重型病毒性肝炎的终末期肝病模型预后分析

目的探讨终末期肝病模型(MELD)评分系统对重型病毒性肝炎患者短期预后的预测能力及临床应用价值,应用c-统计值评估MELD模型的预测准确性,该值等同于受试者工作特征曲线的曲线下面积,并求出作为判断患者3个月内生存与否的MELD最佳临界值。方法121例住院的重型病毒性肝炎患者分为血浆置换(PE)组与非PE组,应用MELD模型公式对每个患者进行评分,观察3个月内的病死率。结果81例患者在3个月内死亡(PE组35例,非PE组46例)。MELD分值在20～30和30～40范围内的患者病死率,PE组病死率分别为31.6％、57.7％明显低于非PE组的67.6％、81.3％,差异有统计学意义(P<0.05)。MELD分值达到或超过40的患者病死率,PE组为93.3％,非PE组为100％,两组的差异无统计学意义。应用该模型判断患者3个月内死亡与否的最佳MELD临界值,PE组为30,敏感性80.0％,特异性52.0％,c-统计值为0.777;而非PE组的临界值为25,敏感性为82.6％,特异性为86.7％,c-统计值为0.869。结论MELD分值能够作为反映重型病毒性肝炎患者病情严重程度的指标;患者短期内死亡危险性随MELD分值的增加而上升;MELD模型能较准确预测重型病毒性肝炎患者短期的临床预后。

Analysis of prognosis on patients with severe viral hepatitis using the model for end-stage liver disease

Objective To study the practical use of the model for end-stage liver disease (MELD) in clinics and to assess its validity in predicting the prognoses of patients with severe viral hepatitis and to determine the validity of the model by the concordance (c)-statistic which is equivalent to the area under the receiver operating characteristic (ROC) curve. Also, the optimal cutoff values of MELD to discriminate between deceased and surviving patients were calculated using ROC curves. Methods 121 patients were divided into a plasma exchange (PE) group and a non-plasma exchange (non-PE) group, and they were graded with the MELD formula. The death rate was observed within three months. Results 81 patients died within 3 months (35 cases in the PE group, 46 cases in the non-PE group). The mortality rates of patients in the PE group whose MELD scores were between 20-30 and 30-40 were 31.6% and 57.7% respectively, but in non-PE cases they were 67.6%, 81.3% respectively; there was a significant difference between the PE group and non-PE group (P < 0.05). The mortality rates of patients whose MELD score was higher than 40 were 93.3% in the PE group and 100% in the non-PE group, however there was no significant difference between the two groups (P >0.05). The optimal cut-off values of MELD to predict the prognoses of patients were 30 in the PE group whose sensitivity, specificity and c-statistic were 80.0%, 52.0% and 0.777, but in the non-PE group they were 25, 82.6%, 86.7% and 0.869, respectively. Conclusions This study suggests that MELD scores can serve as an index of the severity of the disease of patients with severe viral hepatitis, and that the mortality rates of the patients increase with the increase of their MELD scores. MELD can accurately predict the short-term prognoses of patients with severe viral hepatitis.