D-二聚体有助于乙型肝炎慢加急性肝衰竭的诊断与预后

D-dimer contributes to the diagnosis and prognosis in hepatitis B-related acute-on-chronic liver failure

目的探讨D-二聚体水平对乙型肝炎相关的慢加急性肝衰竭(HBV-ACLF)患者诊断和预测预后的价值。方法利用HBV-ACLF诊断中国标准研究(COSSH-ACLF)开放队列,随机纳入142例ACLF患者为研究对象,比较ACLF患者和非ACLF患者,不同ACLF等级患者血浆D-二聚体水平,并分别以28 d和90 d为终点比较生存组和病死组患者的D-二聚体水平;研究D-二聚体和其他实验室指标以及预后评分之间的相关性;通过受试者操作特征曲线下面积(AUROC)评估D-二聚体预测ACLF患者预后的价值。并利用外部125例ACLF患者进行验证。用Student t检验或Mann-Whitney U检验比较两组间的连续计量数据,用Kruskal-Wallis检验比较多组间的连续计量数据。结果ACLF组中血浆D-二聚体水平[2588.5(1142.8,5472.8)μg/L]与非ACLF组中的[1385.5(612.0,3840.3)μg/L]差异有统计学意义(P<0.001)。ACLF-3级患者的D-二聚体水平明显高于ACLF-1/2级(ACLF-3对比ACLF-1,P<0.001;ACLF-3对比ACLF-2,P<0.05)。28/90 d病死患者的D-二聚体水平显著高于生存组的患者(P<0.001)。D-二聚体水平与凝血酶原时间、国际标准化比值、高密度脂蛋白C等指标以及各项预后评分(COSSH-ACLFs、CLIF-C ACLFs、CLIF-OFs、MELDs)呈显著正相关。D-二聚体预测ACLF患者28 d和90 d预后的AUROC分别为0.751(95%可信区间:0.649~0.852)和0.787(95%可信区间:0.695~0.878),与其他评分的预测能力相比,差异无统计学意义(P>0.05)。125例外部验证组验证了类似结果。结论D-二聚体水平在ACLF患者中显著增高,同时是影响ACLF患者28 d和90 d预后的独立预测因素。

Objective To investigate the diagnostic and prognostic value of D-dimer level in patients with hepatitis B-related acute-on-chronic liver failure(HBV-ACLF).Methods A total of 142 cases diagnosed with ACLF were randomly selected as research objects in the open cohort using the Chinese Group on the Study of Severe Hepatitis B-ACLF(COSSH-ACLF).Plasma D-dimer levels were compared between patients with ACLF and non-ACLF and patients with different ACLF grades.Survival and death group D-dimer levels were compared with the end points of 28 days and 90 days,respectively.The correlation between D-dimer and other laboratory indicators and prognostic scores were investigated.Area under receiver operating characteristic curve(AUROC)was used to evaluate the D-dimer value for predicting the prognosis of ACLF patients.125 external ACLF cases were used for validation.A Student t test or Mann-Whitney U test was used to compare continuous measurement data between two groups.Kruskal-Wallis test was used to compare continuous measurement data between multiple groups.Results Plasma D-dimer levels in the ACLF[2588.5(1142.8,5472.8)μg/L]]and non-ACLF group[1385.5(612.0,3840.3)μg/L]had a significant difference(P<0.001).ACLF-3 patients had significantly higher D-dimer levels than ACLF-1/2 patients(ACLF-3 vs.ACLF-1,P<0.001;ACLF-3 vs.ACLF-2,P<0.05).Patients who died at 28/90 days had significantly higher D-dimer levels than those whom survived(P<0.001).There was a significant positive correlation between D-dimer level with prothrombin time(PT),international normalized ratio(INR),high-density lipoprotein C,as well as various prognostic scores(COSSH-ACLFs,CLIF-C ACLFs,CLIF-OFs,MELDs).AUROC of D-dimer in predicting the prognosis of ACLF patients at 28 days and 90 days was 0.751(95%CI:0.649-0.852)and 0.787(95%CI:0.695-0.878),respectively,which did not differ significantly compared with the predictive ability of other scores(P<0.05),and similar results were confirmed by an external validation group of 125 cases.Conclusion D-dimer level is significantly higher in patients with ACLF,so it is an independent predictor of prognosis at 28 and 90 days.