MELD 3.0、MELD和MELD-Na评分对慢加急性肝衰竭患者短期预后的评估价值

Value of MELD 3.0,MELD,and MELD-Na scores in assessing the short-term prognosis of patients with acute-on-chronic liver failure:A comparative study

目的比较MELD 3.0、MELD和MELD-Na评分对慢加急性肝衰竭(ACLF)患者90 d生存预后的评估价值。方法回顾性分析2012年11月—2019年6月天津市第三中心医院、解放军总医院第五医学中心和北京佑安医院共605例ACLF患者的临床资料,根据入院后90 d随访结果将其分为生存组(n=392)和死亡组(n=213),应用受试者工作特征曲线(ROC曲线)以及曲线下面积(AUC)、净重分类改善度(NRI)、综合区分改善度(IDI)和决策曲线(DCA曲线)研究基线、3 d、1周和2周时MELD 3.0、MELD和MELD-Na评分对疾病预后的预测价值。结果在3 d和1周时,MELD 3.0评分的AUC分别为0.775、0.808,优于MELD评分(P值均<0.05);在3 d、1周和2周时,MELD 3.0相较于MELD预测ACLF患者预后的NRI分别为0.125、0.100、0.081,相较于MELD-Na预测ACLF患者预后的NRI分别为0.093、0.140、0.204;在基线、3 d、1周和2周时,MELD 3.0相较于MELD预测ACLF患者预后的IDI分别为0.011、0.025、0.017、0.013;在3 d和2周时,MELD 3.0相较于MELD-Na预测ACLF患者预后的IDI分别为0.027、0.038;以上NRI和IDI均>0,为正向改善(P值均<0.05);DCA曲线发现MELD 3.0在3 d时优于MELD,MELD 3.0在2周时明显优于MELD-Na;3种评分对不同分型ACLF患者预后预测能力无明显差异(P值均>0.05);3种评分对病因为HBV感染、酒精、HBV感染合并酒精ACLF患者预后预测能力无明显差异(P值均>0.05),但是对于其他病因的患者,MELD 3.0优于MELD评分(P<0.05)。结论MELD 3.0评分对ACLF患者90 d生存情况的预测能力优于MELD和MELD-Na评分,但优势有限。

Objective To investigate the value of MELD 3.0,MELD,and MELD-Na scores in assessing the 90-day prognosis of patients with acute-on-chronic liver failure(ACLF)through a comparative study.Methods A retrospective analysis was performed for the clinical data of 605 patients with ACLF who were treated in Tianjin Third Central Hospital,The Fifth Medical Center of Chinese PLA General Hospital,and Beijing YouAn Hospital from November 2012 to June 2019,and according to the 90-day follow-up results after admission,they were divided into survival group with 392 patients and death group with 213 patients.The receiver operating characteristic(ROC)curve,the area under the ROC curve(AUC),net reclassification improvement(NRI),integrated discrimination improvement(IDI),and decision curve analysis(DCA)curve were used to investigate the value of MELD 3.0,MELD,and MELD-Na scores at baseline,day 3,week 1,and week 2 in predicting the prognosis of the disease.Results At day 3 and week 1,MELD 3.0 score had an AUC of 0.775 and 0.808,respectively,with a better AUC than MELD score(P<0.05).At day 3,week 1,and week 2,MELD 3.0 score showed an NRI of 0.125,0.100,and 0.081,respectively,compared with MELD in predicting the prognosis of ACLF patients,as well as an NRI of 0.093,0.140,and 0.204,respectively,compared with MELD-Na score in predicting prognosis.At baseline,day 3,week 1,and week 2,MELD 3.0 showed an IDI of 0.011,0.025,0.017,and 0.013,respectively,compared with MELD in predicting the prognosis of ACLF patients.At day 3 and week 2,MELD 3.0 showed an IDI of 0.027 and 0.038,respectively,compared with MELD-Na in predicting the prognosis of ACLF patients.All the above NRIs and IDIs were>0,indicating a positive improvement(all P<0.05).DCA curves showed that MELD 3.0 was superior to MELD at day 3 and was significantly superior to MELD-Na at week 2.There was no significant difference in the ability of the three scores in predicting the prognosis of ACLF patients with different types,and there was also no significant difference in the ability of the three scores in predicting the prognosis of ACLF patients with the etiology of HBV infection,alcohol,or HBV infection combined with alcohol,while MELD 3.0 was superior to MELD for ACLF patients with other etiologies(P<0.05).Conclusion MELD 3.0 score is better than MELD and MELD-Na scores in predicting the 90-day survival of patients with ACLF,but with limited superiority.