终末期肝病模型评分与Child-Turcotte-Pugh分级对非生物型人工肝治疗乙型肝炎相关性肝衰竭患者预测价值的研究

Prognostic value of hepatitis B-related liver failure patients treated with non-biotype artificial liver by model for end-stage liver disease and Child-Turcotte-Pugh score systems

目的应用终末期肝病模型(MELD)评分和Child-Turcotte-Pugh(CTP)分级系统评估和预测非生物型人工肝支持系统(NB-ALSS)治疗乙型肝炎相关性肝衰竭患者疗效和预后的临床价值。方法将210例乙型肝炎相关性肝衰竭患者分为人工肝组(115例)和对照组(95例),并进行MELD和CTP评分。根据评分将每组进一步分成MELD<20分、20分≤MELD<30分、30分≤MELD<40分和MELD>40分四个亚组。观察两组患者治疗前后各亚组MELD分值的变化和人工肝组患者治疗前后临床生化指标的变化,并对各亚组实际病死率与预期病死率及不同CTP评分分级进行比较。同时,绘制Kaplan-Meier生存曲线,分析比较不同MELD评分的短期生存率和病死率。结果人工肝治疗后各亚组患者的临床生化指标中凝血酶原时间国际标准化比值(INR)[(1.3±0.3)vs.(1.4±0.3);(2.2±0.8)vs.(2.6±0.8);(4.1±1.5)vs.(5.2±1.7);(9.6±2.8)vs.(12.2±4.8),t=4.303、3.152、3.545、3.130,P均<0.05]和总胆红素(TBIL)水平[(152±74)μmol/L vs.(287±118)μmol/L;(266±160)μmol/L vs.(422±114)μmol/L;(370±144)μmol/L vs.(517±126)μmol/L;(564±180)μmol/L vs.(628±121)μmol/L,t=4.960、5.951、4.915、2.577,P均<0.05]均低于治疗前。人工肝治疗后MELD分值除MELD≥40分组外,其他三组较治疗前均显著下降[(10.2±3.4)分vs.(16.6±2.5)分;(18.2±4.2)分vs.(24.7±2.6)分;(30.1±7.5)分vs.(36.2±2.3)分,t=7.036、9.094、5.476,P均<0.05],并且此三组的人工肝组与对照组治疗前后MELD下降分值(△MELD)的比较,差异均有统计学意义(t=2.286、2.906、2.021,P均<0.05)。20分≤MELD<30分及30分≤MELD<40分,人工肝组病死率低于预期病死率(40.8%vs.76.0%、51.4%vs.83.0%,χ2=12.119、8.880,P均<0.05),且均低于对照组病死率(40.8%vs.61.9%、51.4%vs.82.4%,χ2=4.030、4.710,P均<0.05);20分≤MELD<30分及30分≤MELD<40分,CTP C级人工肝组患者病死率均低于对照组(38.8%vs.59.6%、51.4%vs.76.5%,χ2=3.900、4.400,P均<0.05)。同时,Kaplan-Meier生存曲线显示,20分≤MELD<30分及30分≤MELD<40分的人工肝组患者短期生存率均高于对照组(χ2=3.890、5.700,P均<0.05)。结论在MELD评分系统基础上引入CTP分级可指导NB-ALSS治疗乙型肝炎相关性肝衰竭患者的预后评判。

Objective To assess and predict the effect and the clinical prognostic value of non-biotype artificial liver support system（NB-ALSS） in hepatitis B-related liver failure patients by model for end-stage liver disease（MELD） and Child-Turcotte-Pugh（CTP） score systems.Methods The randomly selected 210 cases of hepatitis B-related liver failure patients were divided into the artificial liver group（n = 115） and control group（n = 95）, based on MELD and CTP scores.Each group were further divided into four subgroups： MELD 20, 20 ≤ MELD〈 30, 30 ≤ MELD〉 40, and MELD 40. The changes of MELD score between these two groups and of the laboratory parameters in the artificial liver group before and after the treatment were observed, and actual short-term mortality rate with expected mortality according to CTP score system were compared.Results After the artificial liver treatment, prothrombin time international normalized ratio（INR）decreased significantly in four artificial liver subgroups [（1.3 ± 0.3） vs.（1.4 ± 0.3）;（2.2 ± 0.8） vs.（2.6 ±0.8）;（4.1 ± 1.5） vs.（5.2 ± 1.7）;（9.6 ± 2.8） vs.（12.2 ± 4.8）; t = 4.303, 3.152, 3.545, 3.130; all P〈0.05], total bilirubin（TBIL） also showed significant improvement in these artificial liver groups after the treatment [（152 ± 74） μmol / L vs.（287 ± 118） μmol / L;（266 ± 160） μmol / L vs.（422 ± 114） μmol / L;（370 ± 144） μmol / L vs.（517 ± 126） μmol / L;（564 ± 180） μmol / L vs.（628 ± 121） μmol / L; t = 4.960,5.951, 4.915, 2.577; all P〈0.05]. Except the MELD ≥ 40 subgroup, MELD scores in the other three artificial liver subgroups were markedly dropped after the treatment [（10.2 ± 3.4） vs.（16.6 ±2.5）;（18.2 ± 4.2） vs.（24.7 ± 2.6）;（30.1 ± 7.5） vs.（36.2 ± 2.3）; t = 7.036, 9.094, 5.476; all P〈0.05],MELD score decreased（△MELD） between the artificial liver groups and control groups were statistically significant in these three subgroups（t = 2.286, 2.906, 2.021; all P〈0.05）. In the 20 ≤MELD 〈30 and 30 ≤ MELD〈 40 subgroups, the mortality rates of the artificial liver groups were lower than expected mortality rates（40.8% vs. 76.0%, 51.4% vs. 83.0%; χ^2= 12.119, 8.880;all P〈0.05）, and also lower than that of the control groups（40.8% vs. 61.9%, 51.4% vs. 82.4%; χ^2=4.03, 4.71; all P〈0.05）. Comparing the mortality rates between the artificial liver groups and control groups in the CTP C level： in the 20 ≤ MELD 30 and 30 ≤ MELD 40 subgroups, the mortality rates of two sets were significantly different（38.8% vs. 59.6%, 51.4% vs. 76.5%; χ^2= 3.90,4.40; all P〈0.05）. Kaplan-Meier survival curves showed that in the 20 ≤ MELD〈 30 and 30 ≤MELD〈 40 subgroups, the short-term survival rates in the artificial liver groups was higher than that in the control groups（ χ^2= 3.89, 5.70; all P〈0.05）. Conclusion Combined MELD score and CTP classification system can assess the prognosis of NB-ALSS in treatment of hepatitis B-related liver failure patients.