Clinical and Molecular Hepatology (대한간학회지)

The Korean Association for the Study of the Liver (대한간학회)
권호 표지

Clinical outcomes and predictive factors of spontaneous survival in patients with fulminant hepatitis A

전격성 A형간염의 임상양상 및 자발생존에 관한 예측인자

Kim, Jwa-Min;Lee, Yoon-Seon;Lee, Jae-Ho;Kim, Won;Lim, Kyung-Soo
김좌민;이윤선;이재호;김원;임경수

  • Published : 20080000
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Abstract

Backgrounds/Aims: The occurrence of acute hepatitis A is increasing and its progression to fulminant hepatic failure (FHF) is frequent. We investigated the frequency and clinical outcomes of fulminant hepatitis A and also analyzed the predictive factors of spontaneous survival. Methods: A total of 568 patients presented with acute hepatitis A from January 2003 to June 2008, of which the 35 (6.2%) patients with FHF were divided into two groups: spontaneous survival and transplant/death. These two groups were compared according to various clinical features including the MELD score and King’s College Hospital (KCH) criteria. Results: The rate of FHF development increased over time among patients with acute hepatitis A: 0% in 2003, 3.4% in 2004, 3.2% in 2005, 6.0% in 2006, 7.7% in 2007, and 13.0% in 2008. Twenty patients (57.1%) showed spontaneous survival, 13 (37.1%) received liver transplantation, and 5 (14.3%) died during hospitalization. The two groups of spontaneous survival (N=20) and transplant/death (N=15) showed significant differences in prothrombin time at admission and at its worst value, albumin at its worst value, and hepatic encephalopathy grade at admission and at its worst value. The MELD score was lower in the spontaneous-survival group than in the transplant/death group (27.0±7.8 vs. 37.0±7.1, mean±SD; P=0.001). However, KCH criteria did not differ significantly between the two groups. On multivariate analysis, HEP grade was the only significant predictive factor, being negatively correlated with spontaneous survival (OR=0.068, P=0.025). Conclusions: FHF due to hepatitis A has increased in recent years, and in our cohort the HEP grade was closely associated with spontaneous survival. (Korean J Hepatol 2008;14:474-482)

목적: 급성 A형간염은 과거에는 주로 소아기에 불현성 감염으로 지나가는 경우가 대부분이었으며 현성 감염이라 하더라도 치명적인 합병증이 없이 거의 모든 환자에서 완전 회복을 보여 왔다. 그러나 최근 급성 A형간염이 급증하면서 간성뇌증을 동반한 전격성 간부전으로의 진행이 점점 증가하고 있다. 전격성 간부전은 적극적인 내과적 치료에도 불구하고 높은 사망률을 보이며 간이식술만이 생존을 기대할 수 있는 유일한 치료이다. 따라서 저자들은 우리나라에서 최근 변화하는 급성 A형간염의 임상경과에 대해 알아보고, 전격성 간부전 환자들에서 자발생존을 예측할 수 있는 인자를 규명하고자 하였다. 대상과 방법: 2003년 1월부터 2008년 6월까지 울산대학교 의과대학 서울아산병원 응급실에 내원한 급성 A형간염 환자 568명 중 전격성 간부전 35예를 자발생존군과 간이식/사망군으로 나누어 성별, 연령, 간성뇌증 발생까지의 시간, 내원 시와 임상적으로 가장 악화 시의 혈액검사 소견과 간성뇌증의 중증도 등을 후향적으로 비교 분석하였다. 또한 MELD 점수와 KCH 기준에 대해 두 군 간의 차이를 분석하였다. 결과: 568명의 급성 A형간염 환자 중 35명(6.2%)에서 전격성 간부전이 발생하였으며, 빈도는 최근 들어 급증하였다. 전격성 간부전 환자 35명 중 20명(57.1%)이 자발생존을 보였고, 13명(37.1%)이 간이식술을 시행받았으며, 5명(14.3%)이 사망하였다. 전격성 간부전 환자의 평균 나이는 31.4세였고, 남자가 23명이었다. 자발생존군(n=20명)과 간이식/사망군(n=15명)의 단변량 분석에서 내원 시 프로트롬빈 시간(INR)(2.1±0.8 vs. 3.4±1.8; P=0.012), 가장 악화된 시점의 프로트롬빈 시간(INR)(2.2±0.8 vs. 3.7±1.6; P=0.001), 가장 악화된 시점의 혈청 알부민 수치(2.6±0.4 vs. 2.2±0.5 g/dL; P=0.023), 내원 시와 가장 악화된 시점의 간성뇌증의 중증도(P<0.001)가 두 군 간에 의미 있는 차이를 보였다. MELD 점수는 자발생존군이 간이식/사망군에 비해 유의하게 낮았다(27.0±7.8 vs. 37.0±7.1; P=0.001). 그러나 KCH 기준해당은 두 군 간에 유의한 차이가 없었다. 다변량 분석에서는 간성뇌증의 중증도가 유일하게 예후와 독립적 연관이 있었다(OR=0.068; P=0.025). 결론: HAV 감염으로 인한 전격성 간부전으로의 진행이 증가하고 있고, 전격성 A형간염의 경우 간성뇌증의 중증도가 예후와 유의한 독립적 관련을 보였다. 따라서, 치명적 합병증의 높은 발생률과 사망률을 고려할 때, 급성 A형간염 발생 시 좀더 신중한 관찰이 필요하겠고, HAV에 대한 백신 접종이 권장되어야 할 것이다.

Keywords

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