终末期肝病模型(MELD)评分联合血清甲胎蛋白和胆碱酯酶对乙型肝炎病毒相关慢加急性肝衰竭患者短期预后的评估价值

Prediction of Model for End-Stage Liver Disease Combined with Serum Alpha-Fetoprotein and Cholinesterase Levels on the Short-Term Prognosis in Patients with Acute-on-Chronic Hepatitis B Liver Failure

摘要: 目的：探讨终末期肝病模型(MELD)评分联合血清甲胎蛋白(AFP)和胆碱酯酶(CHE)预测乙型肝炎病毒相关慢加急性肝衰竭(HBV-ACLF)患者短期预后的临床价值。方法：选取2008年1月~2015年12月我院住院的HBV-ACLF患者662例，随访3个月，生存416例和死亡246例，记录并比较两组患者血清谷丙转氨酶(ALT)、总胆红素(TBIL)、肌酐(Cr)、白蛋白(ALB)、AFP、CHE、国际标准化比值(INR)、血清钠(Na⁺)和MELD评分等临床资料。应用受试者工作特征曲线下面积(AUC)分析MELD评分联合血清AFP和CHE对HBV-ACLF患者短期预后的预测价值。结果：死亡组血清ALT (534.8 ± 45.1 U/L对438.5 ± 91.2 U/L)、TBIL (328.9 ± 71.9 μmol/L对244.5 ± 62.7 μmol/L)、Cr (96.9 ± 23.8 μmol/L对70.2 ± 22.3 μmol/L)、ALB (24.5 ± 6.8 g/L对28.7 ± 7.4 g/L)、AFP [21.5(7.6,50.4)μg/L对60.6(16.3,146.1)μg/L]、CHE (2.5 ± 1.2 kU/L对4.2 ± 1.4 kU/L)、INR (2.5 ± 1.1对2.1 ± 0.5)、MELD评分(26.3 ± 5.5对22.4 ± 5.2)均高于生存组，血清Na+水平(128.6 ± 13.1 mmol/L对132.8 ± 9.5 mmol/L)低于生存组，差异均有统计学意义(P均 <0.001)；MELD评分、AFP、CHE预测HBV-ACLF患者近期死亡危险性的最佳截断点分别为24.8、20.6 μg/L、2.9 kU/L；MELD评分联合AFP和CHE判断HBV-ACLF患者短期预后的AUC为0.894，高于单独MELD评分AUC的0.834、AFPAUC的0.803或CHE AUC的0.621，差异均有统计学意义(P均 <0.001)。结论：MELD评分联合血清AFP和CHE对HBV-ACLF患者短期预后的预测价值良好。

Abstract: Objective: To investigate the application of model for end-stage liver disease (MELD) scores, serum alpha-fetoprotein (AFP) and cholinesterase (CHE) levels in predicting the short-term prognosis of patients with hepatitis B virus related acute-on-chronic liver failure (HBV-ACLF). Methods: A total of 662 HBV-ACLF patients in Third People’s Hospital of Yunnan Province were recruited in this study, and 416 patients survived, while 246 died during three-month followed-up. Serum alanine aminotransferase (ALT), total bilirubin (TBIL), creatinine (Cr), albumin (ALB), AFP, CHE, in-ternational normalized ratio (INR) were measured, based on which MELD scores were calculated. The receiver operating characteristic curve (ROC) was used to evaluate the capability of MELD score combined with AFP and CHE for predicting the short-term prognosis of patients with HBV- ACLF. Results: Serum levels of ALT (534.8 ± 45.1 U/L vs 438.5 ± 91.2 U/L), TBIL (328.9 ± 71.9 μmol/L vs 244.5 ± 62.7 μmol/L), Cr (96.9 ± 23.8 μmol/L vs 70.2 ± 22.3 μmol/L), ALB (24.5 ± 6.8 g/L vs 28.7 ± 7.4 g/L) and AFP [21.5(7.6, 50.4)μg/L vs 60.6(16.3,146.1) μg/L], CHE (2.5 ± 1.2 kU/L vs 4.2 ± 1.4 kU/L), INR (2.5 ± 1.1 vs 2.1 ± 0.5), and the scores of MELD (26.3 ± 5.5 vs 22.4 ± 5.2) were significantly higher in the death group than in the survival group, while the serum level of Na⁺ (128.6 ± 13.1 mmol/L vs 132.8 ± 9.5 mmol/L) was significantly lower in the death group than in the survival group (all P < 0.001). The optimal cut-off value of MELD, and serum level of AFP and CHE were 24.8, 20.6 μg/L and 2.9 kU/L; The AUC of MELD score with AFP was 0.894, which was higher than 0.834 only by MELD score, 0.803 by AFP or 0.621 by CHE within 3-month for patients with HBV-ACLF. Conclusion: MELD score combined with serum AFP and CHE has a good predictive value on the short-term prognosis in patients with HBV-ACLF.