慢加急性肝衰竭ABC分型的预后及MELD 3.0和COSSH-ACLFⅡ对预后评估

ABC prognostic classification and MELD 3.0 and COSSH-ACLFⅡprognostic evaluation in acute-on-chronic liver failure

目的探讨慢加急性肝衰竭(ACLF)ABC分型的预后及最新终末期肝病模型(MELD)评分3.0和中国重型乙型病毒性肝炎研究小组(COSSH)最新COSSH-ACLFⅡ评分对ACLF预后评估价值。方法对1409例随访队列进行ABC分型,采用受试者操作特征曲线下面积(AUROC)分析和MELD、MELD 3.0、COSSH-Ⅱ及住院3 d后COSSH-Ⅱ评分(COSSH-II-3d),评估对患者360 d预后的预测能力,同时比较了对不同分型及不同病因ACLF预后预测的差异。结果1409例ACLF患者生存曲线显示,A型ACLF与B型、C型ACLF比较,差异有统计学意义,Log Rank(Mantel-Cox)χ2=80.133,P<0.01;A型与C型比较,χ2=76.198,P<0.01;B型与C型差异无统计学意义,χ2=3.717,P>0.05。AUROC分析MELD、MELD 3.0、COSSH-Ⅱ及COSSH-Ⅱ-3d AUROC[95%可信区间(CI)]分别为0.644、0.655、0.817和0.839(P值均<0.01)。COSSH-II对A型ACLF及HBV相关ACLF(HBV-ACLF)360 d预后有更好的预测能力,AUROC(95%CI)分别为0.877和0.881(P值均<0.01)。而MELD3.0未显示出比MELD更好的预测能力。结论ACLF的ABC分型与预后密切相关,COSSH-Ⅱ评分对A型ACLF及HBV-ACLF预后具有更高的预测能力,患者住院3d后COSSH-Ⅱ评分对预后有更好的评估价值,提示应当重视ACLF入院初期的救治。

Objective To investigate the ABC prognostic classification and the updated version of Model for End-stage Liver Disease(MELD)score 3.0 and Chinese Group on the Study of Severe Hepatitis B ACLFⅡscore(COSSH-ACLFⅡscore)to evaluate the prognostic value in acute-on-chronic liver failure(ACLF).Methods ABC classification was performed on a 1409 follow-up cohorts.The area under the receiver operating characteristic curve(AUROC)was used to analyze MELD,MELD 3.0,COSSH-Ⅱand COSSH-Ⅱscore after 3 days of hospitalization(COSSH-Ⅱ-3d).The prognostic predictive ability of patients were evaluated for 360 days,and the prediction differences of different classifications and different etiologies on the prognosis of ACLF were compared.Results The survival curve of 1409 cases with ACLF showed that the difference between class A,B,and C was statistically significant,Log Rank(Mantel-Cox)χ2=80.133,P<0.01.Compared with class A and C,χ2=76.198,P<0.01,the difference between class B and C,was not statistically significantχ2=3.717,P>0.05.AUROC[95%confidence interval(CI)]analyzed MELD,MELD 3.0,COSSH-Ⅱand COSSH-Ⅱ-3d were 0.644,0.655,0.817 and 0.839,respectively(P<0.01).COSSH-Ⅱhad better prognostic predictive ability with class A ACLF and HBV-related ACLF(HBV-ACLF)for 360-days,and AUROC(95%CI)were 0.877 and 0.881,respectively(P<0.01),while MELD 3.0 prognostic predictive value was not better than MELD.Conclusion ACLF prognosis is closely related to ABC classification.COSSH-Ⅱscore has a high predictive value for the prognostic evaluation of class A ACLF and HBV-ACLF.COSSH-Ⅱscore has a better prognostic evaluation value after 3 days of hospitalization,suggesting that attention should be paid to the treatment of ACLF in the early stage of admission.