CAJ | 학술논문

目的探讨基线终末期肝病模型(MELD)、MELD-Na、整合MELD模型(iMELD)3种模型评估初始治疗乙型肝炎病毒(HBV)相关慢加急性肝衰竭(ACLF)患者近期预后的价值.方法对解放军第三○二医院2011年1月至2013年1月收治的232例初始治疗的HBV相关ACLF患者进行前瞻性临床随访,分析患者入院时MELD、MELD-Na、iMELD与12周时临床转归的关系,评判3种模型对患者近期预后的预测价值.结果最终191例患者完成12周临床随访,完成率为82.33％;死亡85例,病死率为44.50％.与存活组比较,死亡组基线MELD(分:26.65±7.75比21.19±5.42,t=-5.720,P=0.000)、MELD-Na(分:29.16±11.35比21.72±6.33,t=-5.729,P=0.000)、iMELD(分:47.19±10.96比38.02±7.01,t=-7.011,P=0.000)、总胆红素[TBil(μmol/L):374.3±150.1比305.5±147.1,t=-3.182,P=0.002]、肌酐[Cr(μmol/L):110.7±90.1比71.1±35.1,t=-4.157,P=0.000]、国际标准化比值(INR:2.3±0.9比2.0±0.6,t=-2.754,P=0.006)均明显升高,血清Na+水平(mmol/L:132.8±6.1比136.7±5.1,t=4.861,P=0.000)明显降低.Spearman相关分析显示,基线MELD、MELD-Na、iMELD与患者近期预后均呈显著正相关(r值分别为0.398、0.404、0.470,均P=0.000),基线血清Na+水平与患者近期预后呈显著负相关(r=-0.365,P=0.000).受试者工作特征曲线(ROC曲线)分析显示,基线MELD、MELD-Na、iMELD 3种模型的临界值分别为25.07、25.43、43.11分,ROC曲线下面积(AUC)分别为0.731、0.735、0.773,敏感度分别为55.3％、57.7％、63.5％,特异度分别为84.9％、84.0％、84.9％,3种模型的预测价值均无差异.3种模型根据各自的临界值将患者分为4组,病死率整体均存在差异(MELD的x2=34.740,P=0.000;MELD-Na的x2=36.861,P=0.000; iMELD的x2=50.127,P=0.000),且随3种模型分值增加,患者病死率均呈逐渐上升趋势.结论基线MELD、MELD-Na、iMELD均能较好地预测初始治疗HBV相关ACLF患者的近期预后,对指导治疗有较好的临床价值.
목적 탐토기선종말기간병모형(MELD)、MELD-Na、정합MELD모형(iMELD)3충모형평고초시치료을형간염병독(HBV)상관만가급성간쇠갈(ACLF)환자근기예후적개치.방법 대해방군제삼○이의원2011년1월지2013년1월수치적232례초시치료적HBV상관ACLF환자진행전첨성림상수방,분석환자입원시MELD、MELD-Na、iMELD여12주시림상전귀적관계,평판3충모형대환자근기예후적예측개치.결과 최종191례환자완성12주림상수방,완성솔위82.33％;사망85례,병사솔위44.50％.여존활조비교,사망조기선MELD(분:26.65±7.75비21.19±5.42,t=-5.720,P=0.000)、MELD-Na(분:29.16±11.35비21.72±6.33,t=-5.729,P=0.000)、iMELD(분:47.19±10.96비38.02±7.01,t=-7.011,P=0.000)、총담홍소[TBil(μmol/L):374.3±150.1비305.5±147.1,t=-3.182,P=0.002]、기항[Cr(μmol/L):110.7±90.1비71.1±35.1,t=-4.157,P=0.000]、국제표준화비치(INR:2.3±0.9비2.0±0.6,t=-2.754,P=0.006)균명현승고,혈청Na+수평(mmol/L:132.8±6.1비136.7±5.1,t=4.861,P=0.000)명현강저.Spearman상관분석현시,기선MELD、MELD-Na、iMELD여환자근기예후균정현저정상관(r치분별위0.398、0.404、0.470,균P=0.000),기선혈청Na+수평여환자근기예후정현저부상관(r=-0.365,P=0.000).수시자공작특정곡선(ROC곡선)분석현시,기선MELD、MELD-Na、iMELD 3충모형적림계치분별위25.07、25.43、43.11분,ROC곡선하면적(AUC)분별위0.731、0.735、0.773,민감도분별위55.3％、57.7％、63.5％,특이도분별위84.9％、84.0％、84.9％,3충모형적예측개치균무차이.3충모형근거각자적림계치장환자분위4조,병사솔정체균존재차이(MELD적x2=34.740,P=0.000;MELD-Na적x2=36.861,P=0.000; iMELD적x2=50.127,P=0.000),차수3충모형분치증가,환자병사솔균정축점상승추세.결론 기선MELD、MELD-Na、iMELD균능교호지예측초시치료HBV상관ACLF환자적근기예후,대지도치료유교호적림상개치.
Objective To explore the function of the baseline model for end-stage liver disease (MELD) scores,MELD-Na scores and iMELD scores in short-term prognosis in the initial treatment of hepatitis B virus (HBV) related acute-on-chronic liver failure (ACLF) patients.Methods 232 HBV-related ACLF patients who received initial treatment in 302 Military Hospital of China from January 2011 to January 2013 were enrolled in this prospective clinical follow-up.The relationship between the baseline MELD scores,MELD-Na scores,iMELD scores and clinical outcomes were analyzed,and the value of these three models for short term prognosis was assessed.Results Finally the 12-week clinical follow-up was completed in 191 patients,with the completion rate of 82.33％.Eighty-five patients died,with the fatality rate of 44.50％.Compared with the survival group,in non-survival group,the baseline of MELD scores (26.65 ± 7.75 vs.21.19 ± 5.42,t=-5.720,P=0.000),MELD-Na scores (29.16 ± 11.35 vs.21.72 ± 6.33,t=-5.729,P=0.000),iMELD scores (47.19 ± 10.96 vs.38.02 ±7.01,t=-7.011,P=0.000),total bilirubin [TBil (μmol/L):374.3 ± 150.1 vs.305.5 ± 147.1,t=-3.182,P=0.002],creatinine [Cr (μmol/L):110.7 ±90.1 vs.71.1 ± 35.1,t=-4.157,P=0.000] and international normalized ratio (INR:2.3 ± 0.9 vs.2.0 ± 0.6,t=-2.754,P=0.006) were significantly increased,but the baseline of serum Na+ (mmol/L:132.8 ± 6.1 vs.136.7 ± 5.1,t=4.861,P=0.000) was significantly lowered.It was shown by Spearman correlation analysis thai the baseline MELD scores,MELD-Na scores and iMELD scores all had positive correlation with the short-term prognosis of patients (r value was 0.398,0.404,and 0.470,respectively,all P=0.000),the baseline of serum Na+ had a negative correlation with the short-term prognosis of patients (r=-0.365,P=0.000).It was shown by receiver operating characteristic curve (ROC curve) that the cut-off scores of the baseline of MELD scores,MELD-Na scores and iMELD scores were 25.07,25.43 and 43.11 respectively,and the area under ROC curve (AUC) of the baseline of MELD scores,MELD-Na scores and iMELD scores were 0.731,0.735 and 0.773,respectively.The sensitivity of the three models was 55.3％,57.7％,63.5％,and the specificity was 84.9％,84.0％,84.9％ respectively.The value of the three models had no difference in short-term prognostic prediction.According to the respective cut-off score,the three prediction models were divided into four groups,and all of them had differences in fatality rate on the whole (x2 for MELD scores was 34.740,P=0.000; x2 for MELD-Na scores was 36.861,P=0.000; x2 for iMELD scores was 50.127,P=0.000).The mortality was elevated gradually as the equation scores increased.Conclusion The baseline of MELD scores,MELD-Na scores and iMELD scores can predict well the short-term prognosis of the initial treatment in HBV-related ACLF patients,and have relatively good clinical value for guiding therapy.