HBV相关慢加急性肝衰竭短期预后模型的建立及评价

Establishment and evaluation of short-term prognostic model for hepatitis B virus-related acute-on-chronic liver failure

目的建立一个新型的HBV相关慢加急性肝衰竭(HBV-ACLF)短期预后预测模型:MACLF,并评价MACLF评分对HBV-ACLF患者短期预后的预测价值。方法采用回顾性队列研究分析2015年1月-2018年11月南昌大学第一附属医院收治的270例HBV-ACLF患者的临床资料,根据3个月的病情随访情况分为生存组(n=153)和死亡组(n=117),对影响HBV-ACLF患者短期预后的相关因素进行分析。计数资料2组间比较采用卡方检验,计量资料2组间比较分别采用Mann-Whitney U检验,采用二元logistic回归分析进行多因素分析,多因素分析有意义的指标再次进行二元logistic回归分析并建立模型。绘制受试者工作特征曲线(ROC曲线)评价MACLF评分对HBV-ACLF患者短期预后的预测价值。结果单因素分析结果显示:游离三碘甲状腺原氨酸(FT3)、促甲状腺激素(TSH)、国际标准化比值(INR)、中性粒细胞/淋巴细胞比值(NLR)、PLT、ALT、AST/ALT、TBil、Alb、肌酐(Cr)、总胆固醇(TC)、甘油三酯(TG)、钠(Na)、AFP、血清铁蛋白(SF)、Child-Tuncotte-Pugh(CTP)评分、MELD评分及并发症(肝性脑病、肝肾综合征、自发性腹膜炎、消化道出血、肺部感染)在生存组与死亡组之间差异均有统计学意义(P值均<0.05)。多因素分析的结果显示:TBil(OR=1.007,P=0.001)、INR(OR=5.750,P <0.001)、FT3(OR=0.084,P=0.003)、PLT(OR=0.987,P=0.022)、肝肾综合征(OR=7.146,P=0.045)及肺部感染(OR=3.816,P=0.023)均是影响HBV-ACLF患者短期预后的独立因素;由此为HBV-ACLF患者的短期预后创建新模型(MACLF):Logit(P)=0.007×[TBil(umol/L)]+2.181×INR-2.762×[FT3(pg/ml)]-0.014×[PLT(×10^9/L)]+1.797×[肝肾综合征(有:1;无:0)]+1.339×[肺部感染(有:1;无:0)]-2.291。ROC曲线分析结果显示,MACLF评分的ROC曲线下面积(0.934)、Youden指数(0.774)均明显高于CTP、MELD、MELD-Na评分(ROC曲线下面积分别为0.791、0.884、0.893,Youden指数分别为0.433、0.654、0.715)。结论创建的MACLF新模型对HBV-ACLF患者3个月的短期预后具有良好的预测价值。

Objective To establish a new prognostic model,MACLF,for predicting the short-term prognosis of hepatitis B virus-associated acute-on-chronic liver failure(HBV-ACLF),and to investigate its value in predicting the short-term prognosis of HBV-ACLF.Methods A retrospective cohort study was performed for the clinical data of 270 patients with HBV-ACLF who were admitted to The First Affiliated Hospital of Nanchang University from January 2015 to November 2018.The patients were divided into survival group with 153 patients and death group with 117 patients according to their conditions after 3 months of treatment,and influencing factors for the short-term prognosis of HBV-ACLF were analyzed.The chi-square test was used for comparison of categorical data between two groups,A binary logistic regression analysis was performed for statistically significant indices determined by multivariate analysis and a model was established.and the Mann-Whitney U test was used for comparison of continuous data between two groups.A binary logistic regression analysis was used for multivariate analysis,a binary logistic regression analysis was performed for statistically significant indices determined by multivariate analysis and a model was established,and the receiver operating characteristic(ROC) curve was plotted to evaluate the value of MACLF in predicting the short-term prognosis of HBV-ACLF.Results The univariate analysis showed that there were significant differences between the survival group and the death group in free triiodothyronine(FT3),thyroid stimulating hormone,international normalized ratio,neutrophil-lymphocyte ratio(NLR),platelet count(PLT),alanine aminotransferase,aspartate aminotransferase-alanine aminotransferase ratio,total bilirubin(TBil),albumin,creatinine,total cholesterol,triglyceride,sodium,alpha-fetoprotein,serum ferritin,Child -Turcotte-Pugh(CTP) class,Model for End-Stage Liver Disease(MELD) score,and complications(hepatic encephalopathy,hepatorenal syndrome,spontaneous peritonitis,gastrointestinal bleeding,and pulmonary infection)(all P < 0.05).The multivariate analysis showed that TBil(odds ratio [OR]= 1.007,P = 0.001),INR(OR = 5.750,P < 0.001),FT3(OR = 0.084,P = 0.003),PLT(OR =0.987,P = 0.022),hepatorenal syndrome(OR = 7.146,P = 0.045),and pulmonary infection(OR = 3.816,P = 0.023) were independent influencing factors for the short-term prognosis of HBV-ACLF.Therefore,a new model of MACLF was established for the short-term prognosis of HBV-ACLF: Logit(P)= 0.007 ×[TBil(umol/L)]+ 2.181 × INR-2.762 ×[FT3(pg/mL)]-0.014 ×[PLT(×10^9/L)]+ 1.797 ×[hepatorenal syndrome(with: 1;no: 0)]+ 1.339 ×[pulmonary infection(with: 1;no: 0)]-2.291.The ROC curve analysis showed that MACLF had significantly higher area under the ROC curve(0.934) and Youden index(0.774) than CTP class,MELD,and MELD combined with serum sodium concentration.Conclusion The new model of MACLF has a good value in predicting the short-term prognosis of patients with HBV-ACLF after 3 months of treatment.