5种评分系统对慢加急性肝衰竭患者短期病死率的预测价值

Value of five scoring systems in predicting short-term mortality of patients with acute-on-chronic liver failure

目的应用CTP、MELD、iMELD、CLIF-SOFA和CLIF-C-ACLF评分评估慢加急性肝衰竭(ACLF)患者病情的严重程度,探讨和对比各种评分系统对预测ACLF患者28 d及90 d病死率的应用价值。方法选择2013年1月-2017年12月西京医院消化内科住院的107例ACLF患者,收集诊断成立时第1天、第3~5天及第7~9天的相关实验室检测指标,分别计算CTP、MELD、iMELD、CLIF-SOFA和CLIF-C-ACLF评分,应用受试者工作特征曲线(ROC曲线)比较以上评分系统的诊断价值。符合正态性的计量资料2组间比较采用t检验或Satterthwaite近似t检验,不符合正态性的计量资料2组间比较采用Man-Whithey U检验;计数资料2组间比较采用χ^2检验。结果在107例患者中,治疗28 d死亡44例(41.1%),治疗90 d死亡55例(51.4%)。诊断成立时iMELD、CLIF-SOFA和MELD评分预测28 d病死率的ROC曲线下面积(AUC)分别为0.81、0.73和0.75,预测患者90 d病死率的AUC分别为0.73、0.68和0.70。诊断成立后第3~5天及7~9天MELD和CLIF-SOFA预测28 d病死率的AUC与iMELD比较差异均无统计意义(Z值分别为0、0.15、3.08、3.11,P值均> 0.05),三者预测能力相似;第7~9天MELD和CLIF-SOFA预测90 d病死率的AUC与iMELD比较差异均无统计意义(Z值分别为2.14、1.98,P值均> 0.05),三者预测能力相似。iMELD、CLIFSOFA和MELD评分在诊断成立时、诊断成立后第3~5天及第7~9天的AUC均高于CLIF-C-ACLF和CTP。结论 iMELD是评估ACLF患者病死率的有效预测系统,动态评估iMELD及CLIF-SOFA评分能有效预测ACLF患者的预后。

Objective To assess the severity of patients with acute-on-chronic liver failure( ACLF) using Child-Turcotte-Pugh( CTP),Model for End-Stage Liver Disease( MELD),integrated MELD( iMELD),Chronic Liver Failure-Sequential Organ Failure Assessment( CLIF-SOFA),and Chronic Liver Failure-Consortium ACLF( CLIF-C-ACLF) scores,and to investigate the value of these scoring systems in predicting 28-and 90-day mortality rates.Methods A total of 107 patients with ACLF who were hospitalized in Department of Gastroenterology in Xijing hospital from January 2013 to December 2017 were enrolled,and related laboratory markers on days1,3-5,and 7-9 after diagnosis were collected.The CTP,MELD,iMELD,CLIF-SOFA,and CLIF-C-ACLF scores were calculated,and the receiver operator characteristic( ROC) curve was used to compare the clinical value of these scoring systems.The t-test or the Satterthwaite t-test was used for comparison of normally distributed continuous data between groups,the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups.The chi-square test was used for comparison of categorical data between groups.Results Among the 107 patients,44( 41.1%) died within 28 days and 55( 51.4%) died within 90 days.The scores of iMELD,CLIF-SOFA,and MELD at the time of diagnosis had an area under the ROC curve( AUC) of 0.81,0.73,and 0.75,respectively,in predicting 28-day mortality,as well as an AUC of 0.73,0.68,and 0.70,respectively,in predicting 90-day mortality.On days 3-5 and 7-9 after diagnosis,there was no significant difference in the AUC for predicting 28-day mortality between MELD/CLIF-SOFA and iMELD( Z = 0,0.15,3.08,and 3.11,all P>0.05),suggesting that the three scores had a similar predictive ability;on days 7-9 after diagnosis,there was no significant difference in the AUC for predicting 90-day mortality between MELD/CLIF-SOFA and iMELD( Z = 2.14 and 1.98,both P>0.05),suggesting that the three scores had a similar predictive ability.At the time of diagnosis and on days 3-5 and 7-9 after diagnosis,iMELD,CLIF-SOFA,and MELD scores had a significantly higher AUC than CLIF-C-ACLF and CTP scores.Conclusion The iMELD scoring system is proved to be an effective predictive system for short-term mortality in patients with ACLF,and dynamic evaluation of iMELD and CLIF-SOFA scores can effectively predict the prognosis of ACLF patients.