乙型肝炎病毒相关慢加急性肝衰竭患者预后危险因素分析及预后模型建立

Analysis of prognostic risk factors and establishment of prognosis model in patients with hepatitis B virus-related acute-on-chronic liver failure

目的探讨影响乙型肝炎病毒(hepatitis B virus,HBV)相关慢加急性肝衰竭(acute-on-chronic liver failure,ACLF)患者预后的危险因素,并建立相关预后模型。方法收集2013年1月1日至2018年11月1日在河北医科大学第三医院感染科住院并确诊为HBV相关ACLF的193例患者的相关资料,作为推导队列。另收集石家庄市第五医院2017年7月1日至2018年11月1日住院并确诊为HBV相关ACLF的35例患者的相关资料,作为验证队列。观察所有患者入院后12周的生存情况,采用多因素logistic回归分析影响患者近期预后的危险因素,建立logistic回归方程预测模型,并进行验证。采用受试者操作特征(receiver operating characteristic,ROC)曲线下面积评价预后模型的诊断效能,并与终末期肝病模型(model for end-stage liver disease,MELD)评分、Child-Turcotte-Pugh(CTP)评分、序贯器官衰竭评估(sequential organ failure assessment,SOFA)评分、慢性肝衰竭(chronic liver failure,CLIF)-SOFA评分进行比较。结果多因素logistic回归分析结果显示,年龄(OR=2.133,95%CI 1.033~4.405)、总胆红素(OR=3.371,95%CI 1.610~7.060)、血肌酐(OR=4.448,95%CI 1.697~11.661)、肝性脑病(OR=5.313,95%CI 2.463~11.461)、腹水(OR=2.959,95%CI 1.410~6.210)是判断HBV相关ACLF患者近期预后的独立危险因素。新建立的logistic回归模型=-1.726+0.757×年龄+1.215×总胆红素+1.0492×血肌酐+1.670×肝性脑病(有=1,无=0)+1.085×腹水(有=1,无=0)。Logistic回归模型判断HBV相关ACLF患者近期预后的ROC曲线下面积为0.82(95%CI 0.76~0.88),MELD为0.67(95%CI 0.60~0.75),CTP为0.73(95%CI 0.66~0.80),SOFA为0.77(95%CI 0.70~0.83),CLIF-SOFA为0.72(95%CI 0.65~0.80)。验证队列的ROC曲线下面积为0.81(95%CI 0.65~0.97)。结论年龄、总胆红素、血肌酐、肝性脑病、腹水是影响HBV相关ACLF预后的独立危险因素,据此建立的预后模型能够较为准确地判断患者近期预后,其预测价值优于MELD评分、CTP评分、SOFA评分和CLIF-SOFA评分。

Objective To explore the risk factors for prognosis in patients with hepatitis B virus(HBV)-related acute-on-chronic liver failure(ACLF),and to establish a prognostic model.Methods A total of 193 patients diagnosed with HBV-ACLF who were admitted to the Department of Infectious Diseases of the Third Hospital of Hebei Medical University were collected from 1st January 2013 to 1st November 2018 as a derivation cohort.Thirty-five patients diagnosed with HBV-ACLF who were admitted to the Fifth Hospital of Shijiazhuang during the period from 1st July 2017 to 1st November 2018 were collected as a validation cohort.The survival condition of all patients at week 12 of admission was observed.The risk factors associated with short-term prognosis were analyzed by using multivariate logistic regression analysis,and a logistic regression equation prediction model was established and verified.The diagnostic performance of the prognostic model was evaluated using the receiver operating characteristic(ROC)curve,and was compared with model for end-stage liver disease(MELD)scoring system,Child-Turcotte-Pugh(CTP)scoring system,sequential organ failure assessment(SOFA)scoring system and chronic liver failure(CLIF)-SOFA scoring system.Results Multivariate logistic regression analysis showed that age(odds ratio(OR)=2.133,95%confidence interval(CI)1.033-4.405),total bilirubin(OR=3.371,95%CI 1.610-7.060),serum creatinine(OR=4.448,95%CI 1.697-11.661),hepatic encephalopathy(OR=5.313,95%CI 2.463-11.461),and ascites(OR=2.959,95%CI 1.410-6.210)were independent risk factors for predicting the short-term prognosis of patients with HBV-ACLF.The newly established logistic regression model(LRM)=-1.726+0.757×age+1.215×total bilirubin+1.0492×serum creatinine+1.670×hepatic encephalopathy(with=1,without=0)+1.085×ascites(with=1,without=0).The area under the ROC curve of the LRM for predicting the short-term prognosis of patients with HBV-ACLF was 0.82(95%CI 0.76-0.88).Furthermore,the areas under the ROC curve of the models of MELD,CTP,SOFA,CLIF-SOFA were 0.67(95%CI 0.60-0.75),0.73(95%CI 0.66-0.80),0.77(95%CI 0.70-0.83)and 0.72(95%CI 0.65-0.80),respectively.The ROC-area under curve of the validation cohort was 0.81(95%CI 0.65-0.97).Conclusions Age,total bilirubin,serum creatinine,hepatic encephalopathy,and ascites are independent risk factors for the prognosis of HBV-ACLF.The prognostic model established based on these factors can accurately predict the patients′short-term prognosis,which is superior to MELD,CTP,SOFA and CLIF-SOFA.