摘要
目的 联合吲哚菁绿清除试验(ICG)和总胆红素留存率(TBARR)建立预测经人工肝治疗的HBV相关慢加急性肝衰竭(HBV-ACLF)患者短期预后的新模型。方法 回顾性收集2017年6月—2021年7月西南医科大学附属医院感染科收治的136例经人工肝治疗的HBV-ACLF患者的临床资料,据随访3个月时的转归情况分为存活组(n=92)和死亡组(n=44),检测确诊ACLF时的生化、凝血、吲哚菁绿15分钟滞留率(ICG R_(15))及肝有效血流量(EHBF)等指标,计算终末期肝病模型(MELD)评分、MELD差值(ΔMELD)、Child-Turcotte-Pugh(CTP)评分、总胆红素清除率(TBCR)、总胆红素反弹率(TBRR)和TBARR。偏态分布的计量资料两组间比较采用Mann-Whitney U检验;计数资料两组间比较则采用χ~2检验。应用二分类Logistic回归分析法,构建人工肝治疗HBV-ACLF短期预后的联合预测模型。应用受试者工作特征曲线下面积(AUC)评估各种模型对人工肝治疗HBV-ACLF短期预后判断的准确性,AUC的比较采用Z检验。结果 死亡组与存活组两组间比较,MELD评分、ΔMELD、CTP评分、ICG R_(15)、EHBF、TBRR、TBARR、中性粒细胞计数、中性粒细胞百分比、淋巴细胞计数、PLT、ALP、GGT、Alb、PT、INR、PTA、总胆红素、前白蛋白、纤维蛋白原、血清Na、年龄及肝性脑病发生率差异均有统计学意义(P值均<0.05)。多因素Logistic回归分析显示,年龄(OR=1.096,95%CI:1.056~1.137,P<0.001)、中性粒细胞计数(OR=1.214,95%CI:1.044~1.411,P=0.012)、TBRR(OR=0.989,95%CI:0.982~0.996,P=0.001)、TBARR(OR=1.073,95%CI:1.049~1.098,P<0.001)、ΔMELD(OR=1.480,95%CI:1.288~1.701,P<0.001)、CTP评分(OR=2.081,95%CI:1.585~2.732,P<0.001)以及ICG R_(15)(OR=1.116,95%CI:1.067~1.168,P<0.001)是经人工肝治疗HBV-ACLF患者短期死亡的独立影响因素。应用二分类Logistic回归分析,构建了4种人工肝治疗HBV-ACLF短期预后的联合预测模型,分别为TBRR-ICG R_(15)、TBARR-ICG R_(15)、TBARR-ICG R_(15)-ΔMELD和TBARR-ICG R_(15)-ΔMELD-年龄,AUC分别为0.830、0.867、0.900、0.917,联合预测模型的AUC高于单一指标(年龄、中性粒细胞计数、TBRR、TBARR、ΔMELD、MELD评分、CTP评分、ICG R_(15)),其中TBARR-ICG R_(15)-ΔMELD-年龄模型的AUC最大。联合模型TBARR-ICG R_(15)-ΔMELD和TBARR-ICG R_(15)-ΔMELD-年龄的敏感度和特异度均在80%以上。结论 ICG R_(15)联合TBARR构建的联合预测模型对人工肝治疗HBV-ACLF患者的短期预后有较好的预测价值,联合模型对预后判断的准确性优于单一模型。
Objective To establish a new model of indocyanine green(ICG) clearance test combined with total bilirubin actual resident rate(TBARR) for predicting the short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure(HBV-ACLF) treated with artificial liver support system(ALSS) therapy.Methods A retrospective analysis was performed for the clinical data of 136 patients with HBV-ACLF who underwent ALSS therapy in Department of Infectious Diseases,The Affiliated Hospital of Southwest Medical University,from June 2017 to July 2021,and according to the prognosis at 3-month follow-up,they were divided into survival group with 92 patients and death group with 44 patients.Related indicators were measured at the time of the confirmed diagnosis of ACLF,including biochemical parameters,coagulation,indocyanine green retention rate at 15 minutes(ICGR_(15)),and effective hepatic blood flow(EHBF),and related indices were calculated,including Model for End-Stage Liver Disease(MELD) score,MELD difference(ΔMELD),Child-Turcotte-Pugh(CTP) score,total bilirubin clearance rate(TBCR),total bilirubin rebound rate(TBRR),and TBARR.The Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups;the chi-square test was used for comparison of categorical data between groups.A binary logistic regression analysis was used to establish a combined predictive model for the prognosis of HBV-ACLF after ALSS therapy.The area under the ROC curve(AUC) was used to compare the accuracy of various models in judging the short-term prognosis of patients with HBV-ACLF after ALSS therapy,and the Z test was used for comparison of AUC.Results There were significant differences between the death group and the survival group in MELD score,ΔMELD,CTP score,ICGR_(15),EHBF,TBRR,TBARR,neutrophil count,percentage of neutrophils,lymphocyte count,platelet count,alkaline phosphatase,gamma-glutamyl transpeptidase,total bilirubin,albumin,prothrombin time,international normalized ratio,prothrombin time activity,prealbumin,fibrinogen,serum sodium,age,and the incidence rate of hepatic encephalopathy(all P80%.Conclusion The combined predictive model established by ICGR_(15) and TBARR has a good value for in predicting the short-term prognosis of patients with HBV-ACLF after ALSS therapy,and the combined predictive model has a better accuracy than the single model in judging prognosis.
作者
都泓莲
李烨
王波
马琳坤
胡甜甜
盛云建
陈文
吴刚
邓存良
DU Honglian;LI Ye;WANG Bo;MA Linkun;HU Tiantian;SHENG Yunjian;CHEN Wen;WU Gang;DENG Cunliang(Department of Infectious Diseases,The Affiliated Hospital of Southwest Medical University,Luzhou,Sichuan 646000,China)
出处
《临床肝胆病杂志》
CAS
北大核心
2023年第2期307-315,共9页
Journal of Clinical Hepatology
基金
四川省卫生健康委员会医学科技项目(21PJ098)。
关键词
乙型肝炎病毒
慢加急性肝功能衰竭
肝
人工
预后
吲哚菁绿清除试验
总胆红素留存率
Hepatitis B Virus
Acute-On-Chronic Liver Failure
Liver,Artificial
Prognosis
Indocyanine Green Clearance Test
Total Bilirubin Actual Resident Rate
