BioCliM指数对食管胃底静脉曲张出血内镜下治疗后1年和2年预后的预测价值

Predictive value of BioCiiM index on one-year and two-year prognosis in esophageal and gastric varices bleeding treated by endoscopic therapies

目的 评估BioCliM指数对肝硬化食管胃底静脉曲张出血（EGVB）患者内镜下套扎术（EVL）、内镜下硬化剂注射术（EIS）和内镜下组织黏合剂（ETA）注射治疗后的生存预测价值.方法 回顾性分析2006年12月至2011年12月因首次发生EGVB并行内镜下治疗的166例肝硬化住院患者的临床资料,计算其入院时的终末期肝病模型（MELD）、终末期肝病血清钠模型（MELD-Na）、BioCliM指数和Child-Turcotte-Pugh（CTP）评分.运用ROC曲线和AUC值评价此4种评分系统对患者内镜下治疗后1年和2年预后判断的准确性,获取最佳临界值,并比较组间的病死率.运用卡方检验、t检验和秩和检验进行统计学分析.结果 166例患者中,血肌酐、胆红素、白蛋白、血钠、国际标准化比值和PT水平分别为（0.10 ± 0.06）mmol/L、（0.02 ± 0.01）mmol/L、（30.13 ± 5.06）g/L、（139.13 ± 4.27）mmol/L、1.50 ± 0.32、（17.83 ± 2.88）s.随访1年和2年,分别有14例和23例患者死亡.随访1年和2年时,死亡组门静脉血栓患者比例均低于生存组[分别为10/14比93.4%（142/152）,73.9%（17/23）比94.4%（135/143）],差异均有统计学意义（χ^2 = 8.029、10.774,P均〈 0.01）.随访1年和2年时,死亡组BioCliM指数分别为0.12（-0.82,1.44）和-0.81（-0.87,0.92）,均分别高于生存组的 -0.84（-0.94,-0.73）和-0.84（-0.94,-0.72）,差异均有统计学意义（Z= -3.074,-2.260,P均〈0.05）.随访1年时,MELD、MELD-Na、BioCliM指数和CTP评分评估预后的AUC值分别为0.698、0.691、0.749和0.723.随访2年时,MELD、MELD-Na、BioCliM指数和CTP评分评估预后的AUC值分别为0.587、0.582、0.647和0.633.BioCliM 指数对随访1年和2年预后评估的AUC值与 MELD、MELD-Na和CTP评分相比,差异均无统计学意义（Z=0.509、0.566、0.271和0.687、0.731、0.162,P均〉 0.05）.BioCliM指数的最佳临界值为-0.234,随访1年和2年,BioCliM指数≥-0.234的病死率均高于BioCliM指数〈 -0.234时[（31.0%（9/29）比3.6%（5/137）,34.5%（10/29）比9.5%（13/137）],差异均有统计学意义（χ^2 =23.242、12.526,P均〈0.01）.结论 BioCliM指数对肝硬化EGVB患者行内镜下治疗后1年和2年病死的判断有较高的准确性,临床需重视内镜下治疗前的预后评估.

Objective To assess the predictive value for survival of BioCliM index in liver cirrhosis caused esophageal and gastric varices bleeding（EGVB）treated by endoscopic variceal ligation（EVL）,endoscopic injection sclerotherapy（EIS）and endoscopic tissue adhesives（ETA）.Methods From December 2006 to December 2011, the clinical data of 166 hospitalized patients with first occurrence of EGVB caused by liver cirrhosis and received endoscopic therapies were retrospectively analyzed.The scores of model for end-stage liver disease（MELD）,model for end-stage liver disease-Na（MELD-Na）,BioCliM index and Child-Turcotte-Pugh（CTP）were calculated. Receiver operating characteristic（ROC）curve and area under the curve（AUC）were applied to assess the accuracy of the four models in one-year and two-year prognosis evaluation,and to obtain the best critical value,and the mortality rates were compared among groups.Chi-square test,t test and rank-sum test were performed for statistical analysis.Results Among 166 patients,the levels of creatinine,bilirubin,albumin,sodium,international normalized ratio and prothrombin time were（0.10 ± 0.06）mmol/L,（0.02 ± 0.01）mmol/L,（30.13 ± 5.06）g/L, （139.13 ± 4.27）mmol/L,1.50 ± 0.32 and（17.83 ± 2.88）s,respectively.During the one-year and two-year follow-up,there were 14 patients and 23 patients dead,respectively.During the one-year and two-year follow-up, the incidences of portal thrombosis of death group were lower than those of survival group（10/14 vs 93.4%,142/152;73.9%,17/23 vs 94.4%,135/143）;and the differences were statistically significant（χ^2=8.029 and 10.774, both P〈0.01）.During the one-year and two-year follow-up,BioCliM indexes of death group were 0.12（-0.82, 1.44）and-0.81（-0.87,0.92）,respectively,which were both higher than those of survival group（-0.84,-0.94 to-0.73;and-0.84,-0.94 to-0.72）,and the differences were statistically significant（Z=-3.074 and-2.260,both P〈0.05）.During the one-year follow-up,the AUC values of MELD,MELD-Na,BioCliM index and CTP score were 0.698,0.691,0.749 and 0.723,respectively.During the two-year follow-up,the AUC values of MELD,MELD-Na,BioCliM index and CTP score were 0.587,0.582,0.647 and 0.633,respectively. But there was no statistically significant difference in AUC between BioCliM index and MELD,MELD-Na,and CTP score in one-year and two-year follow-up for prognosis evaluation（Z=0.509,0.566,0.271,0.687,0.731 and 0.162,respectively;all P〉0.05）.The best critical value of BioCliM index was-0.234.Followed up for one year and two years,the mortality rates of patients with BioCliM index over-0.230 were higher than that of patients with BioCliM index less than-0.234（31.0%,9/29 vs 3.6%,5/137;34.5%,10/29 vs 9.5%,13/137）;and the differences were statistically significant（χ^2=23.242 and 12.526,both P〈0.01）.Conclusions BioCliM index has a high accuracy in one-year and two-year mortality rate evaluation in liver cirrhosis patients with EGVB and received endoscopical therapies.We should pay attention to the prognosis evaluation before the endoscopical therapy.