慢加急性肝衰竭预后研究及新评分的建立分析

摘要/Abstract

摘要： 目的研究慢加急性肝衰竭(acute-on-chronic liver failure, ACLF)预后相关因素及国内外常用预后评分模型效能,并分析纳入甲胎蛋白及乳酸脱氢酶指标单指标及联合评分模型对ACLF患者预后评估效果。方法收集2010—2021年青岛大学附属医院及青岛市第六人民医院收治的ACLF的临床资料,使用统计学方法分析可能影响预后的因素,并使用评估ACLF常用的评估模型并分析甲胎蛋白/乳酸脱氢酶单指标及新评分模型对ACLF患者预后的预测力。结果共纳入159例ACLF患者,28 d内有存活与死亡之比为129∶30,90 d内存活与死亡之比为111∶48。其中根据疾病严重程度分为早期48例、中期58例、晚期53例。根据90 d内患者预后情况分为存活组及死亡/肝移植组,两组入院基线指标中: ALT(410比204)、AST(296比211)、ALT/AST(1.27比0.88)、总胆红素(271比349)、胆固醇(2.7比2.2)、甘油三酯(1.07比0.81)、中性粒细胞数(6.35比6.21)、尿素氮(3.7比6.0)、淋巴细胞数(1.45比0.69)、中性粒细胞数/淋巴细胞数(2.38比7.04)、红细胞计数(4.19比3.60)、血红蛋白(132比119)、血小板计数(90比74)、HBV DNA载量(10⁴比10³)、PTA(37.1比30.3)、INR(2.09比2.56)、MLR(0.37比0.61)、血肌酐(59比64)、乳酸脱氢酶(221.0比279.5)、甲胎蛋白(82.30比7.66)、肝性脑病情况、合并腹水情况、MELD得分(20.57比26.34)、COSSH得分(5.05比6.08)相比较差异具有统计学意义(P<0.05)。而年龄、性别、白蛋白、前白蛋白、血尿酸、直接胆红素、间接胆红素、胆碱酯酶、血钠、血氨、γ-谷氨酰转肽酶、ALBI、ALT、AST两组相比差异无统计学意义(P>0.05),甲胎蛋白,乳酸脱氢酶,总胆红素、甘油三酯、红细胞、血红蛋白、ALT/AST、尿素氮/肌酐及纳入甲胎蛋白及乳酸脱氢酶的新评分,是预测ACLF 90 d预后的独立影响因素。新评分模型(AUC=0.87,敏感度89.6%,特异度75.7%,cutoff值-0.990 9)较传统的NLR(AUC=0.72,敏感度68.9%,特异度75.2%,cutoff值3.86),MELD(AUC=0.67,敏感度69.6%,特异度67%,cutoff值14.64),COSSH(AUC=0.76,敏感度75%,特异度76%,cutoff值5.37)在预测ACLF患者预后方面具有更准确的预测性。结论在ACLF患者预后相关因素研究中,乳酸脱氢酶、总胆红素、尿素氮/肌酐、ALT/AST、红细胞为预测ACLF患者90 d预后的独立危险因素,甘油三酯、甲胎蛋白、血红蛋白为独立保护性因素。本研究中由以上8项指标组成的新评分系统在所有ACLF患者人群中较MELD及NLR评分能够更准确预测预后,在本研究乙型肝炎患者人群中新评分较MELD及NLR评分预测力高,但较COSSH评分相比差异并无统计学意义,但总体来讲新评分仍具有很高的预测力,从而节约临床器官的使用,提供最优治疗方案。

关键词: 慢加急性肝衰竭, 危险因素, 评分模型, 乳酸脱氢酶, 甲胎蛋白

Abstract: Objective To investigate the factors related to the prognosis of acute-on-chronic liver failure (ACLF) and the efficacy of common prognostic scoring models in China and abroad, and to analyze the efficacy of single and combined scoring models including alpha fetoprotein (AFP) and lactate dehydrogenase (LDH) indexes in the evaluation of the prognosis of patients with ACLF. Methods The clinical data of patients with ACLF admitted to our hospital from 2010 to 2021 were collected, and the influencing factors of prognosis were analyzed by statistical methods. The prognostic value of the single index of AFP/LDH and the new scoring model for ACLF was analyzed by comparing to common assessment model. Results A total of 159 patients with ACLF were enrolled, with a survival to death ratio of 129∶30 and 111∶48 within 28 and 90 days respectively. Among them, 48 cases were classified as early stage, 58 cases as middle stage and 53 cases as late stage according to the severity of the disease. According to the prognosis within 90 days, patients were divided into survival group and death/liver transplantation group. The baseline indexes including alanine transaminase (ALT) (410 vs 204), aspartate aminotransferase (AST) (296 vs 211), ALT/AST (1.27 vs 0.88), total bilirubin (TBil) (271 vs 349), cholesterol (2.7 vs 2.2), triglyceride (TG) (1.07 vs 0.81), neutrophil count (6.35 vs 6.21), urea nitrogen (3.7 vs 6.0), lymphocyte count (1.45 vs 0.69), neutrophil count/lymphocyte count (2.38 vs 7.04), red blood cell (RBC) count (4.19 vs 3.60), hemoglobin (Hb) (132 vs 119), platelet count (90 vs 74), HBV DNA load (104 vs103), prothrombin activity (PTA) (37.1 vs 30.3), international normalized ratio (INR) (2.09 vs 2.56), MLR(0.37 vs 0.61), serum creatinine (59 vs 64), LDH (221.0 vs 279.5), AFP (82.30 vs 7.66), hepatic encephalopathy, ascites, MELD score (20.57 vs 26.34) and COSSH score (5.05 vs 6.08) between the 2 group were significantly different (P<0.05). There was no significant difference in age, gender, albumin, prealbumin, serum uric acid, direct bilirubin, indirect bilirubin, cholinesterase, serum sodium, serum ammonia, R-glutamyl transpeptidase, ALBI, glutamyl transpeptidase and glutamyl transpeptidase between the 2 groups (P>0.05). AFP, LDH, TBil, TG, RBC, Hb, glutamate/propyl glutamate (GLU), urea nitrogen/creatinine (UREA nitrogen/creatinine) and the new score including AFP and LDH were independent factors for predicting the prognosis of ACLF at 90 days. The predictive value of new scoring model (AUC = 0.87, sensitivity 89.6%, specificity 75.7%, cutoff -0.9909) was better than that of traditional NLR (AUC=0.72, sensitivity 68.9%, specificity 75.2%, Cutoff 3.86), MELD (AUC=0.67, sensitivity 69.6%, specificity 67%, cutoff value 14.64), COSSH (AUC=0.76, sensitivity 75%, specificity 76%, cutoff value 5.37) in patients with ACLF. Conclusion In the study of prognostic factors in patients with ACLF, ADH, TBil, urea nitrogen/creatinine, ALT/AST, erythrocyte, are independent risk factors for predicting the prognosis of ACLF patients within 90 days, while triglyceride, AFP, Hb are independent protective factors. In the study, the new scoring system consisting of the above 8 indicators is more accurate than MELD and NLR in predicting prognosis in all ACLF patients, and the new scoring has higher predictive power than MELD and NLR in the study in hepatitis B patients, but the difference is not statistically significant compared with COSSH, but overall the new scoring still has high predictive power Thus saving the use of clinical organs and providing the best treatment plan.

Key words: Acute-on-chronic liver failure, Analysis of risk factors, Scoring model, Lactic dehydrogenase, Alpha fetal protein

张蒲阳, 牛庆慧, 许传屾, 苟卫, 李金金, 蔡金贞. 慢加急性肝衰竭预后研究及新评分的建立分析[J]. 肝脏, 2023, 28(4): 416-422.

ZHANG Pu-yang, NIU Qing-hui, XU Chuan-shen, GOU Wei, LI Jin-jin, CAI Jin-zhen. Study on the prognosis of acute-on-chronic liver failure and establishment of new score[J]. Chinese Hepatolgy, 2023, 28(4): 416-422.

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