肝衰竭伴非甲状腺疾病综合征患者的临床特点

Clinical features of patients with liver failure accompanied with non-thyroid sick syndrome

目的探讨肝衰竭伴非甲状腺疾病综合征(non-thyroid sick syndrome,NTIS)患者的临床特点,以及其对短期预后的价值。方法天津市第二人民医院2013年1月至2017年12月住院的肝衰竭患者90例,随机选取75例用于建立预后模型,15例用于验证预后模型。另选同期住院的慢性肝炎患者75例。应用电化学发光全自动免疫分析仪检测游离三碘甲状腺原氨酸(free triiodothyronine,FT3)、游离甲状腺素(free thyroxine,FT4)和促甲状腺激素(thyroid-stimulating hormone,TSH)。观察肝功能衰竭伴NTIS患者的临床特征及其入院3个月后存活情况。比较终末期肝病模型(model for end-stage liver disease,MELD)评分、Child-Turcotte-Pugh(CTP)评分和慢性肝衰竭-序贯器官衰竭(chronic liver failure-sequential organ failure assessment,CLIF-SOFA)评分、FT3-MELD预后模型和FT3对肝衰竭预后的诊断价值。统计学处理采用t检验、Mann-Whitney U检验和χ^2检验。结果与慢性肝炎患者比较,肝衰竭患者FT3、TSH、白蛋白下降,总胆红素、INR、血肌酐、FT4升高。75例肝衰竭患者中,50例伴NTIS;伴NTIS者死亡32例,不伴NTIS者死亡7例,差异有统计学意义(χ^2=8.654,P=0.003)。生存组与死亡组比较,INR、血肌酐、FT3、MELD评分、CTP评分和CLIF-SOFA评分差异均有统计学意义(t值分别为-3.037、-2.720、4.100、-4.221、-3.471和-3.901,均P<0.01)。FT3与MELD评分呈负相关(r=-0.439,P<0.01)。FT3-MELD预后模型的受试者工作特征曲线下面积为0.816,最佳临界值为0.121 7,灵敏度为0.769,特异度为0.833;FT3、MELD评分、CTP评分和CLIF-SOFA评分的受试者工作特征曲线下面积分别为0.794、0.775、0.699和0.739。结论肝衰竭伴NTIS患者肝功能和甲状腺功能较差。FT3-MELD模型用于评价肝衰竭患者短期预后优于CTP评分和CLIF-SOFA评分。

Objective To investigate clinical characteristics of patients with liver failure accompanied with non-thyroid sick syndrome(NTIS)and the predictive value for short-term prognosis.Methods Ninety patients with liver failure hospitalized in Tianjin Second People′s Hospital from January 2013 to December 2017 were retrospectively enrolled.Among them,75 patients(liver failure group)were randomly selected to establish prognostic models and the other 15 were selected for model validation.Another 75 patients at the same time of hospitalization with chronic hepatitis were randomly selected as the control group.The serum free triiodothyronine(FT3),free thyroxine(FT4)and thyroid-stimulating hormone(TSH)were measured by chemiluminescence.The clinical characteristics and survival rates 3 months after admission of patients with liver failure accompanied with NTIS were analyzed.The predictive value of the model for end-stage liver disease(MELD)score,Child-Turcotte-Pugh(CTP)score,chronic liver failure-sequential organ failure assessment(CLIF-SOFA)score,FT3-MELD model and FT3 for prognosis of liver failure were evaluated.Quantitative data were analyzed with Student′s t-test and Mann-Whitney U test.Count data were analyzed with chi-square test.Results The liver failure group had significantly lower levels of FT3,TSH and albumin(Alb),but higher levels of total bilirubin(TBil),international normalized ration(INR),serum creatinine(Cr)and FT4 than the control group.NTIS was diagnosed in 50 patients with liver failure(50/75,66.67%).There were 32 deaths in patients with NTIS and 7 in patients with non-NTIS.The difference was statistically significant(χ^2=8.654,P=0.003).INR,Cr,FT3,MELD score,CTP score and CLIF-SOFA score were significantly different between the survival and death groups(t=-3.037,t=-2,720,t=4.100,t=-4.221,t=-3.471,and t=-3.901,respectively;all P<0.01).A negative correlation was observed between FT3 and MELD score(r=-0.439,P<0.01).The area under the receiver′s operating characteristic(ROC)curve of the FT3-MELD model was 0.816,with the optimal cut-off-point of 0.121 7,sensitivity of 0.769 and specificity of 0.833.The areas under the curve of the FT3,MELD score,CTP score and CLIF-SOFA score were 0.794,0.775,0.699,and 0.739,respectively.Conclusions Liver function and thyroid function are poor in patients with liver failure accompanied with NTIS.The FT3-MELD model is superior to CTP score and CLIF-SOFA score in predicting the short-term prognosis in patients with liver failure.