事件后进一步失代偿的发生率和类型,并评估死亡的危险因素。
■在2003年至2021年期间,在2所大学医院(帕多瓦和维也纳)共纳入622例肝硬化患者,其中2/3级腹水作为单指标失代偿事件。进一步失代偿的事件,肝移植,并记录死亡。
■平均年龄为57±11岁,大多数患者为男性(n=423,68%),酒精相关(n=366,59%)和病毒性(n=200,32%)肝病为主要病因。总的来说,323例(52%)患者表现为2级和299例(48%)3级腹水。演示时Child-Pugh评分中位数为8(IQR7-9),终末期肝病(MELD)的平均模型为15±6。在49个月的中位随访期间,350例(56%)患者经历了进一步的代偿失调:顽固性腹水(n=130,21%),肝性脑病(n=112,18%),自发性细菌性腹膜炎(n=32,5%),肝肾综合征-急性肾损伤(n=29,5%)。静脉曲张出血作为孤立的进一步失代偿事件是罕见的(n=18,3%),而非出血的进一步失代偿(n=161,26%)和≥2次伴随的进一步失代偿事件(n=171,27%)是常见的.仅81例(13%)患者使用了经颈静脉肝内门体分流术。在出现2级腹水的患者中,MELD≥15表明进一步失代偿的相当大风险(子分布风险比[SHR]2.18;p<0.001;1年发病率:<10:10%vs.10-14:13%vs.≥15:28%)和死亡率(SHR1.89;p=0.004;1年发病率:<10:3%vs.10-14:6%vs.≥15:14%)。重要的是,在整个3级腹水的MELD地层中,死亡率同样很高(p=n.s.对于不同的MELD地层;1年发病率:<10:14%vs.10-14:15%vs.≥15:20%)。
■腹水患者经常发生单指标代偿失调事件,很少发生出血。虽然2级腹水和MELD<15的患者似乎有良好的预后,在所有MELD地层中,3级腹水患者的死亡风险很高.
■失代偿(肝功能恶化导致的症状发展)标志着肝硬化患者病程的转折点。腹水(即,腹部积液)是最常见的第一次代偿失调事件,然而,对于将腹水发展为单一的首次失代偿事件的患者的临床过程知之甚少.在这里,我们表明,腹水的严重程度与死亡率有关,在中度腹水患者中,广泛使用的预后MELD评分可以预测患者预后.
UNASSIGNED: Although ascites is the most frequent first decompensating event in cirrhosis, the clinical course after ascites as the single index decompensation is not well defined. The aim of this multicentre study was thus to systematically investigate the incidence and type of further decompensation after ascites as the first decompensating event and to assess risk factors for mortality.
UNASSIGNED: A total of 622 patients with cirrhosis presenting with grade 2/3 ascites as the single index decompensating event at 2 university hospitals (Padova and Vienna) between 2003 and 2021 were included. Events of further decompensation, liver transplantation, and death were recorded.
UNASSIGNED: The mean age was 57 ± 11 years, and most patients were male (n = 423, 68%) with alcohol-related (n = 366, 59%) and viral (n = 200,32%) liver disease as the main aetiologies. In total, 323 (52%) patients presented with grade 2 and 299 (48%) with grade 3 ascites. The median Child-Pugh score at presentation was 8 (IQR 7-9), and the mean model for end-stage liver disease (MELD) was 15 ± 6. During a median follow-up period of 49 months, 350 (56%) patients experienced further decompensation: refractory ascites (n = 130, 21%), hepatic encephalopathy (n = 112, 18%), spontaneous bacterial peritonitis (n = 32, 5%), hepatorenal syndrome-acute kidney injury (n = 29, 5%). Variceal bleeding as an isolated further decompensation event was rare (n = 18, 3%), whereas non-bleeding further decompensation (n = 161, 26%) and ≥2 concomitant further decompensation events (n = 171, 27%) were frequent. Transjugular intrahepatic portosystemic shunt was used in only 81 (13%) patients. In patients presenting with grade 2 ascites, MELD ≥15 indicated a considerable risk for further decompensation (subdistribution hazard ratio [SHR] 2.18; p <0.001; 1-year incidences: <10: 10% vs. 10-14: 13% vs. ≥15: 28%) and of mortality (SHR 1.89; p = 0.004; 1-year incidences: <10: 3% vs. 10-14: 6% vs. ≥15: 14%). Importantly, mortality was similarly high throughout MELD strata in grade 3 ascites (p = n.s. for different MELD strata; 1-year incidences: <10: 14% vs. 10-14: 15% vs. ≥15: 20%).
UNASSIGNED: Further decompensation is frequent in patients with ascites as a single index decompensation event and only rarely owing to bleeding. Although patients with grade 2 ascites and MELD <15 seem to have a favourable prognosis, those with grade 3 ascites are at a high risk of mortality across all MELD strata.
UNASSIGNED: Decompensation (the development of symptoms as a result of worsening liver function) marks a turning point in the disease course for patients with cirrhosis. Ascites (i.e. , the accumulation of fluid in the abdomen) is the most common first decompensating event, yet little is known about the clinical course of patients who develop ascites as a single first decompensating event. Herein, we show that the severity of ascites is associated with mortality and that in patients with moderate ascites, the widely used prognostic MELD score can predict patient outcomes.