终末期肝病模型评分联合吲哚菁绿清除实验预测HBV相关慢加急性肝衰竭预后
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摘要
【目的】探讨终末期肝病模型(MELD)评分联合吲哚菁绿清除实验(ICG)对HBV相关慢加急性肝衰竭(ACLF)短期预后评估。【方法】回顾性分析2017年6月至2017年12月中山大学附属第三院感染科住院收治的HBV相关ACLF患者共138例,临床确诊为HBV相关ACLF,24 h内予吲哚菁绿,记录15 min滞留率(ICGR_(15))及有效肝脏血流量(EHBF)值,同时记录24 h内临床各项指标。建立ICGR_(15) min滞留率转换模型(ICGR_(15)Score),并应用MELD评分联合ICGR_(15)Score,MELD评分、ICGR15滞留率,EHBF及Child-Pugh评分预测入组病例28 d生存率。根据ROC曲线下的面积(AUC)比较各评分系统对HBV相关ACLF预后预测敏感性和特异性,P<0.05差异有统计学意义。【结果】纳入病例存活组与死亡组比较:死亡组患者的年龄大于生存组(P=0.011),同时临床资料比较分析显示:TBi(lP<0.001),DBi(lP<0.001),PT(P<0.001),PTA(P<0.001),CREA(P=0.008),ICGR_(15) Score(P=0.002),MELD评分(P<0.001),CTP分级(P=0.005),EHBF(P=0.014),Meld+ICGR_(15)Score(P<0.001),死亡组肝脏血流量低于存活组,其他指标死亡组均显著高于存活组,差异有统计学意义。各种模型对HBV-ACLF短期预后评估的曲线下面积(AUC)的比较:MELD+ICGR_(15) Score(AUC:0.877),MELD(AUC:0.851),CTP(AUC:0.638),ICGR_(15)(AUC:0.551),EHBF(AUC:0.378),MELD+ICGR_(15)Score的ROC曲线下面积明显大于其他单一模型的ROC曲线下面积。【结论】MELD评分联合ICGR15Score对于HBV相关ACLF短期预后的预测敏感性和特异性优于MELD评分以及其他模型。
【Objective】To assess the value of the model for end-stage liver disease( MELD) score combining with indocyanine green clearance test(ICG) on the short-term prognosis in the patients with HBV-associated acute-on-chronic liver failure(ACLF).【Methods】A retrospective analysis was performed on 138 HBV-associated ACLF patients who were hospitalized in the Department of Infectious Diseases of the Third Affiliated Hospital of Sun Yat-sen University from June2017 to December 2017. ICG was performed within 24 hours of clinical diagnosis of HB V-associated ACLF. The indocyanine green clearance retention at 15 min(ICGR_(15)), the effective hepatic blood flow(EHBF) value and clinical indicators in 24 hours were recorded. After establishing the ICG R_(15) conversion model(ICGR_(15) Score), the 28-day survival rate of the enrolled patients were predicted by ICGR_(15) score combined MELD score, MELD score, ICGR_(15), EHBF and ChildPugh score. The sensitivity and specificity of each scoring system to predict prognosis of HBV associated ACLF were compared according to the area under the ROC curve(AUC). P < 0.05 were considered statistically significant.【Results】Comparison of the survival group and the non-survival group : Non-survival group was older than the survival group(P =0.011). The clinical data showed that TBil(P<0.001), DBil(P <0.001), PT(P<0.001), PTA(P <0.001),CREA(P = 0.008), ICGR_(15) Score(P = 0.002), MELD score(P<0.001), CTP grade(P = 0.005), EHBF(P = 0.014),MELD+ICGR_(15) score(P <0.001). The non-survival group had a lower liver blood flow than the survival group while the other clinical indicators were significantly higher than the survival group and the difference was statistically significant.Comparison of the AUC of different models for HBV-ACLF prognostic evaluation: MELD+ICGR_(15) score(AUC: 0. 877),MELD(AUC: 0.851), CTP(AUC: 0.638), ICCGR_(15)(AUC: 0.551), EHBF(AUC: 0.378). The AUC of MELD + ICGR_(15) score is significantly larger than other single models.【Conclusion】MELD + ICGR_(15) score has higher sensitivity and specificity in predicting the short-term prognosis of HBV-related ACLF than other single models.
【Objective】To assess the value of the model for end-stage liver disease( MELD) score combining with indocyanine green clearance test(ICG) on the short-term prognosis in the patients with HBV-associated acute-on-chronic liver failure(ACLF).【Methods】A retrospective analysis was performed on 138 HBV-associated ACLF patients who were hospitalized in the Department of Infectious Diseases of the Third Affiliated Hospital of Sun Yat-sen University from June2017 to December 2017. ICG was performed within 24 hours of clinical diagnosis of HB V-associated ACLF. The indocyanine green clearance retention at 15 min(ICGR_(15)), the effective hepatic blood flow(EHBF) value and clinical indicators in 24 hours were recorded. After establishing the ICG R_(15) conversion model(ICGR_(15) Score), the 28-day survival rate of the enrolled patients were predicted by ICGR_(15) score combined MELD score, MELD score, ICGR_(15), EHBF and ChildPugh score. The sensitivity and specificity of each scoring system to predict prognosis of HBV associated ACLF were compared according to the area under the ROC curve(AUC). P < 0.05 were considered statistically significant.【Results】Comparison of the survival group and the non-survival group : Non-survival group was older than the survival group(P =0.011). The clinical data showed that TBil(P<0.001), DBil(P <0.001), PT(P<0.001), PTA(P <0.001),CREA(P = 0.008), ICGR_(15) Score(P = 0.002), MELD score(P<0.001), CTP grade(P = 0.005), EHBF(P = 0.014),MELD+ICGR_(15) score(P <0.001). The non-survival group had a lower liver blood flow than the survival group while the other clinical indicators were significantly higher than the survival group and the difference was statistically significant.Comparison of the AUC of different models for HBV-ACLF prognostic evaluation: MELD+ICGR_(15) score(AUC: 0. 877),MELD(AUC: 0.851), CTP(AUC: 0.638), ICCGR_(15)(AUC: 0.551), EHBF(AUC: 0.378). The AUC of MELD + ICGR_(15) score is significantly larger than other single models.【Conclusion】MELD + ICGR_(15) score has higher sensitivity and specificity in predicting the short-term prognosis of HBV-related ACLF than other single models.
引文
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[13]Pugh RN,Murray-Lyon IM,Dawson JL,et al.Transection of the oesophagus for bleeding oesophageal varices[J].Br J Surg,1973,60(9):646-649.
[14]Malinchoc M,Kamath PS,Gordon FD,et al.Amodel to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts[J].Hepatology,2000,31(9):864-871.
[15]Durand F,Valla D.Assessment of the prognosis of cirrhosis:Child-Pugh versus MELD[J].J Hepatol,2005,42(8):S100-107.
[16]Biggins SW,Kim WR,Terrault NA,et al.Evidence-based incorporation of serum sodium concentration into MELD[J].Gastroenterology,2006,130(6):1652-1660.
[17]Mookerjee RP.Prognosis and biomarkers in acuteon-chronic liver failure[J].Sem Liver Dis,2016,36(2):127-135.
[18]Duan B W,Lu S C,Wu J S,et al.Model for EndStage Liver Disease(MELD)score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients[J].Transpl Proc,2014,46(10):3502-3506.
[19]马春华,陈煜,陈成伟,等.吲哚菁绿清除试验对急性、慢加急性肝衰竭患者预后的评价[J].临床肝胆病杂志,2012,28(5):372.375.Ma CH,Cheng Y,Cheng CW,et al.Prognostic value of indocyanine green and liver reserve function in acute and acute-on-chronic liver failure patients[J].J Clin Hepatol,2012,28(5):372-375.
[20]Biggins SW,Kim WR,Terrault NA,et al.Evidence-based incorporation of serum sodium concentration into MELD[J].Gastroenterology,2006,130(6):1652-1660.
[21]Zheng MH,Sift KQ,Fan YC,et al.A model to determine 3-month mortality risk in patients with acute.on--chronic hepatitis B liver failure[J].Clin Gastroenterol Hepatol,2011,9(1):351-356.
[22]Sun QF,Ding JG,Xu DZ,et al.Prediction of the prognosis of patients with acute-on-chronic hepatitis B liver failure using the model for end-stage liver disease scoring system and a novel logistic regression model[J].J Viral Hepat,2009,16(9):464-470.
[2]李兰娟,段钟平.肝衰竭诊治指南(2012年版)[J].中华移植杂志(电子版),2013,7(1):48-56.Li LJ,Duan ZP.Guideline for diagnosis and treatment of liver failure(2012)[J].Chin J Transplant(E Ed),2013,7(1):48-56.
[3]Pugh RN,Murray-Lyon IM,Dawson,et al.Transection of the oesophagus for bleeding oesophage alvarices[J].Br J Surg,1973,60(9):646-649.
[4]Kamath PS,Wiesner RH,Malinchoc M,et al.Amodel to predict survival in patients with end-stage liver disease[J].Hepatology,2001,33(9):464-470.
[5]Caesar J,Shaldon S,Chiandussi L,et al.The use of indocyanine green in the measurement of hepatic blood flow and as a test of hepatic function[J].Clin Sci,1961,21(9):43-57.
[6]Faybik P,Krenn CG,Baker A,et al.Comparison of invasive and noninvasive measurement of plasma disappearance rate of indocyanine green in patients undergoing liver transplantation:a prospective investigator-blinded study[J].Liver Transpl,2004,10(1):1060-1064.
[7]Merle U,Sieg O,Stremmel W,et al.Sensitivity and specificity of plasma disappearance rate of indocyanine green as a prognostic indicator in acute fiver failure[J].BMC Crastroenterol,2009,9(1):91-97.
[8]中华医学会感染病学分会肝衰竭与人工肝学组,中华医学会肝病学分会重型肝病与人工肝学组.肝衰竭诊疗指南(2012年版)[J].中华临床感染病杂志,2012,5(6):321-326.Chinese Society of Infectious Diseases Liver Failure and Artificial Liver Group,Chinese Society of Hepatology Severe Liver Disease and Artificial Liver Group.Guideline for diagnosis and treatment of liver failure(2012)[J].Chin J Clin Infect Dis,2012,5(6):321-326.
[9]Kamath PS,Wiesner RH,Malinchoc M,et al.AModel to predict survival in patients with endstage liver disease[J].Hepatology,2001,33(2):464-470.
[10]叶任高,陆再英.内科学[M].北京:人民卫生出版社,2004:448.Ye RG,Lu ZY.Internal Medicine[M].Beijing:People's Medical Publishing House,2004:448.
[11]刘晓燕,胡锦华,王慧芬,等.1977例急性、亚急性、慢加急性肝衰竭患者的病因与转归分析[J].中华肝脏病杂志,2008,10(9):772-775.Liu XY,Hu M,Wang HF,et al.Etiological analysis of 1977 patients with acute fiver failure,subacute liver failure and acute-on chronic liver failure[J].Chin J Hepatol,2008,10(9):772-775.
[12]Ling Q,Xu X,Wei Q,et al.Downgrading MELDimproves the outcomes after liver transplantation in patients with acute-on-chronic hepatitis B liver failure[J].PLoS One,2012,7:e30322.
[13]Pugh RN,Murray-Lyon IM,Dawson JL,et al.Transection of the oesophagus for bleeding oesophageal varices[J].Br J Surg,1973,60(9):646-649.
[14]Malinchoc M,Kamath PS,Gordon FD,et al.Amodel to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts[J].Hepatology,2000,31(9):864-871.
[15]Durand F,Valla D.Assessment of the prognosis of cirrhosis:Child-Pugh versus MELD[J].J Hepatol,2005,42(8):S100-107.
[16]Biggins SW,Kim WR,Terrault NA,et al.Evidence-based incorporation of serum sodium concentration into MELD[J].Gastroenterology,2006,130(6):1652-1660.
[17]Mookerjee RP.Prognosis and biomarkers in acuteon-chronic liver failure[J].Sem Liver Dis,2016,36(2):127-135.
[18]Duan B W,Lu S C,Wu J S,et al.Model for EndStage Liver Disease(MELD)score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients[J].Transpl Proc,2014,46(10):3502-3506.
[19]马春华,陈煜,陈成伟,等.吲哚菁绿清除试验对急性、慢加急性肝衰竭患者预后的评价[J].临床肝胆病杂志,2012,28(5):372.375.Ma CH,Cheng Y,Cheng CW,et al.Prognostic value of indocyanine green and liver reserve function in acute and acute-on-chronic liver failure patients[J].J Clin Hepatol,2012,28(5):372-375.
[20]Biggins SW,Kim WR,Terrault NA,et al.Evidence-based incorporation of serum sodium concentration into MELD[J].Gastroenterology,2006,130(6):1652-1660.
[21]Zheng MH,Sift KQ,Fan YC,et al.A model to determine 3-month mortality risk in patients with acute.on--chronic hepatitis B liver failure[J].Clin Gastroenterol Hepatol,2011,9(1):351-356.
[22]Sun QF,Ding JG,Xu DZ,et al.Prediction of the prognosis of patients with acute-on-chronic hepatitis B liver failure using the model for end-stage liver disease scoring system and a novel logistic regression model[J].J Viral Hepat,2009,16(9):464-470.