APACHE Ⅳ评分和MELD评分对肝移植术后患者死亡分辨能力研究

Discriminability of acute physiology and chronic health evaluation Ⅳ and model for end-stage liver disease scores on mortality after liver transplantation

目的探讨急性生理学和慢性健康状况(APACHE)Ⅳ评分和终末期肝病模型(MELD)评分对肝移植术后患者住院期间死亡的分辨能力。方法回顾性研究2006年2月至2009年7月在中山大学附属第三医院肝移植中心接受同种异体原位肝移植的195例患者临床资料。其中男171例,女24例;年龄(48±11)岁。所有患者均签署知情同意书,符合医学伦理学规定。收集患者APACHEⅣ评分和MELD评分所需要的参数及住院期间死亡情况,分别计算患者APACHEⅣ评分和MELD评分。绘制两种评分对患者死亡分辨力的受试者工作特征(ROC)曲线,根据ROC曲线下面积(A)判断两种评分对患者住院期间死亡的分辨力,A值<0.5时无分辨力,0.5～0.7时分辨力较低,0.7～0.9时分辨力中等,>0.9时分辨力较高。两种评分的ROC曲线A值比较采用Wilcoxon秩和检验。结果本研究195例患者中住院期间病死率为13.8%(27/195);患者APACHEⅣ评分和MELD评分分别为(41±22)、(18±11)分,其中存活患者的APACHEⅣ评分和MELD评分分别为(36±16)、(17±10)分,死亡患者的APACHEⅣ评分和MELD评分分别为(75±25)、(26±13)分。APACHEⅣ评分对患者住院期间死亡分辨能力的ROC曲线A值为0.937,分辨力较高;MELD评分的ROC曲线A值为0.694,分辨力较低;APACHEⅣ评分的分辨力明显高于MELD评分(Z=3,493,P<0.05)。应用APACHEⅣ评分预测切点为56分,灵敏度0.85,特异度0.91,Youden指数0.76;MELD评分预测切点为20分,灵敏度0.70,特异度0.72,Youden指数0.43。结论与MELD评分比较,APACHEⅣ评分对肝移植术后患者住院期间死亡分辨能力更高,且分辨力的灵敏度和特异度更高。

Objective To explore the discriminability of acute physiology and chronic health evaluation （APACHE） IV and model for end-stage liver disease （MELD） scores on hospital mortality after liver transplantation （LT）. Methods Clinical data of 195 patients [171 males, 24 females, mean age of （48±11） years old] who underwent orthotopic LT from February 2006 to July 2009 in Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sun University were studied retrospectively. The informed consents of all patients were obtained and the ethical committee approval was received. The required parameters for APACHE IV and MELD scores and hospital mortality were collected, and the APACHE IV and MELD scores were calculated. The receiver operating characteristic （ROC） curves of discriminating patients＇ mortality by two scores were drawn. The discriminability of two scores on hospital mortality were judged from the area under ROC curves （A）. The discriminability was invalid when A value was 〈0.5, and was low when 0.5-0.7, moderate when 0.7-0.9, high when 〉0.9. The difference of A value between two scores were compared by Wilcoxon rank sum test. Results The hospital mortality of 195 patients in this study was 13.8% （27/195）. The mean APACHE IV and MELD scores were （42±22）, （18±11） respectively for all the patients. The mean APACHE IV and MELD scores were （36±16）, （17±10） respectively for the survivals, while were （75±25）, （26±13） respectively for the deaths. The A value of APACHE IV score in discriminating hospital mortality was 0.937 with a high discrimination. The A value of MELD score in discriminating hospital mortality was 0.694 with a low discrimination. The discriminability of APACHE IV score was higher than that of MELD score （Z=3,493, P〈0.05）. The predictive cutoff point of APACHE IV score was 56 with the sensitivity 0.85, specificity 0.91 and Youden index 0.76. The predictive cutoff point of MELD score was 20 with the sensitivity 0.70, specificity 0.72 and Youden index 0.43. Conclusions Compared with MELD score, the discriminability of APACHE IV score on hospital mortality after liver transplantation is higher, and the sensitivity and specificity are also higher.