PNI联合MELD评分对肝硬化失代偿期患者预后预测价值

摘要/Abstract

摘要： 目的探讨预后营养指数(PNI)联合MELD评分评估肝硬化失代偿期患者预后的价值。方法纳入2020年1月至2023年1月合肥市第一人民医院确诊的失代偿期肝硬化患者216例,以死亡为终点事件,按照随访1年的转归情况分为生存组156例和死亡组60例,比较两组患者入院时PNI、CTP评分、MELD水平。运用单因素和多因素Cox回归模型预测1年死亡的独立影响因素,以ROC曲线下面积(AUC)评估PNI预测的准确性。按照约登指数计算PNI的最佳临界值,绘制Kaplan-Meier曲线分析不同PNI水平患者的1年生存率。通过二分类变量logistic回归对PNI、MELD评分进行联合预测患者1年死亡的价值。采用限制性立方样条(restricted cubic spline,RCS)拟合Cox回归模型评估不同的PNI截点与1年死亡风险的关系。结果随访1年死亡60例(27.78%),死亡组入院时PNI明显低于生存组[29.0(25.7～31.7)比36.5(30.6～41.0) , P<0.001]。PNI与CTP评分、MELD 评分呈负相关性(r=-0.766、-0.483, P<0.001)。PNI是患者1年死亡风险的独立影响因素(OR:0.938, 95%CI:0.889~0.991, P=0.021);ROC曲线显示PNI及MELD评分预测患者1年死亡风险最佳临界值分别为33.45、16.61,AUC分别为0.780、0.871。而PNI联合MELD评分对患者1年死亡预测效率可提高至0.885(P<0.001)。RCS显示PNI和1年死亡风险呈线性关系(P for nonlinear＞0.05)。结论肝硬化失代偿期患者PNI联合MELD评分能够有效预测1年死亡风险。

关键词: 肝硬化, 预后营养指数, 终末期肝病模型评分

Abstract: Objective To explore the value of Prognostic Nutritional Index (PNI) combined with the Model for End Stage Liver Disease (MELD) score in assessing 1the 1-year mortality risk in patients with decompensated cirrhosis. Methods A total of 216 patients diagnosed with decompensated cirrhosis in our hospital from January 2020 to January 2023 were retrospectively included. Death was regarded as the terminal event. Patients were categorized into a survival cohort (156 cases) and a deceased cohort (60 cases) based on the outcome of 1-year follow-up. The differences in PNI, Child-Pugh score, and MELD level at admission between the two groups were compared. Univariate and multivariate Cox proportional hazards models were used to predict the independent factors influencing 1-year mortality in patients. Receiver operating characteristic (ROC) curves were constructed, and the area under the curve (AUC) was evaluated for comparison. The optimal cut-off value of PNI was calculated according to the Youden index, and Kaplan-Meier curves were constructed to analyze the 1-year survival rate of patients with different PNI levels. Logistic regression was used for joint prediction of the value of PNI and MELD score in predicting 1-year mortality in patients. Finally, the non-linear association between PNI and 1-year mortality risk was evaluated using restricted cubic spline (RCS) fitted Cox regression models. Results 60 cases (27.78%) died during the 1-year follow-up. The PNI at admission was significantly decreased in the death group compared to the survival group(29.0 (25.7～31.7)vs. 36.5 (30.6～41.0) , P＜0.001). PNI was negatively correlated with Child-Pugh score (r=-0.766, P＜0.001) and MELD score (r=-0.483, P＜0.001). PNI were independent factors predicting the 1-year mortality risk (OR:0.938, 95%CI:0.889~0.991, P=0.021). ROC curves showed that the optimal cut-off values for predicting 1-year mortality risk were 33.45 for PNI and 16.61 for MELD score, with AUC of 0.780 and 0.871, respectively (P<0.001); while the combination of PNI and MELD score improved the efficiency of predicting 1-year mortality in patients ( AUC=0.885, P<0.001). The RCS graph showed a linear relationship between PNI and 1-year mortality risk (P for nonlinear＞0.05). Conclusion The joint utilization of PNI and MELD score proves to be effective in forecasting the risk of 1-year mortality in patients suffering from decompensated cirrhosis.

Key words: Liver cirrhosis, Prognostic Nutritional Index, MELD score

徐鹤翔, 郑吉顺. PNI联合MELD评分对肝硬化失代偿期患者预后预测价值[J]. 肝脏, 2025, 30(4): 509-513.

XU He-xiang, ZHEN Ji-shun. The prognostic significance of PNI and MELD scores for predicting outcomes in patients with decompensated cirrhosis[J]. Chinese Hepatolgy, 2025, 30(4): 509-513.

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参考文献

[1] GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019[J]. Lancet, 2020, 396(10258):1204-1222.
[2] Ginès P, Krag A, Abraldes J G, et al. Liver cirrhosis[J]. Lancet, 2021, 398(10308):1359-1376.
[3] Xiao J, Wang F, Wong N K, et al. Global liver disease burdens and research trends: analysis from a Chinese perspective[J]. J Hepatol, 2019, 71(1):212-221.
[4] Pugh R N, Murray-Lyon I M, Dawson J L, et al. Transection of the oesophagus for bleeding oesophageal varices[J]. Br J Surg, 1973, 60(8):646-649.
[5] Kamath P S, Wiesner R H, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease[J]. Hepatology, 2001, 33(2):464-470.
[6] Arroyo V, Angeli P, Moreau R, et al. The systemic inflammation hypothesis: towards a new paradigm of acute decompensation and multiorgan failure in cirrhosis[J]. J Hepatol, 2021, 74(3):670-685.
[7] Maharshi S, Sharma B C, Srivastava S. Malnutrition in cirrhosis increases morbidity and mortality[J]. J Gastroenterol Hepatol, 2015, 30(10):1507-1513.
[8] Li T, Yuan D, Wang P, et al. Association of prognostic nutritional index level and diabetes status with the prognosis of coronary artery disease: a cohort study[J]. Diabetol Metab Syndr, 2023, 15(1):58.
[9] Liu T D, Zheng Y Y, Tang J N, et al. Prognostic nutritional index as a novel predictor of long-term prognosis in patients with coronary artery disease after percutaneous coronary intervention[J]. Clin Appl Thromb Hemost, 2022, 28:10760296221103271.
[10] Correa-Rodríguez M, Pocovi-Gerardino G, Callejas-Rubio J L, et al. The prognostic nutritional index and nutritional risk index are associated with disease activity in patients with systemic lupus erythematosus[J]. Nutrients, 2019, 11(3):638.
[11] 中华医学会肝病学分会. 肝硬化诊治指南[J]. 中华肝脏病杂志, 2019, (11):846-865.
[12] Onodera T, Goseki N, Kosaki G. Prognostic nutritional index in gastrointestinal surgery of malnourished cancer patients[J]. Nihon Geka Gakkai Zasshi, 1984, 85(9):1001-1005.
[13] 薛红, 刘先进, 明芳,等. 预后营养指数与乙型肝炎病毒相关慢加急性肝衰竭患者预后的关系[J]. 实用医学杂志, 2022, 38(10):1240-1245.
[14] 张旭, 马丽娜, 王梦甜,等. 中性粒/淋巴细胞比值联合预后营养指数对乙型肝炎病毒相关慢加急性肝衰竭短期预后的预测价值[J]. 中华肝脏病杂志, 2023, 31(08):847-854.
[15] Wu D, Wang X, Ding Y, et al. PNI, NLR and PLR combined detection prognosis of patients with chronic hepatitis C-associated cirrhosis complicated by T2DM[J]. J Infect Dev Ctries, 2023,17 (10):1356-1361.
[16] 徐传翀, 陈芳, 邹蓓蓓,等. 预后营养指数在乙型肝炎肝硬化患者病情严重程度及预后评估中的应用[J]. 慢性病学杂志, 2019, 20(12):1782-1785.
[17] 韩才均, 李文浩, 吴政燮,等. NLR、LMR和PNI在肝硬化相关自发性细菌性腹膜炎抗感染治疗中的作用[J]. 国际检验医学杂志, 2022, 43(24):3012-3015+3021.
[18] 袁满, 刘申香, 严雪冰,等. 预后营养指数对晚期肝细胞癌患者预后的影响[J]. 国际医药卫生导报, 2021, 27(3):400-404.
[19] Xie Y, He C, Wang W. Prognostic nutritional index: a potential biomarker for predicting the prognosis of decompensated liver cirrhosis[J]. Front Nutr, 2022, 9:1092059.
[20] Soeters P B, Wolfe R R, Shenkin A. Hypoalbuminemia: pathogenesis and clinical significance[J]. JPEN J Parenter Enteral Nutr, 2019, 43(2):181-193.
[21] Traub J, Reiss L, Aliwa B, et al. Malnutrition in patients with liver cirrhosis[J]. Nutrients, 2021, 13(2):540.
[22] Evans D C, Corkins M R, Malone A, et al. The use of visceral proteins as nutrition markers: an ASPEN position paper[J]. Nutr Clin Pract, 2021, 36(1):22-28.
[23] Levitt D G, Levitt M D. Protein losing enteropathy: comprehensive review of the mechanistic association with clinical and subclinical disease states[J]. Clin Exp Gastroenterol, 2017, 10:147-168.
[24] de Mattos Â Z, Simonetto D A, Terra C, et al. Albumin administration in patients with cirrhosis: current role and novel perspectives[J]. World J Gastroenterol, 2022, 28(33):4773-4786.
[25] Janka T, Tornai D, Papp M, et al. The value of neutrophil-to-lymphocyte ratio to identify bacterial infection and predict short-term mortality in patients with acutely decompensated cirrhosis[J]. Diagnostics, 2023, 13(18):2954.
[26] 梁利民, 徐鹤翔, 郑吉顺,等. RDW、NLR联合MELD评分评估失代偿期肝硬化患者预后的临床价值[J]. 南京医科大学学报(自然科学版), 2020, 40(02):217-222.