HBV相关慢加急性肝衰竭患者短期预后预测模型的建立与评价

目的探讨HBV相关慢加急性肝衰竭(HBV-ACLF)患者短期(12周)生存预后的预测因素,建立新型预测模型。方法收集2015年4月-2018年8月在安徽医科大学附属省立医院确诊HBV-ACLF的67例患者的临床资料,根据确诊后12周随访生存情况分为生存组(n=28)和死亡组(n=39)。收集患者临床资料,包括性别、年龄、TBil、国际标准化比值(INR)、肌酐(Cr)、血清钠、PLT、ALT、AST、Alb、血清胱抑素C(CysC),是否有急性肾损伤(AKI)。正态分布的计量资料2组间比较采用t检验,偏态分布的计量资料2组间比较采用Wilcoxon秩和检验;计数资料组间比较采用χ2检验;影响HBV-ACLF患者预后因素采用多因素logistic回归法并建立预测模型;采用受试者工作特征曲线(ROC曲线)评价预测模型,ROC曲线下面积(AUC)的比较采用DeLong法。结果死亡组患者的年龄、TBil、INR、CysC、MELD评分均高于生存组,合并AKI患者的近期生存率明显低于无AKI者(P值均<0.05)。TBil比值比(OR)=1.013,95%可信区间(95%CI):1.003~1.024,P=0.014]、INR(OR=6.857,95%CI:1.449~32.449,P=0.015)、CysC(OR=2.826,95%CI:1.001~7.983,P=0.050)、PLT(OR=0.982,95%CI:0.964~1.000,P=0.048)是HBV-ACLF患者短期生存的独立影响因素。TBil、INR、CysC和PLT联合建立TICP模型,TICP模型的AUC(95%CI)为0.879(0.776~0.946),MELD评分的AUC(95%CI)为0.760(0.644~0.859),两者比较有差异统计学意义(Z=2.708,P=0.007)。TICP预测HBVACLF患者短期生存情况的准确度(87.05%vs 67.16%)、敏感度(84.62%vs 56.41%)、约登指数(0.70 vs 0.42)均优于MELD评分。结论TBil、INR、CysC、PLT是HBV-ACLF患者短期预后的独立影响因素,四者联合建立的TICP预测模型对患者短期生存预后具有良好的预测价值。

Establishment and evaluation of a predictive model for short-time prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure

Objective To investigate the predictive factors for short-term(12-week)survival and prognosis of patients with hepatitis B virus(HBV)-related acute-on-chronic liver failure(HBV-ACLF),and to establish a new predictive model.Methods Related clinical data were collected from 67 patients who were diagnosed with HBV-ACLF in The Affiliated Provincial Hospital of Anhui Medical University from April 2015 to August 2018,and according to their survival at 12-week follow-up after diagnosis,they were divided into survival group with 28 patients and death group with 39 patients.Their clinical data were collected,including sex,age,total bilirubin(TBil),international normalized ratio(INR),creatinine(Cr),serum sodium,platelet count(PLT),alanine aminotransferase(ALT),aspartate aminotransferase(AST),albumin(Alb),serum cystatin C(CysC),and presence or absence of acute kidney injury(AKI).The t-test was used for comparison of normally distributed continuous data between two groups,and the Wilcoxon rank-sum 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;logistic regression was used to perform the factorial analysis and establish a predictive model;the receiver operator characteristic(ROC)curve was used to evaluate the predictive model,and the method by DeLong et al.was used to compare the area under the ROC curve(AUC).Results The death group had significantly higher age,TBil,INR,CysC,and Model for End-Stage Liver Disease(MELD)score than the survival group,and the patients with AKI had a significantly lower short-term survival rate than those without AKI(all P<0.05).TBil(odds ratioOR]=1.013,95%confidence intervalCI]:1.003-1.024,P=0.014),INR(OR=6.857,95%CI:1.449-32.449,P=0.015),CysC(OR=2.826,95%CI:1.001-7.983,P=0.050),and PLT(OR=0.982,95%CI:0.964-1.000,P=0.048)were independent predictive factors for patient survival.A TICP model was established with the combination of TBil,INR,CysC,and PLT,and there was a significant difference in AUC between the TICP model and MELD score0.879(95%CI:0.776-0.946)vs 0.760(95%CI:0.644-0.859),Z=2.708,P=0.007].Compared with MELD score,the TICP model had significantly better accuracy(87.05%vs 67.16%),sensitivity(84.62%vs 56.41%),and Youden index(0.70 vs 0.42).Conclusion TBil,INR,CysC,and PLT are independent influencing factors for short-term prognosis of HBV-ACLF patients,and the TICP predictive model with the combination of these four indices has a good value in predicting the short-term survival and prognosis of HBV-ACLF patients.