3种评分系统对急性肝衰竭患儿预后的评估价值

The evaluation value of three scoring systems for the prognosis of pediatric acute liver failure

目的探讨Child-Turcotte-Pugh(CTP)评分、终末期肝病模型(PELD/MELD)评分及序贯器官功能衰竭(SOFA)评分对儿童急性肝衰竭(PALF)患儿第28天预后的应用价值。方法纳入2012年6月1日至2019年6月1日青岛妇女儿童医院儿童重症监护室和感染科收治的PALF患儿54例。根据第28天患儿的生存情况分为存活组(28例)和死亡组(26例),收集、比较患儿的一般资料和实验室检查等资料,应用受试者工作特征(ROC)曲线评价CTP评分、PELD/MELD评分和SOFA评分对PALF患儿预后评估的应用价值。结果54例PALF患儿死亡率为48.1%。与存活组PALF患儿相比,死亡组PALF患儿年龄较低[11.0(3.8~39.0)个月比14.5(7.3~84.0)个月],差异有统计学意义(Z=-2.145,P=0.020);CTP评分、PELD/MELD评分、SOFA评分均较高[14.0(11.7~15.0)比9.0(7.0~10.0)、32.0(29.0~36.0)比25.0(22.0~26.0)、13.0(11.0~16.0)比6.0(4.0~7.0)],差异均有统计学意义(Z=-5.095、-4.894、-5.502,均P<0.05);血乳酸、血氨、血清总胆红素、结合胆红素、国际标准化比值均较高[3.4(2.1~5.3)mmol/L比1.5(0.8~2.3)mmol/L、69.5(46.9~102.9)μmol/L比41.7(27.3~50.3)μmol/L、173.0(97.0~237.2)μmol/L比71.9(62.0~136.9)μmol/L、132.3(53.6~206.2)μmol/L比59.3(62.0~99.7)μmol/L、2.6(1.8~3.5)比1.7(1.5~1.9)],差异均有统计学意义(Z=-4.027、-3.220、-2.649、-2.268、-3.807,均P<0.05);凝血酶原时间明显延长[27.5(19.2~41.9)s比17.8(16.9~22.2)s],差异有统计学意义(Z=-3.489,P<0.05);血清白蛋白、丙氨酸转氨酶(ALT)和甲胎蛋白(AFP)均较低[(30.9±1.0)g/L比(33.6±0.9)g/L、379.2(163.3~880.3)U/L比962.5(457.0~1657.3)U/L、7.5(0.7~115.8)μg/L比22.1(7.9~91.3)μg/L],差异均有统计学意义(t=2.049,Z=-2.510、-2.342,均P<0.05);发生消化道出血的比例明显增加(22/26例比11/28例),差异有统计学意义(χ^(2)=13.340,P<0.05)。CTP评分、PELD/MELD评分和SOFA评分用于评估PALF患儿预后时,截断值分别为11.5分、28.5分和10.0分,SOFA评分的特异度和阳性预测值最高。3种评分联合试验评估PALF患儿预后时,敏感度为92.3%,特异度为89.3%,并联试验的约登指数最高(Z=2.19,P<0.05)。结论CTP评分、PELD/MELD评分和SOFA评分均对PALF患儿短期预后有较高的预测价值,3项指标联合应用时预测效能更佳。

Objective To investigate the prognosis value of the Child-Turcotte-Pugh(CTP),pediatrics end-stage liver disease/model for end-stage liver disease(PELD/MELD)and sequential organ failure assessment(SOFA)scores in pediatric acute liver failure(PALF)at 28th day.Methods Fifty-four PALF patients admitted in the Pediatric Intensive Care Unit(PICU)and Infection Department of Pediatrics,Qingdao Women′s and Children′s Hospital from June 1,2012 to June 1,2019 were included in the study.According to the survival of PALF patients on the 28th day,they were divided into the survival group(28 cases)and the death group(26 cases).Baseline characte-ristics and laboratory examination data of PALF patients in both groups were collected and compared.Receiver operating characteristic(ROC)curve was used to evaluate the prognostic value of CTP,PELD/MELD and SOFA scores in PALF.Results The mortality rate of 54 PALF patients was 48.1%.Compared with the survival group,PALF patients in the death group were significantly younger than those in survival group[11.0(3.8-39.0)months vs.14.5(7.3-84.0)months](Z=-2.145,P=0.020).In addition,CTP,PELD/MELD and SOFA scores were significantly higher in the death group than those in survival group[14.0(11.7-15.0)vs.9.0(7.0-10.0),32.0(29.0-36.0)vs.25.0(22.0-26.0),13.0(11.0-16.0)vs.6.0(4.0-7.0)](Z=-5.095,-4.894,-5.502,all P<0.05).Serum lactate level,blood ammonia level,total bilirubin,direct bilirubin and international normalized ratio were significantly higher in the death group than those in survival group[3.4(2.1-5.3)mmol/L vs.1.5(0.8-2.3)mmol/L,69.5(46.9-102.9)μmol/L vs.41.7(27.3-50.3)μmol/L,173.0(97.0-237.2)μmol/L vs.71.9(62.0-136.9)μmol/L,132.3(53.6-206.2)μmol/L vs.59.3(62.0-99.7)μmol/L,2.6(1.8-3.5)vs.1.7(1.5-1.9)](Z=-4.027,-3.220,-2.649,-2.648,-3.807,all P<0.05).Prothrombin time(PT)was significantly prolonged in the death group than that of survival group[27.5(19.2-41.9)s vs.17.8(16.9-22.2)s](Z=-3.489,P<0.05).Compared with those of survival group,serum albumin,alanine transaminase(ALT)and alpha fetoprotein(AFP)levels were significantly lower in the death group[(30.9±1.0)g/L vs.(33.6±0.9)g/L,379.2(163.3-880.3)U/L vs.962.5(457.0-1657.3)U/L,7.5(0.7-115.8)μg/L vs.22.1(7.9-91.3)μg/L](t=2.049,Z=-2.510,-2.342,respectively,all P<0.05).The incidence of alimentary tract hemorrhage was significantly higher in the death group than that of survival group(22/26 cases vs.11/28 cases)(χ^(2)=13.340,P<0.05).The cut-off value of CTP,PELD/MELD and SOFA scores in predicting the prognosis of PALF were 11.5,28.5 and 10.0,respectively.Among the three scoring systems,the specificity and positive predictive value of SOFA scores remained the highest.The sensitivity and specific of a combination of three scoring systems in predicting the prognosis of PALF were 92.3%and 89.3%,respectively,and its Youden index was the highest than that of a single scoring of either CTP,PELD/MELD or SOFA(Z=2.19,P<0.05).Conclusions CTP,PELD/MELD and SOFA scores have high predictive value for the short-term prognosis of PALF.The combined detection of the three scoring systems can improve the forecasting efficiency of PALD.