5种终末期肝病模型判断原发性肝癌患者预后的比较

Comparison of five models for end-stage liver disease to predict the prognosis of patients with primary hepatic cancer

目的评价终末期肝病模型(MELD)及其联合血清钠相关模型判断原发性肝癌(PHC)患者预后的能力,包括终末期肝病血清钠模型(MELD-Na)、终末期肝病血清钠腹水模型(MELD-AS)、终末期肝病血清钠年龄模型(iMELD)和终末期肝病血清钠值比模型(MESO)。方法回顾性分析300例PHC患者资料。采用受试者工作特征曲线及曲线下面积(AUC)评价5种模型判断患者预后的能力;不同患者生存率的差异采用Kaplan-Meier方法的Log-rank检验进行计算。结果判断患者3、12个月的预后,MELD-AS的AUC最大(0.793和0.639),与其余各模型的AUC差异均有统计学意义;MELD、MELD-Na、MELD-AS、iMELD、MESO的最佳截值点分别为5.0、5.0、6.0、21.0和0.4,以此截值点对患者进行分组,各模型高低分值组间患者的生存率均有显著性差异(P<0.001)。结论 5种终末期肝病模型均可作为判断原发性肝癌患者预后的指标,以MELD-AS判断患者中短期预后能力最佳。

Objective To investigate the prognostic accuracy of the model for end-stage liver disease（MELD） and four new MELD-based models combination with serum sodium in primary hepatic cancer（PHC） patients-the MELD with the incorporation of serum sodium（MELD-Na）, incorporating MELD,persistent ascites and low serum sodium（MELD-AS）,the integrated MELD including serum sodium and age（iMELD）,and the MELD to sodium index（MESO）.Methods A total of 300 patients with PHC were enrolled into the study.MELD,MELD-Na,MELD-AS, iMELD and MESO scores were calculated for each patient following the original formula on the first day of admission.All patients were followed up at least 1 year.The predictive prognosis related with the five models was determined by the area under the receiver operating characteristic curve（AUC）.Kaplan-Meier survival curves were made using the cut-offs identified by means of receiver operating characteristic（ROC）.Results The MELD-AS had the highest AUC（0.793） 3 months after the enrollment,and was followed by the MELD（0.742）,MELD-Na（0.741）,iMELD （0.729） and MESO（0.727）.The difference between the MELD-AS score and each of the other MELD scores was statistically significant（all P0.04）;12 month after enrollment,the MELD-AS had the highest AUC（0.639）,and was followed by the iMELD（0.615）,MELD-Na（0.613）,MELD （0.608） and MESO（0.604）.The difference between the MELD-AS score and each of the other MELD scores was statistically significant except for iMELD（P=0.357）.The most discriminative cut-offs from the ROC with the z-statistic for MELD,MELD-Na,MELD-AS,iMELD and MESO were 5.0,5.0,6.0,21.0 and 0.4 at 3 month of enrollment.Survival curves showed that the MELD and four new MELD-based models were all clearly discriminated the patients who survived or died in short-term as well as intermediate-term（P0.001） according to these cut-offs.Conclusion MELD and four new MELD-based models,changed with serum sodium（MELD-Na,MELDAS, iMELD and MESO）,can exactly predict the prognosis of patients with PHC in short and intermediate period.The MELD-AS may be the best prognostic model for outcome prediction in patients with PHC of the five MELD-based models.