MELD评分对HBV相关肝衰竭患者选择人工肝治疗方式的指导意义

Guiding significance of model for end-stage liver disease score on choosing artificial liver in patients with HBV-related liver failure

摘要:

目的： 探讨终末期肝病模型（model of end-stage liver disease，MELD）评分对乙型肝炎病毒（hepatitis B virus，HBV）相关性肝衰竭患者选择不同人工肝方式，如血浆置换（plasma exchange，PE）、双重血浆分子吸附（double plasma molecular adsorption system，DPMAS）、血浆置换联合双重血浆分子吸附（PE+DPMAS）治疗的指导意义。方法： 回顾性分析210例HBV相关性肝衰竭患者临床资料，将所有患者按照入院时MELD值分成3个区间，即MELD<30、30≤MELD<40和MELD≥40，区间内患者根据人工肝方式不同分为3组：PE组、DPMAS组和PE+DPMAS组，比较不同MELD区间内3组人工肝治疗前后的实验室指标、MELD评分、4周有效率及3个月病死率的变化情况。结果： ①在所有MELD区间，3组患者治疗前后丙氨酸转氨酶（alanine aminotransferase，ALT）、天冬氨酸转氨酶（aspartate transaminase，AST）、总胆红素（total bilirubin，TBIL）、MELD分值明显降低（P<0.05），仅在30≤MELD<40区间，PE+DPMAS组TBIL下降率和MELD下降值最高，存在统计学差异（P<0.01），其余区间组间差异无统计学意义；②所有MELD区间，PE+DPMAS组、PE组凝血酶原活动度（prothrombin activity，PTA）升高，2组间差异无统计学意义；而DPMAS组PTA降低，与PE+DPMAS组、PE组存在统计学差异（P<0.01）；③3组患者治疗前后肌酐（creatinine，Cr）变化不明显，组间差异无统计学意义（P>0.05）；④MELD<30区间，3组之间4周有效率比较无统计学差异（P>0.05），PE组3个月病死率最高，差异有统计学意义（P<0.05）；30≤MELD<40区间，PE+DPMAS组有效率最高（P<0.05），病死率最低（P<0.01），差异有统计学意义（P<0.01）；MELD≥40区间，3组之间有效率及病死率比较，差异均无统计意义（P>0.05）。结论： MELD评分系统可用于指导肝衰竭患者人工肝方式的选择，MELD<30的肝衰竭患者，人工肝方式优先选用DPMAS；30≤MELD<40的肝衰竭患者，选用PE+DPMAS方式疗效更佳，而对于MELD≥40的肝衰竭患者，所有人工肝治疗方式效果均欠佳，应尽早行肝移植术。

Abstract:

Objective: To explore the guiding significance of model for end-stage liver disease (MELD) score in patients with hepatitis B virus (HBV) -related liver failure choosing different ways of artificial liver: plasma exchange (PE), double plasma molecular adsorption system (DPMAS) and PE+DPMAS. Methods: The clinical data of 210 patients with HBV-related liver failure were analyzed retrospectively. All patients were divided into three intervals according to the MELD value at admission: MELD<30, 30≤MELD<40 and MELD≥40.Patients in each interval were divided into three groups according to different ways of artificial liver: the PE group, the DPMAS group and the PE+DPMAS group. Changes of laboratory indexes, MELD score, 4-week effective rate and 12-week mortality rate before and after treatment in three MELD groups were compared. Results: ①In all MELD intervals, the ALT, AST, TBIL and MELD scores in three groups before and after treatment were significantly decreased (P<0.05). Only in the 30≤MELD<40 interval, the decrease rate of TBIL and MELD decrease in the PE+DPMAS group were was the highest, with statistical difference (P<0.01), while there was no significant difference between intergroups in the other two MELD intervals.②In all MELD intervals, the PTA in the PE+DPMAS group and the PE group was increased and the difference between two groups was not statistically significant. PTA in the DPMAS group was decreased, with statistical significance (P<0.01). ③In all MELD intervals, there was no significant change in creatinine (Cr) before and after treatment, with no significant difference among three groups (P>0.05). ④In the MELD<30 interval, the efficiency of 4-week among three groups was not statistically significant (P>0.05), and PE group had the highest mortality at 12 week (P<0.05). In the 30≤MELD<40 interval, the PE+DPMAS group had the highest efficiency (P<0.05) and the lowest case fatality (P<0.01), and the difference was statistically significant; in the MELD≥40 interval, there was no significant difference among three groups in the efficiency and mortality (P>0.05). Conclusion: MELD score can be used for choosing artificial liver in patients with HBV-related liver failure. Patients in MELD<30 interval, prefer to DPMAS, while patients with liver failure in 30≤MELD<40 interval prefer to PE+DPMAS. But for patients in MELD≥40 interval, all artificial liver treatment are poor, therefore, liver transplantation should be performed as soon as possible.