应用MELD与CTP评分预估乙型肝炎患者肝移植后早期临床结果的比较分析

A Correlation between the pretransplantation MELD score/CTP score and clinical results in the early stage after liver transplantation in chronic hepatitis B

目的探讨术前终末期肝病模型（MELD）评分和Child-Turcotte-Pugh（CTP）评分预估乙型肝炎患者肝移植后早期临床结果的价值。方法以31例接受首次肝移植、原发病为慢性乙型肝炎、肝硬化的患者为对象，术前对其进行MELD评分和CTP评分，并计算术前1个月和术前即时MELD评分的差值（△MELD）。均采用背驮式肝移植术式。观察患者的术中情况，统计受者术后6个月存活率以及各类并发症的发生率，分析3种评分与它们的相关关系。结果31例中，MELD评分〈25分者21例，≥25分者10例；△MELD值〈5分者23例，≥5分者8例；术前CTP评分为A级者5例，B级者5例，C级者21例。术前MELD评分〈25分者和≥25分者的6个月存活率分别为85．7％和50．0％（P〈0．05）；△MELD值〈5分者和≥5分者的6个月存活率分别为91．3％和25．0％（P〈0．01）；CTP分组中，A、B、C级间6个月存活率的差异无统计学意义。MELD评分％25分者和△MELD值〈5分者的手术耗时明显短于评分较高者（P〈0．05，P〈0．01），其术中少浆血的需要量也显著减少（P〈0．01）；在术中大出血和低血压的发生率上，△MELD值〈5分者明显低于≥5分者（P〈0．01；P〈0．05）。术前MELD评分〈25分者术后败血症和腹腔感染发生率明显低于≥25分者（P〈0．05，P％0．05）；△MELD值〈5分者术后急性。肾功能衰竭、胆漏、败血症和腹腔感染发生率明显低于≥5分者（P〈0．05，P〈0．05，P〈0．01，P％0．01）。经多因素回归分析，仅有△MELD值与受者术后存活率呈负相关。结论术前MELD评分能较好地预测慢性乙型肝炎患者肝移植术后的早期临床结果；术前MELD评分≥25分和△MELD≥5分，患者肝移植后的存活率低，并发症的发生率较高，预后较差。

Objective To evaluate the prediction of MELD system and Child-Turcotte-Pugh （CTP） grades for survival rate of early stage after liver transplantation in chronic hepatitis B （CHB）, and to explore the therapeutic window of liver transplantation for CHB. Methods The clinical data of 31 patients who had been subjected to transplantation from December 2004 to September 2006 were retrospectively analyzed. We compared the outcome in the 6 month after liver transplantation according to the pretransplantation MELD score, AMELD of one month pretransplantation and CTP grades. Results Patients were stratified according to pretransplantation MELD score less than 25 and higher. Posttransplantation 6-month survival rate was 85.7% and 50% in each group, significantly lower in the groups with a higher AMELD score （P〈0. 05）. If patients were stratified according to △MELD less than 5 and higher, the survival rate was significantly lower in the groups with a higher △MELD score （P〈0. 01）. While patients were stratified according to the subgroups of CTP--CTP-A, CTPB, CTP-C, the difference in the survival rate was not significant. The area under curve （AUC） for MELD, AMELD and CTP as a predictor of 6-month mortality after transplantation was 0. 740, 0. 842 and 0. 656, respectively. There were longer operation time, longer intensive care unit hospitalization time, and more quantity of blood transfusion during operation in group with MELD≥ 25 （P〈0. 05）. The incidence of septicemia and intra with MELDS25. There were longer operation time, operation in group with △MELD≥5 （P〈0.05）. The incidence of septicemia, acute renal failure and intra-abdominal infection was also significantly higher in group with △MELD≥5 （P〈0. 05）. Muliple factor analysis suggested △MELD was the only significant factor. Conclusion Pretransplantation MELD score correlates with survival in the 6 month after liver transplantation in CHB, while CTP score less correlates. The initial level of hepatopathy as well as the development of the disease correlates with survival after transplantation. Patients with pretransplantation MELD score higher than 25 or △MELD higher than 5 get poor prognosis after liver transplantation.