四种评分系统对乙型肝炎相关慢加急性肝衰竭患者短期预后的评估价值

The predictive values of four scoring systems in short-term prognosis of patients with hepatitis B-associated acute-on-chronic liver failure

目的比较MELD、MELD-Na、i MELD及MESO四种评分系统预测乙型肝炎相关慢加急性肝衰竭(ACLF)患者经过人工肝治疗短期预后的价值。方法选取2007年10月-2013年2月于天津市第二人民医院住院的乙型肝炎相关ACLF患者221例,分为存活组(139例)和死亡组(82例),测量并比较2组的TBil、血清肌酐(Cr)、国际标准化比值(INR)、血清钠(Na+)以及MELD、MELD-Na、i MELD、MESO评分值。计量资料两组间比较采用独立样本Mann-Whitney U检验或t检验,多组间比较采用KruskalWaillis H检验;计数资料组间比较采用χ2检验;受试者工作特征曲线下面积(AUC)比较采用正态Z检验。结果死亡组的年龄、TBil、INR、MELD、MELD-Na、i MELD及MESO评分均高于存活组,血清Na+水平低于存活组,差异均有统计学意义(P值均<0.001)。肝衰竭晚期各评分均明显高于中期和早期(P值均<0.001),肝衰竭中期各评分均高于早期(P值均<0.001)。MELD、MELD-Na、i MELD及MESO评分越高,病死率越高。四种评分的最佳临界值分别为37.989、41.291、55.406和2.693。四种评分系统两两比较差异均无统计学意义(P值均>0.05)。结论四种评分系统均能较好地预测乙型肝炎相关ACLF患者经过人工肝联合内科综合治疗后短期临床预后,相比之下,i MELD评分略占优势,但应用时仍应密切结合临床实际情况。

Objective To investigate the predictive values of four scoring systems, the Model for End - Stage Liver Disease （ MEI J） ）, the MELD with incorporation of serum sodium （MELD -Na）, the integrated MELD （iMELD）, and the MELD to serum sodium ratio （ MESO）, in the short -term prognosis of patients with hepatitis B -associated acute -on -chronic liver failure （ACLF） alter artificial liver support therapy. Methods A total of 221 patients with hepatitis B -associated ACLF who were hospitalized from October 2007 to February 2013 were erl- rolled as subjects and divided into survival group （n = 139） and death group （n = 82）. The levels of total bilirubin （TBil）, serum creatirfirle （Cr） , international normalized ratio （INR） , serum sodium （Na ＋ ） , and the scores of MELD, MELD -Na, iMELD, and MESO were determined and compared between the two groups. Comparison of continuous data between two groups was made by the Mann - Whitney I/test or t test; comparison between multiple groups was made by the Kruskal -Wallis H test; comparison of categorical data was made byx2 test; cornparison of area under the receiver operating characteristic curve was made by normal Z test. Results The age, TBil level, INR, and the scores of MELD, MELD - Na, iMELD, and MESO were significantly higher in the death group than in the survival group, while the serum level of Na ＋ was significantly lower in the death group than in the survival group （ P 〈 0. 001 ）. Patients with end - stage liver failure had significantly higher scores than those with early - stage or intermediate - stage liver failure （ P 〈 0.001 ）, while patients with intermediate - stage liver failure had significantly higher scores than those with early - stage liver failure （ P 〈 0.001 ）. The mortality rate increased with increasing scores of MELD, MELD - Na, iMELD, and MESO. The optimal cut - off scores of MELD, MELD - Na, iMELD, and MESO were 37. 989, 41. 291 , 55. 406, and 2. 693, respectively. There were no significant differences between any two scoring systems （P 〉0.05）. Conclusion All four scoring systems can well predict the short - term clinical prognosis in patients with hepatitis B - associated ACLF after artificial liver support therapy combined with comprehensive medical treatment. The iMELD scoring system is slightly superior to the other three scoring systems. However, the application of these scoring systems still needs to be closely associated with actual clinical situations.