终末期肝病模型及CTP评分系统对土三七相关肝窦阻塞综合征患者预后的预测价值

Value of Model for End-Stage Liver Disease and Child-Turcotte-Pugh score in predicting the prognosis of patients with hepatic sinus obstruction syndrome associated with Gynura segetum(Lour.)Merr.

目的研究应用终末期肝病模型(MELD评分)和Child-Tureotte-Pugh评分(CTP评分)系统预测肝窦阻塞综合征患者预后的临床价值。方法选取2012年1月-2018年7月北京佑安医院、北京地坛医院、解放军总医院第五医学中心、天津市第三中心医院、新乡医学院第一附属医院5家医院收治的土三七相关肝窦阻塞综合征患者49例,随访3年,终点事件为死亡。根据患者入院时的实验室检查及临床资料,计算患者MELD和CTP评分,根据CTP评分将患者分为3组:CTP A级组(评分5~6分)(n=8)、CTP B级组(评分7~9分)(n=23)及CTP C级组(评分≥10分)(n=18);根据随访期间患者临床结局分为死亡组(n=12)和生存组(n=37)。计量资料组间比较采用Mann-Whitney U检验,等级资料采用Kruskal-Wallis H检验。受试者工作特征曲线下面积(AUC)用于判定CTP、MELD评分对死亡的预测能力。Kaplane-Meier生存曲线用于判定不同CTP、MELD评分患者的长期预后情况,采用log-rank进行比较。应用受试者工作特征曲线分析两种评分系统对患者死亡的预测效能。结果肝窦阻塞综合征患者MELD评分中位数为13.443(8.792~18.379),死亡组MELD评分为19.844(15.487~25.412),明显高于生存组11.578(8.597~15.785)(Z=-3.511,P <0.001)。CTP分值在6~12分,CTP A、B、C级组患者所占比例分别为16.3%(8例)、46.9%(23例)及36.7%(18例)。随着CTP评分增加,患者病死率升高,差异具有统计学意义(χ~2=16.078,P <0.05)。肝窦阻塞综合征患者A、B、C级组病死率分别为:0、13.0%、50%(χ~2=10.343,P <0.05)。Kaplan-Meier分析显示MELD <14.294 4组(n=26)患者3年预后显著优于MELD≥14.294 4组(n=23)(χ~2=14.893,P <0.001)。CTP评分等级越高,患者3年转归越差,差异具有统计学意义(χ~2=11.083,P <0.05)。CTP分级对肝窦阻塞综合征患者预后预测的AUC为0.780(95%CI:0.639~0.922),MELD评分的AUC为0.840(95%CI:0.722~0.958),两种评分间差异无统计学意义(Z=2.63,P> 0.05)。结论 MELD及CTP评分均可预测肝窦阻塞综合征患者的死亡风险,两者对于患者预后的预测效能相当,其临床应用价值还需要扩大验证。

Objective To investigate the value of Model for End-Stage Liver Disease(MELD)and Child-Turcotte-Pugh(CTP)score in predicting the prognosis of patients with hepatic sinusoidal obstruction syndrome(HSOS)associated with Gynura segetum(Lour.)Merr.Methods A total of 49 patients with HSOS associated with Gynura segetum(Lour.)Merr.who were admitted to Beijing YouAn Hospital,Beijing Ditan Hospital,The Fifth Medical Center of Chinese PLA General Hospital,Tianjin Third Central Hospital,and The First Affiliated Hospital of Xinxiang Medical University from January 2012 to July 2018 were enrolled and followed up for three years,with death as the outcome event.MELD and CTP scores were calculated according to the laboratory examination and clinical data on admission,and according to CTP score,the patients were divided into CTP class A(CTP score 5-6)group(n=8),CTP class B(CTP score 7-9)group(n=23),and CTP class C(CTP score≥10)group(n=18).The patients were divided into death group(n=12)and survival group(n=37)according to the clinical outcome during follow-up.The Mann-Whitney U test was used for comparison of continuous data between groups,and the Kruskal-Wallis H test was used for ranked data.The area under the receiver operator characteristic(ROC)curve(AUC)was used to investigate the ability of CTP and MELD scores in predicting death.The Kaplan-Meier survival curves were used to determine the long-term prognosis of patients with different CTP and MELD scores,and the log-rank test was used for comparison.The ROC curve was used to evaluate the performance of these two scoring systems in predicting death.Results A total of 12 patients died during the 3-year follow-up period.The patients with HSOS had a median MELD score of 13.443(8.792-18.379),and the death group had a significantly higher MELD score than the survival group[19.84(15.49-25.41)vs 11.58(8.60-15.79),Z=-3.511,P<0.001].The patients with HSOS had a CTP score of 6-12,and of all 49 patients,8(16.3%)had CTP class A HSOS,23(46.9%)had CTP class B HSOS,and 18(36.7%)had CTP class C HSOS.The mortality rate of the patients increased significantly with the increase in CTP score(χ2=16.078,P<0.05).The mortality rates of the patients with CTP class A,B,and C HSOS were 0.0%,13.0%,and 50.0%,respectively(χ2=10.343,P<0.05).The Kaplan-Meier analysis showed that the patients with a MELD score of<14.2944 had a significantly better 3-year prognosis than those with a MELD score of≥14.2944(χ2=14.893,P<0.001).The higher the CTP score,the poorer the 3-year prognosis of patients(χ2=11.083,P<0.05).CTP class had an AUC of 0.780(95%confidence interval[CI]:0.639-0.922)in predicting the prognosis of HSOS patients,while MELD score had an AUC of 0.840(95%CI:0.722-0.958),and there was no significant difference between the two scores(Z=2.63,P>0.05).Conclusion Both MELD and CTP scores can predict the risk of death in patients with HSOS,with similar performance in predicting the prognosis of patients,and further studies are needed to validate their clinical value.