国际标准化比值和终末期肝病模型评分对并发肝性脑病的肝硬化患者短期预后的预测价值
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摘要
目的明确肝硬化患者肝性脑病得到控制后早期(30 d)再入院和中期(6个月)死亡的预测因素,以便于临床早期干预,降低早期再入院率及中期死亡率。方法纳入213例因肝性脑病住院的肝硬化患者,并随访6个月。结果出院时的国际标准化比值(international normalized ratio, INR)水平(比值比为2.40;P值为0.003)可独立预测早期再入院的发生。出院时INR>1.62较INR≤1.62的患者早期再入院风险显著增高(44%vs 20%;χ~2值为14.335,P<0.001)。出院时的终末期肝病模型(model for end-stage liver disease, MELD)评分(比值比为1.11;P值为0.048)可独立预测肝性脑病引起的早期再入院的发生。出院时的血红蛋白水平(比值比为0.97;P值为0.005)是早期再入院发生的保护因素。此外,住院期间使用人工肝(风险比为6.67;P值为0.021)可独立预测中期死亡的发生。结论国际标准化比值可用于识别早期再入院率较高的肝硬化患者,MELD评分可用于预测肝性脑病的早期复发。
Objective To determine the predictors of early readmission(30 d) and mid-term mortality(6 months) in cirrhotic patients discharged after hepatic encephalopathy(HE) is controlled. Methods A total of 213 cirrhotic patients with HE, who were discharged after HE was controlled, were enrolled in the study and followed up for 6 months. The early readmission within 30 d after discharge and the mid-term(in 6 months) mortality of the patients were recorded, and the predictors of the short-term prognosis were analyzed. Results The international normalized ratio(INR) [odds ratio(OR)=2.40, P=0.003] at discharge independently predicted the early readmission of the patients. The incidence of early readmission was significantly higher in patients with an INR>1.62 at discharge than in those with an INR ≤1.62(44% vs 20%, Chi-square=14.335, P<0.001). The model for end-stage liver disease(MELD) score at discharge was an independent predictor of early readmission associated with HE(OR=1.11, P=0.048). Hemoglobin at discharge was an independent predictor of non-early readmission(OR=0.97, P=0.005). The use of an artificial liver during the first hospitalization independently predicted the mid-term mortality of the patients after discharge [hazard ratio(HR)=6.67, P=0.021]. Conclusion For cirrhotic patients with HE, INR can be applied to identify those at a high risk of early readmission, and MELD score is capable of predicting early relapse of HE after discharge.
Objective To determine the predictors of early readmission(30 d) and mid-term mortality(6 months) in cirrhotic patients discharged after hepatic encephalopathy(HE) is controlled. Methods A total of 213 cirrhotic patients with HE, who were discharged after HE was controlled, were enrolled in the study and followed up for 6 months. The early readmission within 30 d after discharge and the mid-term(in 6 months) mortality of the patients were recorded, and the predictors of the short-term prognosis were analyzed. Results The international normalized ratio(INR) [odds ratio(OR)=2.40, P=0.003] at discharge independently predicted the early readmission of the patients. The incidence of early readmission was significantly higher in patients with an INR>1.62 at discharge than in those with an INR ≤1.62(44% vs 20%, Chi-square=14.335, P<0.001). The model for end-stage liver disease(MELD) score at discharge was an independent predictor of early readmission associated with HE(OR=1.11, P=0.048). Hemoglobin at discharge was an independent predictor of non-early readmission(OR=0.97, P=0.005). The use of an artificial liver during the first hospitalization independently predicted the mid-term mortality of the patients after discharge [hazard ratio(HR)=6.67, P=0.021]. Conclusion For cirrhotic patients with HE, INR can be applied to identify those at a high risk of early readmission, and MELD score is capable of predicting early relapse of HE after discharge.
引文
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[15] SHALIMAR,ACHARYA S K.Management in acute liver failure[J].J Clin Exp Hepatol,2015,5:S104-S115.DOI:10.1016/j.jceh.2014.11.005.
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[17] KAMATH P S,KIM W R,Advanced Liver Disease Study Group.The model for end-stage liver disease (MELD)[J].Hepatology,2007,45(3):797-805.DOI:10.1002/hep.21563.
[18] PIANO S,TONON M,VETTORE E,et al.Incidence,predictors and outcomes of acute-on-chronic liver failure in outpatients with cirrhosis[J].J Hepatol,2017,67(6):1177-1184.DOI:10.1016/j.jhep.2017.07.008.
[19] PIANO S,MORANDO F,CARRETTA G,et al.Predictors of early readmission in patients with cirrhosis after the resolution of bacterial infections[J].Am J Gastroenterol,2017,112(10):1575-1583.DOI:10.1038/ajg.2017.253.
[20] ASRANI S K,O’LEARY J G.Acute-on-chronic liver failure[J].Clin Liver Dis,2014,18(3):561-574.DOI:10.1016/j.cld.2014.05.004.
[2] SCAGLIONE S J,METCALFE L,KLIETHERMES S,et al.Early hospital readmissions and mortality in patients with decompensated cirrhosis enrolled in a large national health insurance administrative database[J].J Clin Gastroenterol,2017,51(9):839-844.DOI:10.1097/MCG.0000000000000826.
[3] ELLUL M A,GHOLKAR S A,CROSS T J.Hepatic encephalopathy due to liver cirrhosis[J].BMJ,2015:h4187.DOI:10.1136/bmj.h4187.
[4] GONZALEZ H C,JAFRI S M,GORDON S C.Management of acute hepatotoxicity including medical agents and liver support systems[J].Clin Liver Dis,2017,21(1):163-180.DOI:10.1016/j.cld.2016.08.012.
[5] PRAKASH R K,MULLEN K D.Hepatic encephalopathy[M]//PRAKASH R K,MULLEN K D.eds.Schiff’s diseases of the liver.Oxford:Wiley-Blackwell,2011:421-444.DOI:10.1002/9781119950509.ch18
[6] BA?ARES R,CATALINA M V,VAQUERO J.Molecular adsorbent recirculating system and bioartificial devices for liver failure[J].Clin Liver Dis,2014,18(4):945-956.DOI:10.1016/j.cld.2014.07.011.
[7] FLAMM S L,YANG Y X,SINGH S,et al.American gastroenterological association institute guidelines for the diagnosis and management of acute liver failure[J].Gastroenterology,2017,152(3):644-647.DOI:10.1053/j.gastro.2016.12.026.
[8] VILSTRUP H,AMODIO P,BAJAJ J,et al.Hepatic encephalopathy in chronic liver disease:2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver[J].Hepatology,2014,60(2):715-735.DOI:10.1002/hep.27210.
[9] 汤勃,陈玉琪,赵敏.欧洲肝病协会《酒精性肝病临床实践指南》解读[J].军医进修学院学报,2012,33(9):998-1001.TANG B,CHEN Y Q,ZHAO M.Interpretation of European Association for the Study of the Liver:EASL clinical practical guidelines:management of alcoholic liver disease[J].J Chin PLA Postgrad Med School,2012,33(9):998-1001.
[10] European Association for the Study of the Liver.EASL Clinical Practice Guidelines:Management of hepatocellular carcinoma [J].J Hepatol,2018,69(1):182-236.DOI:10.1016/j.jhep.2018.03.019.
[11] KELLUM J A,LAMEIRE N,ASPELIN P,et al.Kidney disease:improving global outcomes (KDIGO) acute kidney injury work group.KDIGO clinical practice guideline for acute kidney injury [J].Kidney Int Suppl,2012,2(1):89-115.
[12] WLODZIMIROW K A,ESLAMI S,ABU-HANNA A,et al.A systematic review on prognostic indicators of acute on chronic liver failure and their predictive value for mortality[J].Liver Int,2013,33(1):40-52.DOI:10.1111/j.1478-3231.2012.02790.x.
[13] MATEI D,GROZA I,FURNEA B,et al.Predictors ofvariceal or nonvariceal source of upper gastrointestinal bleeding.An etiology predictive score established and validated in a tertiary referral center[J].J Gastrointest Liver Dis,2013,22(4):379-384.
[14] 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.肝衰竭诊治指南(2018年版) [J].临床肝胆病杂志,2019,35(1):38-44.DOI:10.3969/j.issn.1001-5256.2019.01.007.Liver Failure and Artificial Liver Group,Chinese Society of Infectious Diseases,Chinese Medical Association;Severe Liver Disease and Artificial Liver Group,Chinese Society of Hepatology,Chinese Medical Association.Guideline for diagnosis and treatment of liver failure (2018) [J].J Clin Hepatol,2019,35(1):38-44.DOI:10.3969/j.issn.1001-5256.2019.01.007.
[15] SHALIMAR,ACHARYA S K.Management in acute liver failure[J].J Clin Exp Hepatol,2015,5:S104-S115.DOI:10.1016/j.jceh.2014.11.005.
[16] WIESNER R H,MCDIARMID S V,KAMATH P S,et al.MELD and PELD:application of survival models to liver allocation[J].Liver Transpl,2001,7(7):567-580.DOI:10.1053/jlts.2001.25879.
[17] KAMATH P S,KIM W R,Advanced Liver Disease Study Group.The model for end-stage liver disease (MELD)[J].Hepatology,2007,45(3):797-805.DOI:10.1002/hep.21563.
[18] PIANO S,TONON M,VETTORE E,et al.Incidence,predictors and outcomes of acute-on-chronic liver failure in outpatients with cirrhosis[J].J Hepatol,2017,67(6):1177-1184.DOI:10.1016/j.jhep.2017.07.008.
[19] PIANO S,MORANDO F,CARRETTA G,et al.Predictors of early readmission in patients with cirrhosis after the resolution of bacterial infections[J].Am J Gastroenterol,2017,112(10):1575-1583.DOI:10.1038/ajg.2017.253.
[20] ASRANI S K,O’LEARY J G.Acute-on-chronic liver failure[J].Clin Liver Dis,2014,18(3):561-574.DOI:10.1016/j.cld.2014.05.004.