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