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中华危重症医学杂志(电子版)

中华危重症医学杂志(电子版) ›› 2016, Vol. 09 ›› Issue (01) : 20 -27. doi: 10.3877/cma.j.issn.1674-6880.2016.01.004

所属专题： 文献；

论著

终末期肝病模型评分与Child-Turcotte-Pugh分级对非生物型人工肝治疗乙型肝炎相关性肝衰竭患者预测价值的研究
杨文龙1, 孙水林1,†(), 周锡进2, 陈明发1, 席文娜1, 高珍1, 杨玲玲3, 罗杰1, 何金秋3   
  1. 1. 330006　江西南昌，南昌大学第二附属医院感染科
    2. 330006　江西南昌，南昌大学第一附院消化科
    3. 330002　江西南昌，南昌大学附属感染病医院人工肝治疗中心
  • 收稿日期:2015-06-16 出版日期:2016-02-01
  • 通信作者: 孙水林
  • 基金资助:
    江西省科技厅重大项目(200709)

Prognostic value of hepatitis B-related liver failure patients treated with non-biotype artificial liver by model for end-stage liver disease and Child-Turcotte-Pugh score systems

Wenlong Yang1, Shuilin Sun1,†(), Xijing Zhou2, Mingfa Chen1, Wenna Xi1, Zhen Gao1, Lingling Yang3, Jie Luo1, Jinqiu He3   

  1. 1. Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China
    2. Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, China
    3. Artificial Liver Treatment Center, Infectious Diseases Hospital Affiliated of Nanchang University, Nanchang, 330002, China
  • Received:2015-06-16 Published:2016-02-01
  • Corresponding author: Shuilin Sun
  • About author:
    Corresponding author: Sun Shuilin, Email:
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引用本文：

杨文龙, 孙水林, 周锡进, 陈明发, 席文娜, 高珍, 杨玲玲, 罗杰, 何金秋. 终末期肝病模型评分与Child-Turcotte-Pugh分级对非生物型人工肝治疗乙型肝炎相关性肝衰竭患者预测价值的研究[J]. 中华危重症医学杂志(电子版), 2016, 09(01): 20-27.

Wenlong Yang, Shuilin Sun, Xijing Zhou, Mingfa Chen, Wenna Xi, Zhen Gao, Lingling Yang, Jie Luo, Jinqiu He. Prognostic value of hepatitis B-related liver failure patients treated with non-biotype artificial liver by model for end-stage liver disease and Child-Turcotte-Pugh score systems[J]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2016, 09(01): 20-27.

目的

应用终末期肝病模型（MELD）评分和Child-Turcotte-Pugh（CTP）分级系统评估和预测非生物型人工肝支持系统（NB-ALSS）治疗乙型肝炎相关性肝衰竭患者疗效和预后的临床价值。

方法

将210例乙型肝炎相关性肝衰竭患者分为人工肝组（115例）和对照组（95例），并进行MELD和CTP评分。根据评分将每组进一步分成MELD< 20分、20分≤ MELD< 30分、30分≤ MELD< 40分和MELD> 40分四个亚组。观察两组患者治疗前后各亚组MELD分值的变化和人工肝组患者治疗前后临床生化指标的变化，并对各亚组实际病死率与预期病死率及不同CTP评分分级进行比较。同时，绘制Kaplan-Meier生存曲线，分析比较不同MELD评分的短期生存率和病死率。

结果

人工肝治疗后各亚组患者的临床生化指标中凝血酶原时间国际标准化比值（INR）[（1.3 ± 0.3）vs.（1.4 ± 0.3）；（2.2 ± 0.8）vs.（2.6 ± 0.8）；（4.1 ± 1.5）vs.（5.2 ± 1.7）；（9.6 ± 2.8）vs.（12.2 ± 4.8），t = 4.303、3.152、3.545、3.130，P均< 0.05]和总胆红素（TBIL）水平[（152 ± 74）μmol/L vs.（287 ± 118）μmol/L；（266 ± 160）μmol/L vs.（422 ± 114）μmol/L；（370 ± 144）μmol/L vs.（517 ± 126）μmol/L；（564 ± 180）μmol/L vs.（628 ± 121）μmol/L，t = 4.960、5.951、4.915、2.577，P均< 0.05]均低于治疗前。人工肝治疗后MELD分值除MELD ≥ 40分组外，其他三组较治疗前均显著下降[（10.2 ± 3.4）分vs.（16.6 ± 2.5）分；（18.2 ± 4.2）分vs.（24.7 ± 2.6）分；（30.1 ± 7.5）分vs.（36.2 ± 2.3）分，t = 7.036、9.094、5.476，P均< 0.05]，并且此三组的人工肝组与对照组治疗前后MELD下降分值（△MELD）的比较，差异均有统计学意义（t = 2.286、2.906、2.021，P均< 0.05）。20分≤ MELD< 30分及30分≤ MELD< 40分，人工肝组病死率低于预期病死率（40.8% vs. 76.0%、51.4% vs. 83.0%，χ2 = 12.119、8.880，P均< 0.05），且均低于对照组病死率（40.8% vs. 61.9%、51.4% vs. 82.4%，χ2 = 4.030、4.710，P均< 0.05）；20分≤ MELD< 30分及30分≤ MELD< 40分，CTP C级人工肝组患者病死率均低于对照组（38.8% vs. 59.6%、51.4% vs. 76.5%，χ2 = 3.900、4.400，P均< 0.05）。同时，Kaplan-Meier生存曲线显示，20分≤ MELD< 30分及30分≤ MELD< 40分的人工肝组患者短期生存率均高于对照组（χ2 = 3.890、5.700，P均< 0.05）。

结论

在MELD评分系统基础上引入CTP分级可指导NB-ALSS治疗乙型肝炎相关性肝衰竭患者的预后评判。

关键词: 肝炎病毒，乙型, 肝功能衰竭, 人工肝支持系统, 终末期肝病模型评分, Child-Turcotte-Pugh分级
Objective

To assess and predict the effect and the clinical prognostic value of non-biotype artificial liver support system (NB-ALSS) in hepatitis B-related liver failure patients by model for end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) score systems.

Methods

The randomly selected 210 cases of hepatitis B-related liver failure patients were divided into the artificial liver group(n = 115) and control group(n = 95), based on MELD and CTP scores. Each group were further divided into four subgroups: MELD< 20, 20 ≤ MELD< 30, 30 ≤ MELD< 40, and MELD> 40. The changes of MELD score between these two groups and of the laboratory parameters in the artificial liver group before and after the treatment were observed, and actual short-term mortality rate with expected mortality according to CTP score system were compared.

Results

After the artificial liver treatment, prothrombin time international normalized ratio (INR) decreased significantly in four artificial liver subgroups [(1.3 ± 0.3) vs. (1.4 ± 0.3); (2.2 ± 0.8) vs. (2.6 ± 0.8); (4.1 ± 1.5) vs. (5.2 ± 1.7); (9.6 ± 2.8) vs. (12.2 ± 4.8); t = 4.303, 3.152, 3.545, 3.130; all P< 0.05], total bilirubin (TBIL) also showed significant improvement in these artificial liver groups after the treatment [(152 ± 74) μmol/L vs. (287 ± 118) μmol/L; (266 ± 160) μmol/L vs. (422 ± 114) μmol/L; (370 ± 144) μmol/L vs. (517 ± 126) μmol/L; (564 ± 180) μmol/L vs.(628 ± 121) μmol/L; t = 4.960, 5.951, 4.915, 2.577; all P< 0.05]. Except the MELD ≥ 40 subgroup, MELD scores in the other three artificial liver subgroups were markedly dropped after the treatment [(10.2 ± 3.4) vs. (16.6 ± 2.5); (18.2 ± 4.2) vs. (24.7 ± 2.6); (30.1 ± 7.5) vs. (36.2 ± 2.3); t = 7.036, 9.094, 5.476; all P< 0.05], MELD score decreased (△MELD) between the artificial liver groups and control groups were statistically significant in these three subgroups (t = 2.286, 2.906, 2.021; all P < 0.05). In the 20 ≤ MELD< 30 and 30 ≤ MELD< 40 subgroups, the mortality rates of the artificial liver groups were lower than expected mortality rates (40.8% vs. 76.0%, 51.4% vs. 83.0%; χ2 = 12.119, 8.880; all P < 0.05), and also lower than that of the control groups (40.8% vs. 61.9%, 51.4% vs. 82.4%; χ2 = 4.03, 4.71; all P < 0.05). Comparing the mortality rates between the artificial liver groups and control groups in the CTP C level: in the 20 ≤ MELD< 30 and 30 ≤ MELD< 40 subgroups, the mortality rates of two sets were significantly different(38.8% vs. 59.6%, 51.4% vs. 76.5%; χ2 = 3.90, 4.40; all P < 0.05). Kaplan-Meier survival curves showed that in the 20 ≤ MELD< 30 and 30 ≤ MELD< 40 subgroups, the short-term survival rates in the artificial liver groups was higher than that in the control groups (χ2 = 3.89, 5.70; all P < 0.05).

Conclusion

Combined MELD score and CTP classification system can assess the prognosis of NB-ALSS in treatment of hepatitis B-related liver failure patients.

Key words: Hepatitis B virus, Liver failure, Artificial liver support system, Model for end-stage liver disease, Child-Turcotte-Pugh score
表1 两组乙型肝炎相关性肝衰竭患者治疗前临床生化指标与MELD分值的比较（±s）
组别 例数 ALB(g/L) PTA(%) INR TBIL(μmol/L) Cr(μmol/L) MELD（分）
A1组 18 36 ± 4 32 ± 9 1.4 ± 0.3 287 ± 118 62 ± 15 16.6 ± 2.5
B1组 22 36 ± 6 31 ± 8 1.7 ± 0.5 251 ± 123 64 ± 17 17.2 ± 1.6
A2组 49 33 ± 5 28 ± 7 2.6 ± 0.8 422 ± 114 69 ± 14 24.7 ± 2.6
B2组 42 31 ± 6 31 ± 7 2.3 ± 1.0 408 ± 131 71 ± 15 23.9 ± 2.3
A3组 37 31 ± 4 16 ± 7 5.2 ± 1.7 517 ± 126 94 ± 42 36.2 ± 2.3
B3组 17 30 ± 3 18 ± 7 4.9 ± 1.3 489 ± 118 92 ± 46 35.8 ± 2.7
A4组 11 28 ± 4 13 ± 6 12.2 ± 4.8 628 ± 121 205 ± 146 45.1 ± 6.2
B4组 14 26 ± 4 15 ± 6 10.1 ± 4.8 589 ± 90 216 ± 134 43.5 ± 3.8
表2 人工肝组（A组）患者治疗前后临床生化指标的比较（±s）
MELD分组 例数 ALB(g/L) PTA(%) INR TBIL(μmol/L) Cr(μmol/L)
A1组 ? ? ? ? ? ?
? 人工肝前 18 35.7 ± 4.3 32 ± 9 1.4 ± 0.3 287 ± 118 62 ± 15
? 人工肝后 18 36.9 ± 3.0 46 ± 12a 1.3 ± 0.3a 152 ± 74a 64 ± 12
A2组 ? ? ? ? ? ?
? 人工肝前 49 32.7 ± 4.6 28 ± 7 2.6 ± 0.8 422 ± 114 69 ± 14
? 人工肝后 49 33.8 ± 3.1a 42 ± 17a 2.2 ± 0.8a 266 ± 160a 74 ± 23
A3组 ? ? ? ? ? ?
? 人工肝前 37 31.1 ± 4.5 16 ± 7 5.2 ± 1.7 517 ± 126 94 ± 42
? 人工肝后 37 32.3 ± 3.0 32 ± 11a 4.1 ± 1.5a 370 ± 144a 91 ± 51
A4组 ? ? ? ? ? ?
? 人工肝前 11 27.8 ± 4.3 13 ± 6 12.2 ± 4.8 628 ± 121 205 ± 146
? 人工肝后 11 26.4 ± 2.9 14 ± 4 9.6 ± 2.8a 564 ± 180a 196 ± 123
表3 两组乙型肝炎相关性肝衰竭患者各亚组治疗前后MELD及△MELD评分的比较（分，±s）
组别 例数 治疗前 治疗后 △MELD
A1组 18 16.6 ± 2.5 10.2 ± 3.4a 6.4 ± 3.9b
B1组 22 17.2 ± 1.6 14.5 ± 5.8a 2.7 ± 5.9
A2组 49 24.7 ± 2.6 18.2 ± 4.2a 6.5 ± 4.6b
B2组 42 23.9 ± 2.3 20.8 ± 6.5a 3.4 ± 6.6
A3组 37 36.2 ± 2.3 30.1 ± 7.5a 6.2 ± 6.8b
B3组 17 35.8 ± 2.7 33.4 ± 4.5 2.4 ± 5.4
A4组 11 45.1 ± 6.2 40.0 ± 7.0 5.1 ± 10.4
B4组 14 43.5 ± 3.8 38.5 ± 7.5 5.0 ± 8.3
图1 两组乙型肝炎相关性肝衰竭患者各生存曲线比较。注：a为两组MELD< 20分患者的生存曲线图；b为两组20分≤ MELD< 30分患者的生存曲线图；c图为两组30分≤ MELD< 40分患者的生存曲线图；d图为两组MELD> 40分患者的生存曲线图；e图为人工肝组患者不同MELD分值间的生存曲线图；f图为对照组患者不同MELD分值间的生存曲线图；MELD：终末期肝病模型（model for end-stage liver disease）
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