血浆置换经治乙型肝炎病毒相关慢加急性肝衰竭患者预后模型的建立与评价

摘要/Abstract

摘要： 目的探讨血浆置换(PE)经治乙型肝炎病毒相关慢加急性肝衰竭(HBV-ACLF)患者短期预后的影响因素,建立预后新模型并评价预后价值。方法选取福建医科大学孟超肝胆医院2020年1月至2024年12月接受≥3次PE治疗的294例HBV-ACLF患者,根据24周生存情况,分为生存组和死亡组。分析两组基线特征差异,采用多因素分析患者预后的危险因素,建立预后模型。并用受试者工作特征(ROC)曲线评价新模型、终末期肝病模型(MELD)和前白蛋白-胆红素(PALBI)评分的预测效能。结果 294例PE经治的HBV-ACLF患者中,生存组230例,死亡组64例。与生存组比较,死亡组合并腹水(58.26%比79.69%,χ²=9.853,P=0.002)、肝性脑病(6.09%比37.50%,χ²=43.899,P＜0.001) 、感染(68.26%比89.06%,χ²=10.938,P=0.001)的发生率高,总胆红素高[347.60 (294.20,423.33)μmol/L比396.00 (309.65,511.33)μmol/L,Z=-2.366,P=0.018],前白蛋白低[52.00 (35.75,64.25)g/L比35.00(26.00,47.00)g/L,Z=-5.461,P＜0.001],凝血酶原时间延长[22.10(19.58,24.83)s比28.80(23.00,33.25)s,Z=-7.582,P＜0.001],血尿素氮高[3.50 (2.70,4.53)μmol/L比4.45(3.30,5.55)μmol/L,Z=-3.231,P=0.001],甲胎蛋白低[101.05 (33.30,231.60)μg/L比29.15(9.75,107.25)μg/L,Z=-5.236,P＜0.001],血乳酸高[1.30(1.00,1.70)mmol/L比1.57(1.10,1.98)mmol/L,Z=-2.135,P=0.033]。多因素分析显示:总胆红素、前白蛋白、凝血酶原时间、尿素氮、甲胎蛋白是PE经治的HBV-ACLF患者短期预后不良的独立影响因素,总胆红素的回归系数是0.006(95%CI:1.003~1.009, P＜0.001),前白蛋白的回归系数是-0.043(95%CI:0.936~0.981, P＜0.001),凝血酶原时间的回归系数是0.186(95%CI:1.123~1.293,P＜0.001),血尿素氮的回归系数是0.211(95%CI:1.062~1.435,P=0.006),甲胎蛋白的回归系数是-0.010(95%CI:0.984~0.996, P=0.002);建立TPPBA = 0.006×[TBil(μmol/L)]-0.043×[PAB(mg/L)]+0.186×[PT(s)]+0.211×[BUN(mmol/L)]-0.010×[AFP(μg/L)]-6.768。TPPBA的 ROC曲线下面积(AUC)=0.905(95%CI:0.871~0.939,P＜0.001)、MELD AUC=0.804(95%CI:0.741~0.866,P＜0.001)、PALBI评分AUC=0.750(95%CI:0.681~0.820,P＜0.001)。ROC曲线两两比较,MELD与PALBI对比,Z=1.293,P=0.196,差异无统计学意义;MELD与TPPBA对比,Z=3.958,P＜0.001,差异有统计学意义,PALBI与TPPBA对比,Z=4.826,P＜0.001,差异有统计学意义,TPPBA优于MELD和PALBI评分,差异有统计学意义(P＜0.05)。结论总胆红素、前白蛋白、凝血酶原时间、尿素氮、甲胎蛋白是PE经治HBV-ACLF患者短期预后的独立影响因素,基于上述指标建立的TPPBA模型较MELD、PALBI评分有更好的预测价值。

关键词: 乙型肝炎病毒, 慢加急性肝衰竭, 血浆置换, 预后, 模型

Abstract: Objective To explore the influencing factors of short-term prognosis in patients with hepatitis B virus-associated acute-on-chronic liver failure (HBV-ACLF) treated with plasma exchange (PE), develop a new prognostic model and evaluate its value for prognosis. Methods A total of 294 HBV-ACLF patients who received more than 3 sessions of PE treatment at Meng Chao Hepatobiliary Hospital of Fujian Medical University from January 2020 to December 2024 were selected. They were divided into a survival group and a death group based on their survival status after 24 weeks. The study analyzed the differences in baseline characteristics between the two groups, used multivariate analysis to identify independent predictors of patient prognosis, and established a prognostic model. The predictive performance of the new model, the Model for End-Stage Liver Disease (MELD), and the Prealbumin-Bilirubin (PALBI) score was evaluated using the Receiver Operating Characteristic (ROC) curve. Results Among the 294 HBV-ACLF patients treated for PE, 230 were in the survival group and 64 were in the death group. Compared with the survival group, the death group had a higher proportions of ascites [58.26% vs. 79.69%(χ²=9.853,P=0.002)], hepatic encephalopathy [6.09% vs. 37.50% (χ²=43.899, P<0.001)] and infections [68.26% vs. 89.06% (χ²=10.938, P=0.001)]. There were also higher levels of total bilirubin [347.60 (294.20, 423.33)μmol/L vs. 396.00 (309.65, 511.33)μmol/L (Z=-2.366, P=0.018)], lower levels of prealbumin [52.00 (35.75, 64.25)g/L vs. 35.00 (26.00, 47.00)g/L (Z=-5.461, P<0.001)], prolonged prothrombin time [22.10 (19.58, 24.83)s vs. 28.80 (23.00, 33.25)s (Z=-7.582, P<0.001)], higher levels of blood urea nitrogen [3.50 (2.70, 4.53)μmol/L vs. 4.45 (3.30, 5.55)μmol/L (Z=-3.231, P=0.001)], lower levels of alpha-fetoprotein [101.05 (33.30, 231.60)g/L vs. 29.15 (9.75, 107.25)g/L (Z=-5.236, P<0.001)], and higher levels of lactate [1.30 (1.00, 1.70)mmol/L vs. 1.57 (1.10, 1.98)mmol/L (Z=-2.135, P=0.033)]. Multivariate analysis showed that total bilirubin, prealbumin, prothrombin time, blood urea nitrogen, and alpha-fetoprotein were independent predictors of poor short-term prognosis in HBV-ACLF patients treated with PE. The regression coefficient for total bilirubin was 0.006 (95% CI: 1.003~1.009, P<0.001). The regression coefficient for prealbumin was -0.043 (95% CI: 0.936~0.981,P<0.001). The regression coefficient for prothrombin time was 0.186 (95% CI: 1.123~1.293, P<0.001). The regression coefficient for blood urea nitrogen was 0.211 (95% CI: 1.062~1.435, P=0.006). The regression coefficient for alpha-fetoprotein was -0.010 (95% CI: 0.984~0.996, P=0.002). The equation for TPPBA is: TPPBA = 0.006×[TBil(μmol/L)]-0.043×[PAB(mg/L)]+0.186×[PT(s)]+0.211×[BUN(mmol/L)]-0.010×[AFP(μg/L)]-6.768. The area under the ROC curve for TPPBA was 0.905 (95% CI: 0.871~0.939, P<0.001). Similarly, the AUCs for MELD were 0.804 (95% CI: 0.741~0.866, P<0.001), and those for PALBI scoring were 0.750 (95% CI: 0.681~0.820, P<0.001). When comparing the ROC curves among these three methods, there was no significant difference between MELD and PALBI scoring (Z=1.293, P=0.196). However, there were significant differences between MELD and TPPBA (Z=3.958, P<0.001) and between PALBI and TPPBA (Z=4.826, P<0.001). Thus, TPPBA outperformed both MELD and PALBI scoring in terms of predictive accuracy (P<0.05). Conclusion Total bilirubin, prealbumin, prothrombin time, blood urea nitrogen, and alpha-fetoprotein are independent predictors of short-term prognosis in PE-treated HBV-ACLF patients. The TPPBA model, based on these indicators, demonstrates better predictive value than the MELD and PALBI scores.

Key words: Hepatitis B virus, Chronic-on-acute liver failure, Plasma exchange, Prognosis, Model

陈丽霞, 林建辉. 血浆置换经治乙型肝炎病毒相关慢加急性肝衰竭患者预后模型的建立与评价[J]. 肝脏, 2026, 31(8): 1137-1141.

Chen Lixia, Lin Jianhui. Establishment and evaluation of a prognostic model for patients with hepatitis B virus-associated acute-on-chronic liver failure after plasma exchange treatment[J]. Chinese Hepatolgy, 2026, 31(8): 1137-1141.

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