4种评分系统对肝硬化合并感染患者预后的评估价值

目的探讨Child-Turcotte-Pugh评分(CTP)、终末期肝病模型(MELD)评分、慢性肝衰竭-器官衰竭评分(CLIF-SOFA)以及亚太肝病学会慢加急性肝衰竭研究工作组评分(AARC)评价终末期肝病(ESLD)合并感染的预后价值。方法回顾性分析2014年1月-2017年12月苏州大学附属第一医院收治的肝硬化合并感染患者的临床资料,根据住院期间预后情况将患者分为内科综合治疗病情稳定者(A组)和住院期间治疗无效死亡、自动出院放弃治疗、内科治疗无效行肝移植者(B组)。比较2组患者一般资料,住院期间临床指标最差值,CTP评分、MELD评分、CLIF-SOFA评分、AARC评分、器官替代治疗(包括机械通气、人工肝支持系统、肾脏替代治疗等)。计量资料2组间比较采用t检验或Mann-Whitney U检验;计数资料2组间比较采用χ2检验。将单因素分析中差异有统计学意义的变量进行logistic回归分析;利用受试者工作特征曲线(ROC)分析4种评分系统预测患者预后效能。结果最终纳入522例肝硬化合并感染患者,存活381例,死亡141例,病死率为27. 01%。单因素分析显示PLT、TBil、动脉血乳酸、国际标准化比值、CTP评分、MELD评分、CLIF-SOFA评分、AARC评分以及人工肝支持、连续肾脏替代治疗、机械通气的患者比例在2组间差异均有统计学意义(P值均<0. 05),多因素logistic回归分析显示4种评分系统均有较强的预测价值,CTP评分[比值比(OR)=2. 308,95%可信区间(95%CI):0. 640~0. 796,P=0. 016]、MELD评分(OR=0. 632,95%CI:0. 638~0. 814,P=0. 007)、CLIF-SOFA评分(OR=1. 920,95%CI:0. 788~0. 908,P=0. 017)和AARC评分(OR=0. 713,95%CI:0. 751~0. 882,P=0. 005)是肝硬化合并感染患者预后的独立危险因素。ROC曲线分析显示4种评分均能预测ESLD合并感染患者的预后,其中CLIF-SOFA评分的预测效能最强,ROC曲线下面积为0. 848,敏感度为0. 854,特异度为0. 690。结论 CTP评分、MELD评分、CLIF-SOFA评分及AARC评分均能预测肝硬化合并感染患者预后,对抗感染治疗有指导作用,其中CLIF-SOFA评分具有较高的预测价值,可广泛应用于临床。

Value of four scoring systems in evaluating the prognosis of cirrhotic patients with infection

Objective To investigate the value of Child-Turcotte-Pugh( CTP) score,Model for End-Stage Liver Disease( MELD)score,chronic liver failure-sequential organ failure assessment( CLIF-SOFA) score,and APASL-ACLF Research Consortium( AARC)score in evaluating the prognosis of cirrhotic patients with infection. Methods A retrospective analysis was performed for the clinical data of cirrhotic patients with infection who were admitted to The First Hospital Affiliated to Soochow University from January 2014 to December2017,and according to their prognosis during hospitalization,they were divided into group A( patients with a stable disease after comprehensive internal medicine treatment) and group B( patients who died during hospitalization,who left the hospital and gave up treatment,or who underwent liver transplantation due to no response to internal medicine treatment). The two groups were compared in terms of general information,the worst values of clinic indices during hospitalization,CTP score,MELD score,CLIF-SOFA score,AARC score,and organ replacement therapy( including mechanical ventilation,artificial liver support system,and renal replacement therapy). The t-test or the Mann-Whitney U test was used for comparison of continuous data between groups,and the chi-square test was used for comparison of categorical data between groups. A logistic regression analysis was performed for the variables with statistical significance in the univariate analysis,and the receiver operating characteristic( ROC) curve was used to assess the efficiency of these four scoring systems in predicting prognosis. Results A total of 522 cirrhotic patients with infection were enrolled,among whom 381 survived and 141 died,resulting in a mortality rate of 27. 01%. The univariate analysis showed that there were significant differences between the two groups in platelet count,total bilirubin,arterial blood lactate,international normalized ratio,CTP score,MELD score,CLIF-SOFA score,and AARC score( all P <0. 05),and the multivariate logistic regression analysis showed that all these four scoring systems had a strong predictive value and CTP score( odds ratio [OR]= 2. 308,95% confidence interval [CI]: 0. 640-0. 796,P = 0. 016),MELD score( OR = 0. 632,95% CI: 0. 638-0. 814,P = 0. 007),CLIF-SOFA score( OR = 1. 920,95% CI: 0. 788-0. 908,P = 0. 017),and AARC score( OR = 0. 713,95% CI:0. 751-0. 882,P = 0. 005) were independent factors for the prognosis of cirrhotic patients with infection. The ROC curve analysis showed that all these four scoring systems could predict the prognosis of cirrhotic patients with infection,and the CLIF-SOFA score had the strongest predictive efficiency,with a sensitivity of 0. 854,a specificity of 0. 690,and an area under the ROC curve of 0. 848. Conclusion CTP score,MELD score,CLIF-SOFA score,and AARC score can predict the prognosis of cirrhotic patients with infection and provide guidance to anti-infective therapy. Among them,CLIF-SOFA score has a high predictive value and can be widely used in clinical practice.