两种评分系统对慢性肝衰竭患者预后的判断价值

目的：探讨终末期肝病模型（MELD）和柯伟民评分系统对慢性肝衰竭患者短期预后的预测价值。方法回顾性分析70例慢性乙型肝炎肝衰竭患者的临床资料,按入院后3个月转归情况分为生存和死亡组,进行预后预测。结果柯伟民评分系统包括肝性脑病、总胆红素、腹水、PTA、血清肌酐、肝脏斜径或厚度和感染等指标进行计分。在70例慢性肝衰竭患者中,生存组与死亡组患者MELD计分分别为（10.8±6.7）和（27.3±9.7）,两组相比有统计学差异（P〈0.01）;柯伟民评分＜10分42例,死亡3例（7.1%）,10分≤评分＜20分26例,死亡12例（46.2%）,20分≤评分2例,死亡2例（100%）。柯伟民评分判断肝衰竭患者预后的ROC曲线下面积为0.877,标准误为0.041,P〈0.000,95%置信区间为（0.796,0.958）。应用该模型判断70例慢性肝衰竭患者预后的敏感性为94％（16/17）,特异性为68％（36/53）,准确性为74％。结论 MELD模型和柯伟民评分系统均可以用于慢性肝衰竭患者的预后判断,但后者计算更为简便。     

恩替卡韦在慢加亚急性肝衰竭患者中的初步临床应用

目的研究恩替卡韦对HBV所致的慢加亚急性肝衰竭患者生化及近期预后指标的影响。方法对14例慢加亚急性肝衰竭患者应用恩替卡韦0.5mg/日,分别比较治疗前与治疗后（4周、8周、12周、24周）的生化、凝血酶原活动度的指标及治疗第4周、12周、24周的HBV DNA定量的变化。同时应用MELD评分公式进行评价。结果治疗8、12、24周后的总胆红素（T-BIL）、谷丙转氨酶（ALT）分别与治疗前比较明显降低（P〈0.01）;治疗4周、8周、12周、24周的凝血酶原活动度与治疗前比较明显升高（P〈0.05）,治疗12周、24周的血清白蛋白（ALB）与治疗前比较均明显升高（P〈0.05）;治疗12周、24周的MELD评分值与治疗前相比明显降低（P=0.000,P〈0.01）。第4周、12周、24周的HBVDNA定量与治疗前比较明显降低,差异有统计学意义（P=0.000）。结论恩替卡韦能有效抑制HBV的复制,改善乙型肝炎肝衰竭患者的生化指标,降低其病死率。     

终末期肝病模型评估血浆置换治疗慢性重型肝炎的疗效及预后

目的探讨终末期肝病模型（MELD）评分对血浆置换治疗慢性重型肝炎的疗效和对短期预后的预测能力。方法 210例慢性重型肝炎患者被分成血浆置换组（85例）和对照组（125例）,观察两组在治疗前与治疗后2周MELD评分及3个月时的病死率的变化。采用受试者工作特征（ROC）曲线及曲线下面积评价MELD评分系统的准确性。结果治疗后2周,两组MELD评分均有明显的降低（P〈0.01）,但在MELD〉40的患者,则无明显降低;PE组患者病死率（49.4%）低于对照组（64.8%,P〈0.05）,在MELD≤39的患者,两组病死率差异有统计学意义（P〈0.01）;对照组最佳MELD临界值为26,其敏感度为80.2%,特异度为79.5%,准确性为80.0%,而PE组为30,其敏感度为76.2%,特异度为69.8%,准确性为72.9%。结论 MELD评分能较准确地预测慢性重型肝炎患者的短期预后。     

多种肝功能评分系统预测血浆置换治疗肝衰竭患者预后的价值探讨

目的：探讨终末期肝病模型（MELD）和MELD-Na评分系统及Child-Pugh分级系统对血浆置换治疗的肝衰竭患者预后的价值。方法回顾性分析我院2005年1月至2012年9月收治的238例乙型肝炎肝衰竭患者的临床资料,应用MELD、MELD-Na和Child-Pugh评分系统判断患者在观察3个月期内的预后情况。结果在3个月的观察期内,本组患者生存145例,死亡93例（39.1%）;生存患者入院时凝血酶原时间、INR、血清总胆红素、血清钠和肌酐水平分别为（19.6±3.7）秒、（1.6±2.2）、（199.8±50.6）μmol/L、（137.6±7.7） mmol/L和（127.3±10.8）μmol/L,与死亡患者比[分别为（25.3±5.8）秒、（2.3±1.5）、（332.7±120.9）μmol/L、（127.0±14.6） mmol/L和（210.7±75.3）μmol/L],均有显著性统计学差异（P〈0.01）;生存患者MELD、MELD-Na和Child-Pugh计分分别为（19.3±6.9）、（21.1±4.6）和（11.4±2.3）,均显著低于死亡患者[分别为（29.2±13.4）、（32.4±5.7）和（15.2±6.7）,P〈0.05];MELD-Na和MELD评分系统在预测肝衰竭近期病死率方面优于Child-Pugh分级计分。结论MELD、MELD-Na评分系统和Child-Pugh分级系统对于肝衰竭患者的病情判断均有较好的价值,但MELD和MELD-Na评分系统对肝衰竭预后判断的价值更高。     

拉米夫定联合胸腺肽α1治疗慢性乙型重型肝炎对预后的影响

目的应用终末期肝病模型（MELD）评分系统预测拉米夫定联合胸腺肽α1治疗慢性乙型重型肝炎患者的预后。方法96例慢性乙型重型肝炎患者被随机分为治疗组与对照组，应用MELD评分系统比较两组患者病死率和治疗前后的血生化指标变化。结果在MELD≤30的患者，治疗后血清总胆红素（TBIL）、凝血酶原时间国际标准化比值（INR）、血清肌酐（Cr）、MELD评分明显低于治疗前。差异有统计学意义（P〈0．01），治疗组患者的病死率为47．4％，低于对照组的78．9％，差异有统计学意义（P〈0．05）；在MELD分值30～39的患者，治疗后的TBIL、INR、Cr、MELD评分低于治疗前，治疗组患者的病死率为72．0％，与对照组的86．9％相比，差异无统计学意义（P〉0．05）；在MELD分值≥40的患者，治疗后的TBIL、INR、Cr、MELD评分与治疗前差异无统计学意义（P〉0．05），两组的病死率均为100％。结论拉米夫定联合胸腺肽α1治疗可降低MELD≤30的慢性乙型重型肝炎患者的病死率，但不能降低MELD〉30患者的病死率，故治疗宜在疾病的早期使用。     

肝硬化患者血清C3、C4、CRP与TBA水平的相关性

目的探讨肝硬化患者血清补体3（C3）、补体4（C4）、C反应蛋白（CRP）与总胆汁酸（TBA）水平相关性及其水平变化的临床意义。方法采用国赛NS II型特定蛋白分析仪,免疫散射比浊法和日本产CL-7200全自动生化分析仪分别检测102例肝硬化患者及30例正常献血员对照的血清C3、C4、CRP及TBA水平。结果肝硬化患者血清C3与TBA水平呈明显负相关（r=-0.492,P〈0.01）,而CRP与TBA水平呈明显正相关（r=0.598,P〈0.01）;肝硬化患者血清C3明显低于对照组（P〈0.01）,CRP、TBA明显高于对照组（P〈0.01）,且随肝硬化功能分级C3值逐渐下降,CRP、TBA值逐渐升高,Child-Plugh,C级组同时伴有C4水平下降,与对照组相比（P〈0.01）。结论肝硬化患者存在血清C3水平下降,CRP、TBA水平升高,联合检测血清C3、C4、CRP、TBA水平能较早地反映肝脏合成及其代谢功能,对病情和预后的早期判断有重要的临床价值。     

终末期肝病评分模型在评价肝衰竭预后中的应用

目的：应用终末期肝病评分模型（MELD）评价肝衰竭患者的预后。方法：回顾性分析2004年8月至2009年12月于我院肝病中心治疗的70例肝衰竭患者的临床资料,分析MELD分值与患者经内科治疗后预后的关系。结果：本组肝衰竭患者入院时MELD分值为（13.85±2.62）,经内科综合治疗后,有效组MELD分值为（12.54±1.57）,无效组为（14.99±3.60）,两组差异有显著性意义（P〈0.001）;内科综合治疗有效组并发症的发生率为13.2%（5/38）,无效组并发症发生率为62.5%（20/32）,两组比较差异有显著性意义（P=0.000）。结论：入院时MELD分值超过（14.99±3.60）的或早期出现并发症的肝衰竭患者预后极差,应尽快准备肝移植治疗。     

终末期肝病模型评估肝硬化失代偿期患者的短期预后

目的评价终末期肝病模型（MELD）、MELD-Na、Child-Turcotte-Pugh（CTP）和包含血肌酐值的CTP（CrCTP）评分对肝硬化失代偿期患者短期预后的价值。方法选择265例具有完整住院资料和随访结果的肝硬化失代偿期患者为研究对象,分别计算每例患者人院后首次MELD、MELD-Na、CTP及CrCTP评分,并了解其3个月内的病死率。以受试者工作特征曲线（ROC）下面积（AUC）衡量各评分系统判断患者3个月生存的能力。结果 3个月内有58例死亡。死亡组MELD、MELD-Na、CTP及CrCTP分值（分别为22.15±5.67、31.45±8.50、11.60±2.70、12.72±2.54）均高于生存组（分别为12.35±3.56、17.24±4.75、8.73±2.35、9.05±2.50）（P〈0.01）,两组在MELD分值和CTP分级的分布上差异具有统计学意义（P〈0.01）。MELD、MELD-Na、CTP及CrCTP评分对肝硬化失代偿期患者3个月预后评估的ROC曲线下面积分别为0.875、0.868、0.758、0.794,MELD评估患者短期预后价值优于CTP评分（P〈0.05）,MELD与MELD-Na、CrCTP评分差异无统计学意义。结论 MELD、MELD-Na、CTP及CrCTP模型均可有效预测肝硬化失代偿期患者的短期预后;MELD评估患者短期预后价值优于CTP;在CTP中引入血肌酐值即CrCTP评分可以提高对患者短期预后判断力。     

外周血血红蛋白含量对乙型肝炎慢加亚急性肝衰竭患者预后的评估作用

目的：探讨乙型肝炎慢加亚急性肝衰竭（SACLF）患者外周血血红蛋白（Hb）含量与预后的相关性。方法：分析我院92例乙型肝炎SACLF患者临床资料,并根据预后分为死亡组与存活组,分别检测入院第1天、第14天患者外周血Hb、总胆红素（TBil）、肌酐（Cr）、凝血酶原国际标准化值（INR）等指标,同时计算出终末期肝病模型（MELD）的分值,分析Hb与TBil、MELD两者的相关性。结果：SACLF死亡组与存活组患者入院时在Hb方面比较差异无显著性意义;死亡组患者在第14天Hb含量明显低于存活组（P〈0.05）;两组患者在入院后第1天、第14天Hb差值[Hb（d1-d14）]比较,差异具有显著性意义（P〈0.05）;92例SACLF患者Hb均值为（113.21±22.59）g/L,TBil均值为（342.24±197.22）μmol/L,MELD均值为23.07±9.14,Hb与TBil、MELD均呈负相关（r=-0.508,r=-0.538,P〈0.05,P〈0.05）。结论：SACLF患者外周血Hb下降提示预后不佳,可以作为评估肝衰竭预后的指标之一。     

四种评分模型对慢加急性乙型肝炎肝衰竭患者短期预后的评价

目的比较终末期肝病模型（MELD）、MELD-Na、慢性重型肝炎预后指数（PI）和肝移植标准（LTS）模型对慢加急性乙型肝炎肝衰竭患者短期预后的预测价值.方法在138例慢加急性乙型肝炎肝衰竭患者入院24小时内进行MELD、MELD-Na、PI和LTS评分,并随访3个月.应用受试者工作特征曲线（ROC）下面积（AUC）判断四个模型的预测能力.结果在观察期内与肝病有关的死亡患者72例,生存者66例.死亡组LTS、MELD-Na、MELD和PI平均值明显高于生存组（P〈0.01）,四个模型的AUC分别为0.860、0.801、0.749、和0.749,差异无统计学意义;四个模型预测的正确率分别为82.61%、76.81%、75.36%和73.91%,差异无统计学意义.结论4种模型对慢加急性乙型肝炎肝衰竭患者短期预后均有较好的预测价值.     

终末期肝病模型评价人工肝支持治疗肝衰竭的临床疗效

目的探讨终末期肝病模型（MELD）对人工肝血浆置换（PE）治疗肝衰竭疗效评价的临床应用价值。方法回顾性分析115例肝衰竭患者的临床资料,分别计算人工肝治疗组（PE组）和非人工肝治疗组（对照组）两组患者治疗前后MELD分值,观察90d内的临床转归,并根据MELD评分系统对肝衰竭患者的严重程度以及治疗效果进行量化分析,通过对比病死率及生存时间评价其疗效。结果经过人工肝治疗后1h,MELD分值较治疗前明显下降,但PE组与对照组治疗后30d的MELD分值无统计学差异。MELD分值在〈30,30～40,≥40不同范围内,PE组病死率分别为25%,35%,73%,对照组分别为22%,41%,83%,两组间比较无统计学差异（P〉0.05）。而PE组生存期比对照组延长（P〈0.05）。结论近期随访血浆置换治疗与内科治疗相比,不能明显降低病死率,但可以延长生存期,从而争取时机,等待肝细胞再生恢复或过渡到肝移植。     

Indicators and outcome of liver transplantation in acute liver decompensation after flares of hepatitis B

Summary. Non‐cirrhotic patients having acute liver decompensation in flares of hepatitis B can recover spontaneously or die without liver transplantation. Criteria for identifying patients in need of liver transplantation are lacking. Fifty‐one non‐cirrhotic patients having acute liver decompensation in flares of hepatitis B were retrospectively reviewed. The patients were divided into three groups: group A patients (n = 18) recovered from acute liver decompensation spontaneously; group B patients (n = 22) died of acute liver failure; and group C patients (n = 11) had liver transplantation. Model of end‐stage liver disease (MELD) scores were evaluated to identify the criteria for liver transplantation. The cut‐off point of MELD scores for liver transplantation was evaluated by receiver operating characteristic (ROC) curve. Comparing group A and B patients, MELD score was an independent factor to predict prognosis. By analysing ROC curve, a MELD score > 30 was the most optimal cut‐off point to indicate liver transplantation; however, the false positive rate was 11.1%. By weekly measurement of MELD scores, subsequent increase in MELD scores could help to avoid false positives. Moreover, a MELD score > 34 yielded 0% false positive rate and indicated the necessity of definite liver transplantation. For group C patients, ten of 11 patients were saved by liver transplantation. In conclusion, for the patients having acute liver decompensation in flares of hepatitis B, liver transplantation is definitely indicated by MELD scores > 34. Liver transplantation is also indicated if the MELD score increases in the subsequent 1–2 weeks. Liver transplantation has a good outcome if performed on time.     

恩替卡韦治疗慢加急性乙型肝炎肝衰竭近期疗效评价

目的探讨恩替卡韦治疗慢加急性乙型肝炎肝衰竭近期疗效。方法 68例慢加急性乙型肝炎肝衰竭患者被分成治疗组(42例)和对照组(26例),对照组采用常规内科治疗,治疗组在常规内科治疗基础上加用恩替卡韦0.5mg/d,比较两组治疗后血生化指标、凝血酶原活动度、HBV DNA水平、MELD分值变化及病死率。结果在治疗后12周,治疗组总胆红素和HBV DNA分别为89.7±42.5μmol/L和3.16±2.04log10copies/mL,显著低于对照组患者(145.6±64.2μmol/L和6.28±3.95log10copies/mL,P<0.01),凝血酶原活动度和白蛋白分别为48.5±15.6%和34.8±4.8g/L,显著高于对照组(40.5±12.4%和30.2±4.1g/L,P<0.05或P<0.01);治疗组早中期患者MELD分值和病死率分别为17.6±3.5和20.0%,显著低于对照组(22.4±4.1和52.9%,P<0.05或P<0.01),两组晚期患者MELD分值和病死率差异无统计学意义(P>0.05);治疗组有1例HBeAg阴转,1例HBeAg血清学转换,对照组HBVM无变化。结论恩替卡韦能有效抑制HBV复制,改善慢加急性乙型肝炎肝衰竭患者肝功能,降低早中期患者MELD分值和病死率。尽早抗病毒治疗可提高慢加急性乙型肝炎肝衰竭患者的生存率。     

动态MELD评分有助于预测HBV相关慢加急性肝衰竭预后

目的探讨在判断HBV相关慢加急性肝衰竭(HBV-related acute-on-chronic liver failure,HBV-ACLF)患者预后方面,终末期肝病模型(model for end-stage liver disease,MELD)评分的动态变化是否优于基线MELD评分。方法前瞻性收集2009—2011年在我国4家医院住院治疗的HBV-ACLF患者的临床资料,包括临床表现、实验室检查及转归等,研究MELD评分动态变化与转归的关系。结果①纳入的82例90 d病死率为37.80%。死亡组患者基线MELD评分为(25.50±4.77)分,与存活组[(23.72±4.68)分]相比,差异无统计学意义(P=0.101)。但是从入组第7天开始,死亡组MELD评分逐渐升高,存活组MELD评分逐渐下降,此后各时间点2组MELD评分相比差异均有统计学意义。②低危组(基线MELD评分≤23分者)从第14天开始,存活患者MELD评分显著低于死亡患者[(16.04±4.00)分vs(29.39±12.30)分,P<0.05],高危组(基线MELD评分>23分者)从第7天开始,存活患者MELD评分显著低于死亡患者[(22.38±4.91)分vs(28.92±6.76)分,P=0.001],并且随着时间推移,差距逐渐增加。结论判断HBV-ACLF的预后应在基线MELD评分基础上,注意其动态变化,这将有助于提高预测的准确性。     

Evaluation of effect of hybrid bioartificial liver using end-stage liver disease model

AIM: To study the role of hybrid bioartificial liver (HBL) in clearing proinflammatory cytokines and endotoxin in patients with acute and sub-acute liver failure and the effects of HBL on systemic inflammatory syndrome (SIRS) and multiple organ dysfunction syndrome (MODS).METHODS: Five cases with severe liver failure (3 acute and 2 subacute) were treated with HBL. The clinical signs and symptoms, total bilirubin (TBIL), serum ammonia,endotoxin TNF-~, 1L-6 and prothrombin activity (PTA),cholinesterase (CHE) were recorded before, during and after treatment. The end-stage liver disease (MELD) was used for the study.RESULTS: Two patients were bridged for spontaneous recovery and 1 patient was bridged for OLT successfully.Another 2 patients died on d 8 and d 21. The spontaneous recovery rate was 30.0%. PTA and CHE in all patients were significantly increased (P&lt;0.01), while the serum TBIL,endotoxin,TNF-α, IL-6 were decreased. MELD score (mean 43.6) predicted 100% deaths within 3 mo before treatment with HBL. After treatment with HBL, four out of 5 patients had decreased MELD scores (mean 36.6). The MELD score predicted 66% mortalities.CONCLUSION: The proinflammatory cytokines (TNFα, IL-6 and endotoxin)can be significantly removed by hybrid bioartificial liver and HBL appears to be effective in blocking SIRS and MODS in patients with acute and sub-acute liver failure. MELD is a reliable measure for predicting short-term mortality risk in patients with end-stage liver disease. The prognostic result also corresponds to clinical outcome.     

Comparison scoring model of severe viral hepatitis and model of end stage liver disease for the prognosis of patients with liver failure in China

AIM:To estimate the prognosis of patients with liver failure using a scoring model of severe viral hepatitis (SMSVH) and a model of end stage liver disease (MELD) to provide a scientific basis for clinical decision of treatment. METHODS:One hundred and twenty patients with liver failure due to severe viral hepatitis were investigated with SMSVH established. Patients with acute,subacute,and chronic liver failure were 40,46 and 34,respectively. The follow-up time was 6 mo. The survival rates of patients with liver failure in 2 wk,4 wk,3 mo and 6 mo were estimated with Kaplan-Meier method. Comparison between SMSVH and MELD was made using ROC statistic analysis. RESULTS:The survival curves of group A (at low risk,SMSVH score ≤ 4) and group B (at high risk,SMSVH score ≥ 5) were significantly different (The 4-wk,3-mo,6-mo survival rates were 94.59%,54.05%,43.24% in group A,and 51.81%,20.48%,12.05% in group B,respectively,P < 0.001). The survival curves of group C (SMSVH scores unchanged or increased),group D (SMSVH scores decreased by 1) and group E (SMSVH scores decreased by 2 or more) were significantly different .The survival rates of groups C,D and E were 66.15%,100%,100% in 2-wk; 40.0%,91.18%,100% in 4-wk; 0%,58.82%,80.95% in 3-mo and 0%,38.24%,61.90% in 6-mo,respectively,P < 0.001). The area under the ROC curve (AUC) of SMSVH scores at baseline and after 2 wk of therapy was significantly higher than that under the ROC curve of MELD scores (0.804 and 0.934 vs 0.689,P < 0.001). CONCLUSION:SMSVH is superior to MELD in theestimation of the prognosis of patients with severe viral hepatitis within 6 mo. SMSVH may be regarded as a criterion for estimation of the efficacy of medical treatment and the decision of clinical treatment.     

Preliminary clinical experience in liver retransplantation

BACKGROUND: The past several decades have witnessed increasingly successful rates of liver transplantation. However, retransplantation remains the only choice for patients with irreversible graft failure after primary transplantation. This article aimed to summarize our clinical experience in liver retransplantation. METHODS: From June 2002 to December 2005, a total of 185 cases of liver transplantation including 8 cases of retransplantation were performed in our hospital. The clinical data were analyzed retrospectively. RESULTS: The rate of liver retransplantation was 4.32%. Retransplantation was indicated for the following reasons: biliary complication (3 cases), chronic rejection (2), hepatic artery thrombosis (1), uncontrollable acute rejection (1) and hepatitis B recurrence (1). The mean model of end-stage liver disease (MELD) scores before primary transplantation and retransplantation were 15.6 and 23.9, respectively (P<0.05). The MELD score reflected the severity of liver disease more precisely than the Child classification. The mean interval between the first and second transplantation was 316 days (78-725 days). The first three patients, with mean interval of 101 days, died of severe infection combined with multiple organ failure after retransplantation. The patients who underwent retransplantation more than six months after the first transplant had better outcomes. The one-year survival rate for retransplantation in our group was 62.5%. CONCLUSIONS: Liver retransplantation is the only means of saving the patient with hepatic allograft failure. Understanding of the indications for retransplantation,careful selection of operation timing, excellent surgical skills and meticulous postoperative management all contribute to the success of each case of retransplantation.