Child-Pugh评分、MELD评分、MELD-Na评分、APASAL评分和R评分对肝硬化伴食管胃静脉曲张再出血及死亡的预测价值

目的验证Child-Pugh评分、MELD评分、MELD-Na评分、APASAL评分和R评分5种风险评分系统对肝硬化伴食管胃静脉曲张出血患者再出血及死亡的诊断价值。方法选取2013年1月-2016年1月因肝硬化伴食管胃静脉曲张破裂出血于首都医科大学附属北京地坛医院行内镜下治疗,并为出血首次行内镜治疗且随访时间超过3年的患者。观察指标包括年龄、性别、体质量、血压、血常规、肝肾功能、凝血、腹部超声等影像学指标及肝性脑病、腹水、感染等并发症发生情况。以静脉曲张再出血为主要研究终点,以死亡为次要研究终点。计量资料两组间比较采用t检验或Wilcoxon秩和检验;计数资料两组间比较采用χ^2检验。相关性分析采用Spearman相关分析。采用受试者工作特征曲线(ROC曲线)评价5种风险评分系统对患者再出血及死亡的诊断价值。结果共纳入305例患者,其中53例(17.38%)患者在随访过程中出现了静脉曲张再出血。再出血组与无再出血组患者比较,年龄、ALT、DBil、国际化标准比值、门静脉内径、MELD评分、MELD-Na评分及R评分差异均有统计学意义(P值均<0.05)。相关性分析结果显示,除APASAL评分与MELD评分、R评分,MELD-Na评分与R评分以外,余下评分系统之间均存在显著相关性(P值均<0.001)。ROC曲线评估结果显示,MELD评分、MELD-Na评分和R评分对再出血具有一定的预测价值(ROC曲线下面积分别为0.645、0.637、0.647,95%可信区间分别为0.563~0.727、0.552~0.723、0.565~0.729,P值分别为0.001、0.002、0.001);Child-Pugh评分对患者死亡结局具有一定诊断价值(ROC曲线下面积为0.610,95%可信区间:0.541~0.680,P=0.002)。结论Child-Pugh评分、MELD评分、MELD-Na评分、APASAL评分及R评分对静脉曲张再出血的预测价值均有限,仅Child-Pugh评分对患者死亡结局具有一定诊断价值。

Value of Child-Pugh score,Model for End-Stage Liver Disease score,MELD combined with serum sodium concentration,APASAL score,and R-score in predicting rebleeding and death in cirrhotic patients with esophagogastric variceal bleeding

Objective To investigate the value of Child-Pugh score,Model for End-Stage Liver Disease(MELD)score,MELD combined with serum sodium concentration(MELD-Na score),APASAL score,and R-score in predicting rebleeding and death in cirrhotic patients with esophagogastric variceal bleeding.Methods The patients with liver cirrhosis and gastroesophageal variceal bleeding who underwent endoscopic therapy for bleeding for the first time in Beijing Ditan Hospital,Capital Medical University,from January 2013 to January 2016 and were followed up for more than 3 years were enrolled.Observation indices included age,sex,body weight,blood pressure,routine blood test results,hepatic and renal function,coagulation,radiological examination(including abdominal ultrasound),and complications(including hepatic encephalopathy,ascites,and infection).Variceal rebleeding was the primary endpoint,and death was the secondary endpoint.The t-test or the Wilcoxon rank-sum test was used for comparison of continuous data between two groups,and the chi-square test was used for comparison of categorical data between two groups.A Spearman correlation analysis was performed,and the receiver operating characteristic(ROC)curve was used to investigate the value of these five risk scoring systems in the diagnosis of rebleeding and death.Results A total of 305 patients were enrolled,among whom 53(17.38%)experienced variceal rebleeding during follow-up.There were significant differences between the rebleeding group and the non-rebleeding group in age,alanine aminotransferase,direct bilirubin,international normalized ratio,diameter of the portal vein,MELD score,MELD-Na score,and R-score(all P<0.05).The correlation analysis showed a significant correlation between any two scores except between APASAL score and MELD score/R-score and between MELD-Na score and R-score(all P<0.05).The ROC curve analysis showed that MELD score,MELD-Na score,and R-score had a certain value in predicting rebleeding,with an area under the ROC curve(AUC)of 0.645(95%confidence intervalCI]:0.563-0.727,P=0.001),0.637(95%CI:0.552-0.723,P=0.002),and 0.647(95%CI:0.565-0.729,P=0.001),respectively,and Child-Pugh score had a certain diagnostic value for death,with an AUC of 0.610(95%CI:0.541-0.680,P=0.002).Conclusion Child-Pugh score,MELD score,MELD-Na score,APASAL score,and R-score have a limited value in predicting variceal rebleeding,and only Child-Pugh score has a certain diagnostic value for death.