终末期肝病模型对肝硬化腹水患者并发自发性腹膜炎的预测价值

The predictive value of end-stage liver disease model for spontaneous bacterial peritonitis in cirrhotic patients with ascites

目的研究应用终末期肝病模型（model for end—stage liver disease，MELD）对肝硬化腹水患者并发自发性腹膜炎（spontaneous bacterial peritonitis，SBP）的预测价值，为临床早期诊治和预后判定提供依据。方法回顾性分析天津医科大学总医院2003年6月-2006年6月确诊为肝硬化腹水的患者254例，分别对伴SBP患者与不伴SBP患者进行MELD评分并比较，根据MELD分值分为≤9分组、10～19分组、20—29分组和≥30分组，分析各组SBP发生情况。应用受试者工作特征（receiver operating characteristic，ROC）曲线评价MELD对肝硬化腹水患者并发SBP的预测价值。结果65例（26％）患者发生SBP，平均MELD评分为23分；不伴SBP患者189例（74％），平均MELD评分为14分（P〈0．01）。MELD≤9分组与10～19分组间SBP发病率的OR值为1．44（P〉0．05），考虑在MELD≤19分时SBP发病率与MELD评分无关，故将MELD≤9分组和10～19分组合并为MELD≤19分组。SBP发病率在MELD≤19分组、20～29分组和≥30分组分别为12．50％，52．38％和66．67％。MELD／〉30分组与≤19分组的肝硬化腹水患者并发SBP比较，OR值为14（95％CI5．41～36．20）；20～29分组与≤19分组比较，OR值为7．7（95％CI 4．17～14．20）。ROC曲线下面积（AUC）为0．774（95％ CI 0．689～0．855）。结论MELD分值和肝硬化腹水患者SBP发病率线性正相关，高MELD分值提示发生SBP风险增加。

Objective Spontaneous bacterial peritonitis （SBP） is a severe complication in cirrhotics with ascites. Early identification of high-risk patients is crucial for prognostic improvement. We aimed to investigate the predictive value of model for end-stage liver disease（MELD） score at admission in predicting incidence rate of SBP in cirrhotic patients with ascites, so as to evaluate its use in early diagnosis and prognosis of this complication. Methods A retrospective study enrolling 254 consecutive patients with cirrhosis and ascites between June 2003 and June 2006 was carried out. The data collected included the age, sex, etiology of liver disease, serum creatinine, total bihrubin, prothrombin time with international normalized ratio and ascitic fluid analysis of the patients. The patients were graded with MELD formula into 4 groups （ MELD ≤9, 10-19, 20-29, MELD ≥30）. The incidence rate of SBP was compared in the 4 groups according to the MELD score. The predictive accuracy in patients with and without SBP was evaluated with receiver operating characteristic （ROC）curve. Results SBP developed in 65 （26%） patients during hospitalization. The clinical characteristics were similar between the patients with and without SBP. The mean MELD score for patients with SBP was 23 and for those without was 14 （P 〈 0. 01 ）. Patients with 10-19 had an odds ratio of 1.44 （P 〉 0. 05 ）for SBP, as compared with patients with MELD ≥ 9. The frequency of spontaneous bacterial peritonitis was higher in the patients with MELD ≥ 20 than those with MELD ≤ 19. The incidence rate of SBP with MELD ≤ 19, 20-29 and MELD ≥30 were 12. 5%, 52. 38%, and 66. 67% respectively. Patients with MELD ≥ 30 had an odds ratio of 14 （95% CI 5.41-36. 20） for SBP, as compared with patients with MELD ≤ 19. Patients with 20-29 had an odds ratio of 7.7 （ 95% CI 4. 17-14. 20） for SBP, as compared with patients with MELD≤19. Area under curve（AUC） of MELD was 0. 774 （95% CI 0. 689-0. 855 ）. Conclusion The cirrhotic patients with complicating ascites with higher MELD score have a greater risk of SBP. High MELD score might be an useful predictor of SBP in cirrhotic patients with ascites.