无创肝纤维化指标对肝硬化患者高风险胃食管静脉曲张的预测价值

目的评估常规肝纤维化指标在肝硬化患者高风险胃食管静脉曲张(HRGOV)非创伤性诊断中的临床应用价值。方法选取2018年1月-12月于南方医科大学南方医院接受胃镜检查以及常规实验室检查的肝硬化患者165例,以胃镜检查为金标准,结合Child-Pugh评分诊断有无HRGOV。计量资料两组间比较采用独立样本t检验或Mann-Whitney U检验;计数资料两组间比较采用χ^2检验。计算并比较受试者工作特征曲线下面积(AUC),应用似然比确定诊断、排除界值。结果165例患者中83例(50.3%)发生HRGOV;HRGOV组与非HRGOV组比较,Alb(t=-5.118,P<0.001)、血小板计数(Z=-5.409,P<0.001)、男性比例(χ^2=3.883,P=0.049)、PT(Z=-4.433,P<0.001)、PTA(Z=-4.447,P<0.001)、INR(Z=-4.426,P<0.001)、WBC(Z=-2.371,P=0.018)、脾厚度(Z=-6.296,P<0.001)、天门冬氨酸转氨酶-血小板比值(APRI)(Z=-3.409,P=0.001)、肝纤维化4因子(FIB-4)(Z=-4.494,P<0.001)、γ-谷氨酰转肽酶-血小板比值(GPR)(Z=-2.377,P=0.017)、红细胞体积分布宽度-血小板比值(RPR)(Z=-5.345,P<0.001)、简易肝纤维化检测(eLIFT)(t=3.170,P=0.002)、胃镜分级(χ^2=131.714,P<0.001)、Child-Pugh分级(χ^2=30.663,P<0.001)差异均有统计学意义。超声脾厚度、血小板计数、RPR、FIB-4、APRI、eLIFT、GPR诊断HRGOV的AUC依次为0.785、0.747、0.744、0.703、0.652、0.622、0.606,AUC>0.7的模型之间比较差异均无统计学意义(P值均>0.05)。应用脾厚度<29.5 mm排除诊断,脾厚度≥53.0 mm确定诊断,51例(30.9%)患者免于行胃镜检查,准确度为94.1%;应用RPR<0.067排除诊断、RPR≥0.480确定诊断,19例(11.5%)患者免于胃镜检查,准确度为89.5%;脾厚度序贯联合RPR确定63例(38.2%)患者有无HRGOV,准确度为92.1%。结论脾厚度、RPR、血小板计数、FIB-4诊断HRGOV具有中等效能,诊断效能依次减弱;常规指标超声脾厚度序贯联合RPR可应用于临床筛查肝硬化HRGOV而免除部分患者胃镜检查。

Value of noninvasive liver fibrosis markers in predicting high-risk gastroesophageal varices in patients with liver cirrhosis

Objective To investigate the clinical value of routine liver fibrosis markers in the noninvasive diagnosis of high-risk gastroesophageal varices(HRGOV)in patients with liver cirrhosis.Methods A total of 165 patients with liver cirrhosis who underwent gastroscopy and routine laboratory examinations in Nanfang Hospital,Southern Medical University,from January to December 2018 were enrolled,and the presence or absence of HRGOV was determined based on the gold standard of gastroscopy with reference to Child-Pugh score.The independent samples t-test or the Mann-Whitney U 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.The area under the receiver operating characteristic curve(AUC)was calculated and compared,and likelihood ratio was used to confirm diagnosis and exclude cut-off values.Results Of all 165 patients,83(50.3%)patients were diagnosed with HRGOV.There were significant differences between the HRGOV group and the non-HRGOV group in albumin(t=-5.118,P<0.001),platelet count(Z=-5.409,P<0.001),proportion of male patients(χ^2=3.883,P=0.049),prothrombin time(Z=-4.433,P<0.001),prothrombin time activity(Z=-4.447,P<0.001),international normalized ratio(Z=-4.426,P<0.001),white blood cell count(Z=-2.371,P=0.018),spleen thickness(Z=-6.296,P<0.001),aspartate aminotransferase-to-platelet ratio index(APRI)(Z=-3.409,P=0.001),fibrosis index based on four factors(FIB-4)(Z=-4.494,P<0.001),gamma-glutamyl transpeptidase-to-platelet ratio(GPR)(Z=-2.377,P=0.017),red blood cell distribution width-to-platelet ratio(RPR)(Z=-5.345,P<0.001),Easy Liver Fibrosis Test(eLIFT)(t=3.170,P=0.002),gastroscopic grade(χ^2=131.714,P<0.001),and Child-Pugh class(χ^2=30.663,P<0.001).Spleen thickness on ultrasound,platelet count,RPR,FIB-4,APRI,eLIFT,and GPR had an AUC of 0.785,0.747,0.744,0.703,0.652,0.622,and 0.606,respectively,in the diagnosis of HRGOV,and there was no significant difference between the models with an AUC of>0.7(P>0.05).With spleen thickness<29.5 mm for exclusion and spleen thickness≥53.0 mm for confirmed diagnosis,51 patients(30.9%)had no need to undergo gastroscopy,with a diagnostic accuracy of 94.1%;with RPR<0.067 for exclusion and RPR≥0.480 for confirmed diagnosis,19 patients(11.5%)had no need to undergo gastroscopy,with a diagnostic accuracy of 89.5%.Spleen thickness followed by RPR was used to confirm the presence or absence of HRGOV in 63 patients(38.2%)and achieved a diagnostic accuracy of 92.1%.Conclusion Spleen thickness,RPR,platelet count,and FIB-4 had moderate efficiency in the diagnosis of HRGOV,among which spleen thickness has the highest diagnostic efficiency,followed by RPR,platelet count,and FIB-4.Spleen thickness followed by RPR can be used for the screening for HRGOV in liver cirrhosis patients,helping some patients avoid gastroscopy.