MELD联合TBRR预测人工肝治疗慢加急性肝衰竭短期预后的临床意义

Clinical significance of model for end-stage liver disease combined with total bilirubin rebound rate in predicting short-term prognosis of acute-on-chronic liver failure treated with artificial liver

摘要:

目的： 探讨经人工肝治疗的乙型肝炎病毒相关慢加急性肝衰竭（hepatitis B virus related acute-on-chronic liver failure，HBV-ACLF）患者的短期预后危险因素并建立预后评估模型。方法： 利用终末期肝病模型（model for end-stage liver disease，MELD）评分联合总胆红素反弹率（total bilirubin rebound rate，TBRR）建立HBV-ACLF患者90 d预后评估模型。回顾性收集西南医科大学附属医院114名HBV-ACLF患者人工肝治疗前后的相关实验室指标，根据入院90 d的结局分为存活组和死亡组，通过单因素分析、二元logistic回归分析等方法检验HBV-ACLF患者短期死亡的危险因素，建立预测模型并绘制ROC曲线比较预测价值。结果： 死亡组总胆红素（total bilirubin，TBil）、肌酐（creatinine，Crea）、凝血酶原时间（prothrombin time，PT）、国际标准化比值（international normalized ratio，INR）、TBRR、总胆红素留存率（total bilirubin actual resident rate，TBARR）、驻MELD、MELD及肝功能分级（Child-Turcotte-Pugh，CTP）高于存活组，凝血酶原活动度（prothrombin activity，PTA）低于存活组（P<0.05）；组间总胆红素清除率（total bilirubin clearance rate，TBCR）差异不具有统计学意义（P=0.852）。多因素回归分析发现，TBRR、MELD及CTP是HBV-ACLF患者90 d死亡的独立危险因素，建立MELD、MELD-TBRR及MELD-TBRR-CTP 3个预后预测模型，其AUC分别为0.786、0.875和0.897，敏感性和特异性分别为58.33%和88.46%、86.11%和70.51%、86.11%和79.49%。MELD-TBRR与MELD-TBRR-CTP两者间ROC曲线下面积（the area under the receiver operating characteristic curve，AUC）差异无统计学意义（P=0.200）。结论： TBRR、MELD及CTP是经人工肝治疗的HBV-ACLF患者短期死亡的独立危险因素，MELD评分联合TBRR对HBV-ACLF患者人工肝治疗后的短期预后有较好的预测价值。

Abstract:

Objective: To investigate the short-term prognostic risk factors of patients with hepatitis B virus related acute-on-chronic liver failure (HBV-ACLF) treated with artificial liver and to establish a prognostic evaluation model. Methods: The model for end stage liver disease (MELD) combined with total bilirubin rebound rate (TBRR) was used to establish a 90-day prognostic model for HBV-ACLF patients. The relevant laboratory indexes of 114 patients with HBV-ACLF before and after artificial liver treatment in our hospital were retrospectively analyzed. According to the outcome of 90 days after admission, they were divided into the survival group and the death group. The risk factors of patients’short-term death were tested by univariate analysis, binary logistic regression analysis and other methods, the predictive model was establish, and the ROC curve was drawn to compare the predictive value. Results: Total bilirubin (TBil), creatinine (Crea), prothrombin time (PT), international normalized ratio (INR), TBRR, total bilirubin actual resident rate (TBARR), MELD, MELD and Child-Turcotte-Pugh (CTP) in the death group were higher than those in the survival group, while prothrombin activity (PTA) was lower than those in the survival group (P<0.05). There was no significant difference in total bilirubin clearance rate (TBCR) between groups (P=0.852). Binary logistic regression analysis revealed that TBRR, MELD and CTP were independent risk factors for 90-day mortality in patients with HBV-ACLF. Three prognostic prediction models of MELD, MELD-TBRR and MELD-TBRR-CTP were established, with the area under the receiver operating characteristic curve (AUC) of 0.786, 0.875 and 0.897, sensitivity of 58.33%, 88.46%, and 86.11%, and specificity of 70.51%, 86.11%and 79.49%, respectively. There was no significant difference in AUC between MELD-TBRR and MELD-TBRR-CTP (P=0.200). Conclusion: TBRR, MELD and CTP are independent risk factors for short-term mortality of patients with HBV-ACLF treated with artificial liver, and MELD combined with TBRR has a good predictive value for short-term prognosis of HBV-ACLF after artificial liver treatment.