血清肌酐与胱抑素C比值(CCR)对HBV相关慢加急性肝衰竭预后的评估价值

Value of serum creatinine-to-cystatin C ratio in assessing the prognosis of hepatitis B virus-related acute-onchronic liver failure

目的探讨血清肌酐与胱抑素C比值(CCR)评估HBV相关慢加急性肝衰竭(HBV-ACLF)预后的临床价值。方法回顾性分析2021年1月—2022年11月苏州大学附属第一医院感染病科住院治疗的130例HBV-ACLF患者(治疗组)临床资料,根据治疗结局分为生存组(n=87)和死亡组(n=43);根据是否合并感染,分为感染组(n=37)和非感染组(n=93)。以同期30例健康体检者作为对照组。收集入院当天血常规指标,包括白细胞、血小板、中性粒细胞和淋巴细胞计数;观察入院当天、住院第5天、第10天、第15天血清肌酐、胱抑素C、血清Alb、PT,计算CCR、中性粒细胞与淋巴细胞比值(NLR)、血小板与淋巴细胞比值(PLR)、营养指数(PNI)、CCR5(入院后第5天CCR)、ΔCCR5(入院后第5天CCR-入院当天CCR)、CCR10(入院后第10天CCR)、ΔCCR10(入院后第10天CCR-入院后第5天CCR)、CCR15(入院后第15天CCR)、ΔCCR15(入院后第15天CCR-入院后第10天CCR),比较生存组和死亡组、感染组与非感染组上述指标的差异。计量资料两组间比较采用Mann-Whitney U检验;多组间比较采用Kruskal-Wallis H检验。单因素和多因素Logistic回归分析探讨影响疾病预后的因素;受试者工作特征曲线(ROC曲线)评估CCR对HBV-ACLF死亡事件的预测价值,ROC曲线下面积(AUC)比较采用De Long检验。结果治疗组基线CCR、NLR、PNI、PT和Alb与健康对照组比较,差异均有统计学意义(P值均<0.001)。生存组与死亡组患者入院当天CCR、NLR、PT比较,差异均有统计学意义(P值均<0.05)。在130例HBV-ACLF患者中,有25例处于前期,48例处于早期,32例处于中期,25例处于晚期。各分期HBV-ACLF患者基线CCR、PLR及PT比较,差异均有统计学意义(P值均<0.05)。感染组与非感染组患者基线ΔCCR5、NLR比较,差异均有统计学意义(P值均<0.05)。患者入院第5天、第10天、第15天生存组与死亡组ΔCCR5、CCR10、CCR15比较,差异均有统计学意义(P值均<0.05)。多因素Logistic回归分析发现ΔCCR5(OR=1.175,95%CI:1.098~1.256,P<0.001)、NLR(OR=0.921,95%CI:0.880~0.964,P<0.001)和PT(OR=0.921,95%CI:0.873~0.973,P=0.003)是HBV-ACLF患者预后的独立影响因素。ΔCCR5的AUC为0.774,敏感度为0.687,特异度为0.757;ΔCCR5+PT+NLR联合的AUC为0.824,高于ΔCCR5、NLR、PT单独预测时的AUC(P值均<0.05)。结论ΔCCR5、NLR、PT可反映HBV-ACLF患者的病情及预后,是HBV-ACLF患者死亡事件的独立预测指标,ΔCCR5+PT+NLR联合时预测效能最佳。

Objective To investigate the clinical value of serum creatinine-to-cystatin C ratio(CCR)in evaluating the prognosis of hepatitis B virus-related acute-on-chronic liver failure(HBV-ACLF).Methods A retrospective analysis was performed for the clinical data of 130 patients with HBV-ACLF(treatment group)who were hospitalized in Department of Infectious Diseases,The First Affiliated Hospital of Soochow University,from January 2021 to November 2022.According to the treatment outcome,they were divided into survival group with 87 patients and death group with 43 patients;according to the presence or absence of infection,they were divided into infection group with 37 patients and non-infection group with 93 patients.A total of 30 individuals who underwent physical examination during the same period of time were enrolled as control group.Routine blood test results were collected on the day of admission,including white blood cell count,platelet count,neutrophil count,and lymphocyte count;serum creatinine,cystatin C,serum albumin(Alb),and prothrombin time(PT)were observed on the day of admission and on days 5,10,and 15 of hospitalization,and related indicators were calculated,including CCR,neutrophil-to-lymphocyte ratio(NLR),platelet-to-lymphocyte ratio(PLR),prognostic nutritional index(PNI),CCR5(CCR on day 5 after admission),ΔCCR5(CCR on day 5 after admission minus CCR on the day of admission),CCR10(CCR on day 10 after admission),ΔCCR10(CCR on day 10 after admission minus CCR on day 5 after admission),CCR15(CCR on day 15 after admission),andΔCCR15(CCR on day 15 after admission minus CCR on day 10 after admission).The above indicators were compared between the survival group and the death group and between the infection group and the non-infection group.The Mann-Whitney U test was used for comparison of continuous data between two groups,and the Kruskal-Wallis H test was used for comparison between multiple groups.The univariate and multivariate logistic regression analyses were used to investigate the influencing factors for disease prognosis;the receiver operating characteristic(ROC)curve was used to assess the value of CCR in predicting HBV-ACLF death events,and the DeLong test was used for comparison of the area under the ROC curve(AUC).Results There were significant differences in CCR,NLR,PNI,PT,and Alb at baseline between the treatment group and the healthy control group(all P<0.001),and there were significant differences in CCR,NLR,and PT between the survival group and the death group on the day of admission(all P<0.05).Among the 130 patients with HBV-ACLF,there were 25 in the precancerous stage,48 in the early stage,32 in the intermediate stage,and 25 in the advanced stage,and there were significant differences in baseline CCR,PLR,and PT between the patients in different stages of HBV-ACLF(all P<0.05).There were significant differences inΔCCR5 and NLR between the infection group and the non-infection group(P<0.05),and there were significant differences inΔCCR5,CCR10,and CCR15 between the survival group and the death group(all P<0.05).The multivariate logistic regression analysis showed thatΔCCR5(odds ratio[OR]=1.175,95%confidence interval[CI]:1.098—1.256,P<0.001),NLR(OR=0.921,95%CI:0.880—0.964,P<0.001),and PT(OR=0.921,95%CI:0.873—0.973,P=0.003)were independent influencing factors for the prognosis of HBVACLF patients.ΔCCR5 had an AUC of 0.774,a sensitivity of 0.687,and a specificity of 0.757,and the AUC ofΔCCR5+PT+NLR was 0.824,which was significantly higher than the AUC ofΔCCR5,NLR,or PT alone(all P<0.05).ConclusionΔCCR5,NLR,and PT can reflect the condition and prognosis of patients with HBV-ACLF and are independent predictive indicators for death events in patients with HBV-ACLF.The combination ofΔCCR5,PT,and NLR has the best predictive efficiency.