COSSH ACLFⅡ评分模型对乙肝病毒相关慢加急性肝衰竭患者短期预后评估和病情分级的应用价值

Application values of the COSSH ACLFⅡ score in predicting short-term prognosis and stratifying disease severity in patients with hepatitis B virus-related acute-on-chronic liver failure

目的:评估中国重症乙型肝炎研究学组(COSSH)慢加急性肝衰竭(acute-on-chronic liver failure,ACLF2.0(COSSH ACLFⅡ)评分对乙肝病毒相关ACLF(HBV-ACLF)患者短期预后评估和病情分级的应用价值。方法:回顾性分析皖南医学院附属第一医院2017年1月—2021年12月收治的114例HBV-ACLF患者的临床资料和生存信息。根据患者90 d生存情况分为存活组(n=67)和死亡组(n=47),比较两组基线特征的差异。采用受试者工作特征曲线下面积(area under curve,AUC)比较COSSH ACLFⅡ评分和COSSH ACLF评分、慢性肝衰竭联盟(CLIF-C)ACLF评分、CLIF-C脏器衰竭(CLIF-C OF)评分、终末期肝病模型(MELD)评分、MELD联合血清钠(MELD-Na)评分和Child-Turcotte-Pugh(CTP)评分预测患者90 d死亡的价值。分别按照COSSH ACLF分级(ACLF-1,n=83;ACLF-2,n=23;ACLF-3,n=8)和COSSH ACLFⅡ危险分层(<7.4,n=82;7.4~<8.4,n=21;≥8.4,n=11)将患者分组,Kaplan-Meier法比较各组90 d生存率的差异。结果:死亡组的年龄、肝性脑病或细菌感染的发生率、白细胞计数、中性粒细胞计数、国际标准化比值、总胆红素、血肌酐、血尿素氮以及以上7种预后评分均高于存活组(P均<0.05),凝血衰竭和中枢衰竭的发生率以及ACLF-1患者比例亦高于存活组(P均<0.01)。COSSH ACLFⅡ评分预测患者90 d死亡的AUC(0.892)大于CLIF-C ACLF评分(AUC=0.853,P=0.089)、COSSH ACLF评分(AUC=0.841,P<0.05)、CLIF-C OF评分(AUC=0.813,P<0.05)、MELD-Na评分(AUC=0.771,P<0.01)、MELD评分(AUC=0.792,P<0.01)和CTP评分(AUC=0.655,P<0.001)。患者90 d生存率随ACLF分级和COSSH ACLFⅡ危险分层上升均呈递减趋势(73.5%vs.26.1%vs.0%,P均<0.001;72.0%vs.38.1%vs.0%,P均<0.01)。结论:COSSH ACLFⅡ评分对HBV-ACLF患者短期预后的预测价值较高,采用COSSH ACLFⅡ危险分层有助于简化HBV-ACLF患者病情分级。

Objective:This study aimed to verify the application values of the Chinese Group on the Study of Severe Hepatitis B(COSSH)acute-on-chronic liver failure(ACLF)Ⅱscore in predicting short-term prognosis and stratifying disease severity in patients with hepatitis B virus-related ACLF(HBV-ACLF).Methods:Clinical data and survival information of 114 patients admitted with HBV-ACLFtotheFirstAffiliatedHospitalofWannanMedicalCollegefromJanuary 2017toDecember 2021wereretrospectively evaluated.Baseline characteristics were compared between the survival group(n=67)and the death group(n=47)at day 90 from inclusion.Prognostic accuracies between the COSSH ACLFⅡscore and the COSSH ACLF score,the Chronic Liver Failure-Consortium(CLIF-C)ACLF score,the CLIF-C organ failure(CLIF-C OF)score,the model of end-stage liver disease(MELD)score,the MELD-sodium(MELD-Na)score,and the Child-Turcotte-Pugh(CTP)score in 90-day mortality prediction were compared using the area under the receiver operating characteristic curve(AUC)method.All patients were divided into three groups according to COSSH ACLF grade(ACLF-1,n=83;ACLF-2,n=23;ACLF-3,n=8)or the risk strata of the COSSH ACLFⅡscore(<7.4,n=82;7.4~<8.4,n=21;and≥8.4,n=11),and the cumulative 90-day survival rates among them were compared using the Kaplan-Meier method.Results:Compared with the survival group,the death group had greater age,a higher incidence of hepatic encephalopathy or bacterial infection,higher values of white blood cell count,neutrophil count,international normalized ratio,total bilirubin,creatinine,urea,and the above-mentioned 7 scores(P<0.05).The incidence of coagulation failure or cerebral failure and the proportion of patients with ACLF-1in the death group were also higher than those in the survival group(P<0.01).For 90-day mortality prediction,the AUC of COSSH ACLFⅡscore(0.892)was larger than that of the CLIF-C ACLF score(AUC=0.853,P=0.089),the COSSH ACLF score(AUC=0.841,P<0.05),the CLIF-C OF score(AUC=0.813,P<0.05),the MELD-Na score(AUC=0.771,P<0.01),the MELD score(AUC=0.792,P<0.01),and the CTP score(AUC=0.655,P<0.001).The cumulative 90-day survival rates significantly decreased with COSSH ACLF grade and risk strata of the COSSH ACLFⅡscore ascending(73.5%vs.26.1%vs.0,P<0.001;72.0%vs.38.1%vs.0,P<0.01).Conclusion:The COSSH ACLFⅡscore showed excellent prognostic performance in predicting short-term prognosis in patients with HBV-ACLF.Using risk strata of the new score can simplify the severity stratification of HBV-ACLF.