L3-PMI在乙肝肝硬化相关慢加急性肝衰竭患者预后评估中的作用

Role of L3-PMI in prognostic evaluation of patients with acute-on-chronic liver failure related to hepatitis B cirrhosis

背景肌肉减少症是终末期肝病患者死亡的独立危险因素,与患者的预后密切相关,因此受到广泛关注.但对于肌少症来说,目前还缺乏统一的检测方法和诊断标准,临床应用受限.目的评估乙肝肝硬化相关慢加急性肝衰竭(acute-on-chronic liver failure,ACLF)患者的第三腰椎腰大肌指数(the third lumbar level psoas muscle index,L3-PMI)与临床指标的关系及其在预后评估中的作用.方法采用回顾性研究的方法,选取2014-01/2017-12在天津市第三中心医院肝内科住院的符合乙肝肝硬化相关ACLF诊断标准且有腹部CT扫描资料的140例患者为研究对象.由同一名研究者在患者腹部CT图像上手动追踪第三腰椎下缘水平面,测量双侧腰大肌最大前后径和横径,计算腰大肌指数.分析患者的L3-PMI和临床特点及预后.结果将140例患者按90天生存情况分为生存组102例,死亡组38例.死亡组患者L3-PMI值4.89 cm^(2)/m^(2)±1.42 cm^(2)/m^(2)较生存组患者5.94 cm^(2)/m^(2)±1.24 cm^(2)/m^(2)显著降低(P<0.001);血小板(platelet,PLT)、白蛋白(albumin,ALB)、丙氨酸转移酶(alanine aminotransferase,ALT)、天门冬氨酸转移酶(aspartate transaminase,AST)、血肌酐(serum creatinine,SCr)、估算肾小球滤过率(estimated glomerular filtration rate,eGFR)在两组之间无统计学差异,P值均>0.05;死亡组患者白细胞(white blood cell,WBC)、国际标准化比值(international normalized ratio,INR)水平、终末期肝病模型(model for end-stage liver disease,MELD)评分显著高于生存组,而血清钠显著低于生存组(P值均<0.05).此外,ACLF患者中33例合并肝性脑病(hepatic encephalopathy,HE)的患者L3-PMI值5.17 cm^(2)/m^(2)±1.49 cm^(2)/m^(2)显著低于107例未合并HE的患者5.80 cm^(2)/m^(2)±1.29 cm^(2)/m^(2),(P=0.02).所有ACLF患者中男性120例,女性20例,其中男性组L3-PMI值5.92 cm^(2)/m^(2)±1.23 cm^(2)/m^(2)显著高于女性组4.03 cm^(2)/m^(2)±0.92 cm^(2)/m^(2),(P<0.05).按性别分别绘制L3-PMI预测死亡的ROC曲线图,其中男性ROC曲线下面积0.726,截断值为5.02,敏感度为85%,特异度50%;女性ROC曲线下面积0.774,截断值为4.60,敏感度为50%,特异度100%.结论L3-PMI对于评估乙肝肝硬化相关ACLF患者的预后有重要临床应用价值.

BACKGROUND Sarcopenia has received widespread attention in patients with end-stage liver disease since it is an independent risk factor for death and is closely related to the prognosis of the patients.However,there is still a lack of unified detection methods and diagnostic criteria for sarcopenia.AIM To evaluate the relationship between the third lumbar psoas muscle index(L3-PMI)and clinical indicators in patients with acute-on-chronic liver failure(ACLF)associated with hepatitis B cirrhosis and its role in prognostic evaluation.METHODS A retrospective study was performed on 140 patients who were hospitalized at the Department of Hepatology,Tianjin Third Central Hospital from January 2014 to December 2017,met the ACLF diagnostic criteria for hepatitis B cirrhosis,and had abdominal CT data.The same researcher manually tracked the level of the lower edge of the third lumbar vertebra on the CT images of the patient’s abdomen,measured the maximum anteroposterior and transverse diameters of the psoas major on both sides,and calculated the psoas major index.The relationship of L3-PMI with clinical characteristics and prognosis was then analyzed.RESULTS The 140 patients were divided into a survival group with 102 cases and a death group with 38 cases according to their 90-d survival status.The L3-PMI value of patients in the death group was 4.89 cm^(2)/m^(2)±1.42 cm^(2)/m^(2),significantly lower than that of patients in the survival group(5.94 cm^(2)/m^(2)±1.24 cm^(2)/m^(2);P<0.001).There was no statistical difference between the two groups in PLT,ALB,ALT,AST,SCr,or eGFR(P>0.05).The WBC,INR,and MELD scores of the death group were significantly higher than those of the survival group,while the serum sodium was significantly lower than that of the survival group(P<0.05).In addition,33 ACLF patients with hepatic encephalopathy(HE)had an L3-PMI value of 5.17 cm^(2)/m^(2)±1.49 cm^(2)/m^(2),which was significantly lower than that of 107 patients without HE(P=0.020).Among all ACLF patients,there were 120 males and 20 females.The L3-PMI value of the male group(5.92 cm^(2)/m^(2)±1.23 cm^(2)/m^(2))was significantly higher than that of the female group(4.03 cm^(2)/m^(2)±0.92 cm^(2)/m^(2);P<0.05).The ROC curve of L3-PMI for predicting death by gender was plotted.The area under the ROC curve for males was 0.726,the cut-off value was 5.02,and the sensitivity and specificity were 85%and 50%,respectively.The area under the ROC curve for females was 0.774,the cut-off value was 4.60,and the sensitivity and specificity were 50%and 100%,respectively.CONCLUSION L3-PMI has important clinical application value for evaluating the prognosis of ACLF patients related to hepatitis B liver cirrhosis.