终末期肝病模型联合动脉血乳酸乙型肝炎病毒相关慢加急性肝衰竭预后的评价:97例患者的回顾性分析

摘要

目的 探讨患者入院时终末期肝病模型(MELD)联合动脉血乳酸(Lac)对乙型肝炎相关慢加急性肝衰竭患者的预后评价价值.方法 回顾分析2016年3月——2018年3月苏州大学附属第一医院住院治疗慢性乙型肝炎病毒(HBV)相关慢加急性肝衰竭(HBV-ACLF)97例患者临床资料,入院后记录患者年龄、性别、合并症、MELD评分,入科时乳酸(Lac)、总胆红素(TBil)、肌酐(Cr)、血清白蛋白(Alb),高敏C-反应蛋白(CRP)、白细胞计数(WBC)、血小板计数(PLT)、红细胞比积(Hct)、HBV DNA、HBsAg定量,器官支持治疗情况(人工肝支持系统、肾脏替代治疗、呼吸机支持治疗).治疗终点为住院期间内科治疗无效死亡、病情恶化放弃医学治疗及内科治疗效果不佳转外科肝移植治疗者.采用二分类变量logistic回归分析患者治疗终点危险因素.采用Hosmer-Lemeshow检验评分系统的拟合优度评价.用受试者工作特征曲线(ROC)预测MELD-Lac对患者预后评价.结果 纳入97例HBV-ACLF患者,好转56例,未愈41例(包括2例内科治疗效果不佳,转肝移植者),好转率为57.7%,好转组MELD评分、Lac值显著低于未愈组,二分类变量logistic回归分析,多因素分析显示MELD评分[优势比(OR=1.806)],Lac评分[优势比(OR=1.820)]为患者肝衰竭住院死亡危险因素(P<0.05),MELD-Lac预后患者预后评判ROC曲线下面积(AUC)和(95%可信区间)明显优于Lac及MELD评分[0.923(0.84～1.00)比0.804(0.067～0.942)和0.864(0.75～0.977)],P<0.05.MELD-Lac约登指数为0.746时,其最佳临界值为18.36,敏感度及特异性分别为91.3%、83.3%.结论 MELD-Lac对HBV-ACLF患者预后具有较高预测价值.%Objective To explore the prognostic value of model for end-stage liver disease(MELD)combined with arterial blood lactate(Lac)in admitted patients with hepatitis B virus-associated acute-on-chronic liver failure(HBV-ACLF).Methods Clinical data of 97 cases with hepatitis B virus-associated acute-on-chronic liver failure(HBV-ACLF)admitted to the First Affiliated Hospital of Suzhou University between March 2016 and March 2018 was retrospectively analyzed.Age,gender,complications,MELD score,lactic acid(Lac),total bilirubin(TBil),creatinine(Cr),serum albumin(Alb),high-sensitivity C-reactive protein(CRP),white blood cell count(WBC),platelet count(PLT),hematocrit(Hct),quantification of HBV DNA and HBsAg,and organ support treatment(artificial liver support system,renal replacement therapy and mechanical ventilation)were documented after admission.The primary endpoint of treatment was death due to ineffective medical treatment during hospitalization,abandonment of medical treatment due to deterioration of the health condition,and switch to liver transplantation for patients with poor medical treatment.The risk factors for primary endpoint of treatment were analyzed by binary logistic regression.Hosmer-Lemeshow test was used to evaluate the goodness of fit for the scoring system,and the ROC to predict the prognosis of MELD-Lac.Results Ninety-seven cases with HBV-ACLF were included,56 cases had good prognosis,and 41 cases had bad prognosis(including two cases with poor medical treatment and liver transplantation).The overall improvement rate was 57.7%.MELD score and Lac value in treated group was significantly lower than non-treated group.Bivariable and multivariable logistic regression analysis showed that the MELD score [odds ratio(OR=1.806)],and Lac score [odds ratio(OR=1.820)] was the risk factor for hospitalization and mortality in patients with liver failure(P<0.05).The area under the ROC curve(AUC)and the 95% confidence interval(95% Cl)of prognostic patients with MELD-Lac were significantly better than Lac and MELD scores[0.923(0.84 to 1.00)vs.0.804(0.067 to 0.942)and 0.864(0.75).0.977)],P < 0.05.When the MELD-Lac Youden index was set at 0.746,the optimal threshold was 18.36,and the sensitivity and specificity were 91.3% and 83.3%,respectively.Conclusion MELD-Lac score has a high prognostic value in HBV-ACLF patients.