多发伤后急性肝损伤的临床特点及危险因素分析

Clinical Characteristics and Risk Factors Analysis of Acute Liver Injury Following Multiple Trauma

摘要: 目的：探讨多发伤后发生急性肝损伤的临床特点及危险因素。方法：收集2021年1月至2023年1月陕西省人民医院收治的216例多发伤成人患者资料。根据是否并发急性肝损伤分为多发伤急性肝损伤组(81例)和多发伤无急性肝损伤组(135例)，通过比较急性肝损伤组和无急性肝损伤组患者的临床资料、实验室指标，使用单因素以及多因素Logistic回归分析多发伤患者并发急性肝损伤的危险因素，并绘制ROC曲线，评估其在预测多发伤患者发生急性肝损伤发生中的价值。并将急性肝损伤组分为肝细胞型、胆管细胞型、胆红素型、混合型4个亚组，比较不同亚组间的临床特点。结果：单因素分析结果显示，ISS评分、住院时间、休克纠正时间、PT-T、HCT、ALT、AST、Tbil、合并腹腔感染、失血性休克、感染性休克、脓毒症是多发伤后急性肝损伤患者的危险因素(均P < 0.05)；多因素Logistic回归分析显示，休克纠正时间、合并腹腔感染、脓毒症是多发伤患者发生急性肝损伤的独立危险因素；ROC曲线分析显示，休克纠正时间、腹腔感染、脓毒症以及联合上述三项指标预测多发伤急性肝损伤发生的ROC曲线下面积(AUC)分别为0.57 (95% CI为0.493~0.648)、0.649 (95% CI为0.57~0.729)、0.614 (95% CI为0.535~0.692)、0.732 (95% CI为0.662~0.803)；以联合三项预测指标对多发伤急性肝损伤预测价值最高，而休克纠正时间的预测价值最低。多发伤后急性肝损伤患者四个亚组间在ISS评分、合并脓毒症上比较，有明显统计学差异(P < 0.05)。其中，肝细胞型和胆管细胞型肝损伤组中ISS评分高的人数更多；胆红素型和混合型肝损伤组中合并脓毒症人数更多。结论：多发伤后急性肝损伤患者临床特点：住院时间更长，ISS评分更高、休克纠正时间长、合并腹腔感染、脓毒症的几率更高；急性肝损伤患者ISS评分高者以肝细胞型和胆管细胞型肝损伤为主，急性肝损伤并发脓毒症的患者以胆红素型和混合型肝损伤为主。多发伤后急性肝损伤的独立危险因素有：休克纠正时间、合并腹腔感染、脓毒症；联合三项预测指标对多发伤急性肝损伤预测价值最高。

Abstract: Objective: To investigate the clinical characteristics and risk factors for the development of acute liver injury following multiple trauma. Methods: Data from 216 adult patients admitted to the Shaanxi Provincial People’s Hospital from January 2021 to January 2023 with multiple trauma were collected. Patients were divided into two groups based on whether they had acute liver injury: the multiple trauma acute liver injury group (81 cases) and the multiple trauma no acute liver injury group (135 cases). Clinical data and laboratory parameters were compared between the two groups using univariate and multivariate logistic regression analysis to identify risk factors for acute liver injury in multiple trauma patients. ROC curve analysis was conducted to assess the predictive value of these risk factors in predicting acute liver injury in multiple trauma patients. The Acute Liver Injury group was further categorized into four subgroups: hepatocellular, cholangiocyte, bilirubin, and mixed-type, and clinical characteristics among these subgroups were compared. Results: Univariate analysis revealed that ISS score, length of hospital stay, time to correct shock, PT-T, HCT, ALT, AST, Tbil, concomitant abdominal infection, hemorrhagic shock, septic shock, and sepsis were risk factors for acute liver injury following multiple trauma (P < 0.05). Multivariate logistic regression analysis demonstrated that time to correct shock, concomitant abdominal infection, and sepsis were independent risk factors for acute liver injury in multiple trauma patients. ROC curve analysis showed that the area under the ROC curve (AUC) for predicting acute liver injury in multiple trauma patients was 0.57 (95% CI 0.493~0.648) for time to correct shock, 0.649 (95% CI 0.57~0.729) for abdominal infection, 0.614 (95% CI 0.535~0.692) for sepsis, and 0.732 (95% CI 0.662~0.803) for the combination of these three factors. The combination of the three factors had the highest predictive value for acute liver injury, while time to correct shock had the lowest predictive value. Among the four subgroups of acute liver injury following multiple trauma, significant differences were observed in ISS scores and concomitant sepsis (P < 0.05). High ISS scores were more common in the hepatocellular and cholangiocyte subgroups, while the bilirubin and mixed-type subgroups had a higher incidence of concomitant sepsis. Conclusion: Clinical characteristics of acute liver injury following multiple trauma include longer hospital stays, higher ISS scores, longer time to correct shock, and a higher probability of concomitant abdominal infection and sepsis. Acute liver injury patients with high ISS scores are predominantly of the hepatocellular and cholangiocyte types, while those with sepsis are mainly of the bilirubin and mixed-type liver injury. Independent risk factors for acute liver injury following multiple trauma include time to correct shock, concomitant abdominal infection, and sepsis, with the combination of these three factors having the highest predictive value.