终末期肝病模型动态评分评估HBV相关肝衰竭预后的价值

Value of delta model for end-stage liver disease in evaluating the prognosis of liver failure patients with hepatitis B virus

目的评估终末期肝病模型（MELD）评分及其变化率（△MELD）在预测HBV相关肝衰竭患者预后的价值。方法采用前瞻性研究，选取HBV相关肝衰竭患者98例，随访24周，收集相关临床资料，计算MELD、△MELD分值。比较不同时间点存活与死亡患者MELD及△MELD分值，应用ROC曲线下面积比较MELD及△MELD预测预后的准确性，以最佳临界值分组，比较不同组别不同时间点的病死率；绘制Kaplan-Meier生存曲线，运用生存分析方法比较各组生存率变化。结果98例患者24周内死亡52例，存活46例，死亡组与存活组间MELD、△MELD分值的差异有统计学意义（P〈0．01）；MELDI〉23组8、12、24周病死率均明显高于MELD〈23组，△MELD〉4．5组病死率也高于△MELD〈4．5组，差异有统计学意义（P〈0．001）；判断患者12、24周预后△MELD的AUC（0．823、0．815）明显大于MELD的AUC（0．680、0．684）（P〈0．05）；生存分析显示以最佳临界值分组，各组间累积存活率的差异有统计学意义（P=0．000）。结论终末期肝病模型评分系统适用于我国HBV相关肝衰竭患者预后的预测；△MELD评估预后的准确性要高于初始MELD，有着重要的临床应用价值。

Objective To evaluate the prognostic value of the model for end-stage liver disease （MELD） and △MELD in liver failure patients infected with hepatitis B virus. Methods Based on prospective study design,98 hospitalized cases were studied and followed up for 24 weeks. The clinical data were recorded. We calculated the score of MELD and △MELD, and also compare the score between the survival group and death group. Using ROC curve plotting obtained the better decisive threshold. The case fatality rate were compared at different time points which the patients were classified by the best critical value of MELD and △MELD. We draw the Kaplan-Meier survival curve of different group and analyse the change of survival rate by log-rank analysis. Results 52 of 97 patients died and 46 survive during 24 weeks of followup. There was significant difference between the two groups for MELD and △MELD （ P 〈 0. 01 ）. The case fatality rate in group which MELD t〉 23 was obviously higher than in that MELD 〈 23. The rate in group which △MELD 〉 4.5 was obviously higher than in that △MELD 〈 4.5 （ P 〈 0. 001 ）. The area under curve （AUC） for the twelfth and 24th week＇ s prognosis judgment of △MELD （0. 823,0. 815 ） was larger than that of MELD （ 0. 680, 0. 684） （ P 〈 0. 05 ）. Survival analyses （Kaplan-Meier） indicated that there were significant differences in cumulative survival rates among the groups which were grouped by optimization critical value （P = O. 000）. Conclusions The scoring system of MELD also applied to the forecasting of prognosis for severe hepatitis B patients in China. The accuracy of △MELD to predict the prognosis was higher than that of MELD. The combination of MELD and △MELD showed good clinical practical value.