ALBI评分对肝硬化食管胃底静脉曲张破裂出血患者预后的预测价值

目的研究ALBI评分预测肝硬化伴食管胃底静脉曲张破裂出血患者预后的价值,以明确风险分层和增加临床实用性。方法回顾性分析2012年10月—2018年8月于江苏省苏北人民医院住院治疗的273例肝硬化食管胃底静脉曲张破裂出血患者的临床资料,所有患者入院后均接受标准化治疗,通过查阅电子病历及电话随访获取患者的生存情况,根据随访至2020年8月时的预后情况分为死亡组(n=109)和存活组(n=164),比较两组患者的一般资料,连续变量两组间比较采用Mann-Whitney U检验,分类变量两组间比较采用χ2检验或Fisher确切检验,通过单因素及多因素Cox回归分析识别与预后相关的独立危险因素,运用Kaplan-Meier曲线分析不同ALBI分级患者的生存率,并行log-rank检验进行组间比较,绘制受试者工作特征曲线(ROC曲线)比较ALBI评分、CTP评分及MELD评分预测患者短期(6周)及长期预后的能力。结果随访期间,109例(39.9%)患者死亡,死亡组患者的ALBI评分[-1.49(-1.82~-1.11)]水平明显高于存活组[-1.79(-2.22~-1.49)](Z=5.630,P<0.001)。单因素分析显示:年龄≥55岁、血红蛋白≤100 g/L、中性粒细胞计数≥3.4×109/L、血小板≤42×109/L、白蛋白≤28 g/L、总胆红素≥21μmol/L、ALT≥42 U/L或AST≥48 U/L、肌酐≥94μmol/L、血钠≤137 mmol/L、凝血酶原标准化比值≥1.5、腹水、肝性脑病为肝硬化EGVB患者死亡的危险因素,且ALBI分级为3级的患者较1级和2级患者的死亡风险明显升高,而预防性套扎为肝硬化食管胃底静脉曲张破裂出血患者生存改善的保护性因素(P值均<0.05)。多因素分析显示:年龄≥55岁[HR(95%CI):2.531(1.624~3.946),P<0.001]、肌酐≥94μmol/L[HR(95%CI):1.935(1.208~3.100),P=0.006]、血钠≤137 mmol/L[HR(95%CI):1.519(1.015~2.274),P=0.042]、腹水[HR(95%CI):1.641(1.041~2.585),P=0.033]、肝性脑病[HR(95%CI):9.972(3.961~25.106),P<0.001]、ALBI 3级[HR(95%CI):1.591(1.007~2.515),P=0.047]为死亡的独立危险因素。ALBI 3级患者的生存率明显低于ALBI 1级(χ2=18.691,P<0.001)和ALBI 2级(χ2=21.364,P<0.001),ALBI 1级患者的生存率高于ALBI 2级(χ2=6.513,P=0.011)。ROC曲线分析显示在预测短期(6周)及长期预后方面,ALBI评分、CTP评分及MELD评分的ROC曲线下面积分别为0.770、0.730、0.706和0.701、0.685、0.659。结论ALBI评分对肝硬化食管胃底静脉曲张破裂出血患者短期(6周)及长期预后具有较好的预测价值,患者的死亡风险随ALBI分级的升高而升高,ALBI评分作为一个客观、简单的模型可更好的应用于临床。

Value of albumin-bilirubin score in predicting the prognosis of cirrhotic patients with esophagogastric variceal bleeding

Objective To investigate the value of albumin-bilirubin(ALBI)score in predicting the prognosis of cirrhotic patients with esophagogastric variceal bleeding,and to identify risk stratification and increase clinical applicability.Methods A retrospective analysis was performed for the clinical data of 273 cirrhotic patients with esophagogastric variceal bleeding who were hospitalized in Subei People’s Hospital of Jiangsu from October 2012 to August 2018,and all patients received standard management after admission.Survival status was obtained through electronic medical records and telephone follow-up,and according to the prognosis in August 2020,the patients were divided into death group with 109 patients and survival group with 164 patients.General data were compared between the two groups.The Mann-Whitney U test was used for comparison of continuous variables between two groups,and the chi-square test or the Fisher’s exact test was used for comparison of categorical variables between two groups;univariate and multivariate Cox regression analyses were used to identify independent risk factors for prognosis.The Kaplan-Meier curve was used to analyze the survival rates of patients with different ALBI grades,and the log-rank test was used for comparison between groups;the receiver operating characteristic(ROC)curve was plotted to compare the ability of ALBI score,Child-Turcotte-Pugh(CTP)score,and Model for End-Stage Liver Disease(MELD)score in predicting short-term(6 weeks)and long-term prognoses.Results During follow-up,109 patients(39.9%)died,and the death group had a significantly higher ALBI score than the survival group[-1.49(-1.82 to-1.11)vs-1.79(-2.22 to-1.49),Z=5.630,P<0.001].The univariate analysis showed that age≥55 years,hemoglobin≤100 g/L,neutrophil count≥3.4×109/L,platelet count≤42×109/L,albumin≤28 g/L,total bilirubin≥21μmol/L,alanine aminotransferase≥42 U/L or aspartate aminotransferase≥48 U/L,creatinine≥94μmol/L,serum sodium≤137 mmol/L,international normalized ratio of prothrombin≥1.5,ascites,and hepatic encephalopathy were risk factors for death in cirrhotic patients with esophagogastric variceal bleeding,and the patients with ALBI grade 3 had a significantly higher risk of death than those with ALBI grade 1 or 2;prophylactic ligation was a protective factor for survival improvement in cirrhotic patients with esophagogastric variceal bleeding(all P<0.05).The multivariate analysis showed that age≥55 years(hazard ratio[HR]=2.531,95%confidence interval[CI]:1.624-3.946,P<0.001),creatinine≥94μmol/L(HR=1.935,95%CI:1.208-3.100,P=0.006),serum sodium≤137 mmol/L[HR=1.519,95%CI:1.015-2.274,P=0.042],ascites(HR=1.641,95%CI:1.041-2.585,P=0.033),hepatic encephalopathy(HR=9.972,95%CI:3.961-25.106,P<0.001),and ALBI grade 3(HR=1.591,95%CI:1.007-2.515,P=0.047)were independent risk factors for death.The patients with ALBI grade 3 had a significantly lower survival rate than those with ALBI grade 1(χ2=18.691,P<0.001)and ALBI grade 2(χ2=21.364,P<0.001),and the patients with ALBI grade 1 had a significantly higher survival rate than those with ALBI grade 2(χ2=6.513,P=0.011).The ROC curve analysis showed that ALBI score,CTP score,and MELD score had an area under the ROC curve(AUC)of 0.770,0.730,and 0.706,respectively,in predicting short-term(6 weeks)prognosis,and they had an AUC of 0.701,0.685,and 0.659,respectively,in predicting long-term prognosis.Conclusion ALBI score has a good value in predicting short-term(6 weeks)and long-term prognoses of cirrhotic patients with esophagogastric variceal bleeding,and the risk of death increases with ALBI grade.ALBI score can be used as an objective and simple model in clinical practice.