COSSH-ACLFⅡ评分对慢加急性肝衰竭患者短期预后的预测价值

摘要/Abstract

摘要： 目的探讨COSSH-ACLFⅡ评分对慢加急性肝衰竭(acute-on-chronic liver failure,ACLF)患者短期预后的预测价值。方法收集2020年1月至2022年1月南通市第三人民医院收治确诊的73例慢加急性肝衰竭患者,根据随访90 d时患者生存状态分为生存组(n=49)和死亡组(n=23)。计数资料两组间比较采用χ²检验;计量资料两组间比较采用t检验或者Mann－Whitney U检验。比较两组间临床资料,采用受试者工作特征(ROC)曲线分析COSSH-ACLFⅡ、MELD、MELD-Na、iMELD和CTP评分对ACLF患者预后预测的临床效能,计算COSSH-ACLFⅡ评分的最佳截断值,并应用Kaplan－Meier法绘制生存曲线。结果生存组和死亡组两组间年龄为(50.8±12.5)岁比(63.0±12.5)岁(t=－3.910,P<0.01),肝性脑病为16.33%比37.50%(χ²=4.043,P=0.044),消化道出血为6.22%比41.67%(χ²=11.583,P<0.01),总胆红素为229.10 μmol/L(113.80,363.40)比294.45 μmol/L(241.88,366.30)(U=－2.243,P=0.025) ,国际标准化比值为1.67±0.49比1.94±0.56(t=－2.117,P=0.038),血肌酐为64.14±18.20比94.51±40.60(t=－3.497,P=0.020),尿素氮为4.68(3.12,6.55)比6.82 mmol/L(4.05,10.44)(U=－2.178,P=0.029)。死亡组COSSH-ACLFⅡ(6.58±0.95比7.78±0.86,t=－5.238,P<0.01)、MELD(20.46±6.52比24.28±3.76,t=－2.653,P<0.01)、MELD-Na(21.40±9.45比26.15±8.01,t=－2.120,P=0.038)、iMELD(40.73±8.64比51.81±14.92,t=－4.019,P<0.01)和CTP(10.00±1.74比11.00±1.47,t=－2.416,P=0.018)评分均高于生存组,且差异均有统计学意义(P<0.05)。经ROC曲线分析,不同评分系统预测ACLF患者的曲线下面积分别为:COSSH-ACLFⅡ(AUC=0.826,95% CI:0.727~0.925)、MELD(AUC=0.688,95% CI:0.565~0.811)、iMELD(AUC=0.765,95% CI:0.684~0.882)、MELD-Na(AUC=0.651,95% CI:0.521~0.780)和CTP(AUC=0.640,95% CI:0.504~0.775)。用约登指数确定COSSH-ACLFⅡ的最佳截断值为7.02,Kaplan-Meier分析结果显示,COSSH-ACLFⅡ＞7.02组患者累计生存率明显低于COSSH-ACLFⅡ≤7.02组,Log-Rank=19.97,差异有统计学意义(P<0.01)。结论 COSSH-ACLFⅡ评分模型对于ACLF患者短期生存率的预测优于MELD、MELD-Na、iMELD和CTP评分。COSSH-ACLFⅡ＞7.02提示ACLF患者预后不良。

关键词: 评分系统, 慢加急性肝衰竭, 短期, 预后

Abstract: Objective To investigate the predictive value of COSSH-ACLFⅡ score in the short-term prognosis of patients with acute-on-chronic liver failure (ACLF). Methods A total of 73 patients with ACLF admitted to our hospital from January 2020 to January 2022 were collected, they were divided into survival group and death group according to the survival status during the 90-day follow-up. The χ² test was used to compare the enumeration data between the 2 groups. The t test or the Mann-Whitney U test was used to compare the measurement data between the 2 groups. The clinical data between the 2 groups were compared, and the receiver operating characteristic (ROC) curve was used to analyze the clinical efficacy of COSSH-ACLFⅡ, MELD, MELD-Na, iMELD and CTP scores in predicting the prognosis of patients with ACLF, and the optimal cutoff of COSSH-ACLFⅡ score was calculated. The Kaplan-Meier method was used to draw survival curves. Results There were significant differences in age (50.84 ± 12.49 vs 63.00 ± 12.47, t=-3.910, P＜0.01), hepatic encephalopathy (16.33% vs 37.50%, χ²=4.043, P=0.044), gastrointestinal bleeding (6.22% vs 41.67%, χ²=11.583, P＜0.01), total bilirubin [229.10 (113.80,363.40) vs 294.45 (241.88,366.30), U=-2.243, P=0.025], international normalized ratio (1.67±0.49 vs 1.94 ± 0.56, t=-2.117, P=0.038), serum creatinine (64.14 ± 18.20 vs 94.51±40.60, t=-3.497, P=0.020) and blood urea nitrogen [4.68 (3.12,6.55) vs 6.82 (4.05,10.44), U=-2.178, P=0.029] between the survival group and the death group (P<0.05). The COSSH-ACLFⅡ (6.58 ± 0.95 vs 7.78 ± 0.86, t=-5.238, P＜0.01), MELD (20.46 ± 6.52 vs 24.28 ± 3.76, t=-2.653, P＜0.01), MELD-Na (21.40 ± 9.45 vs 26.15 ± 8.01, t=-2.120, P=0.038), iMELD (40.73 ± 8.64 vs 51.81 ± 14.92, t=-4.019, P＜0.01) and CTP (10.00 ± 1.74 vs 11.00 ± 1.47, t=-2.416, P=0.018) scores in the death group were higher than those in the survival group, and the differences were statistically significant (P<0.05). The ROC curve analysis showed that the area under the curve (AUC) of different scoring systems for predicting acute-on-chronic liver failure were: COSSH-ACLFII (AUC = 0.826,95% CI: 0.727~0.925), MELD (AUC = 0.688, 95% CI: 0.565~0.811), iMELD (AUC = 0.765, 95% CI: 0.684~0.882), MELD-Na (AUC = 0.651, 95% CI: 0.521~0.780) and CTP score (AUC=0.640,95% CI: 0.504~0.775). The AUC of the COSSH-ACLFIIs model was higher than that of other models. The optimal cutoff value of COSSH-ACLFII was determined by the Youden index at 7.02, Kaplan-Meier analysis showed that the cumulative survival rate of patients in COSSH-ACLFⅡ > 7.02 group was significantly lower than that in COSSH-ACLFⅡ ≤ 7.02 group, Log-Rank=19.97, and the difference was statistically significant (P<0.0001).Conclusion The COSSH-ACLFⅡ score model performs better than MELD score, MELD-Nascore, iMELD score and CTP score in predicting the short-term survival rate of patients with ACLF. COSSH-ACLFⅡ > 7.02 indicates poor prognosis.

Key words: Scoring model, Acute on chronic liver failure, Short term, Prognosis

沈周明, 陈伟杰, 刘一村, 张莉, 薛红, 卞兆连. COSSH-ACLFⅡ评分对慢加急性肝衰竭患者短期预后的预测价值[J]. 肝脏, 2023, 28(1): 41-45.

SHEN Zhou-ming, CHEN Wei-jie, LIU Yi-cun, ZHANG Li, XUE Hong, BIAN Zhao-lian. Predictive value of COSSH-ACLFⅡ score for short-term prognosis in patients with acute-on-chronic liver failure[J]. Chinese Hepatolgy, 2023, 28(1): 41-45.

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