iMELD评分在慢加急性肝衰竭患者人工肝干预时机选择中的应用  

Application of iMELD score in the timing of artifical liver support system intervention in patients with acute-on-chronic liver failure

作　　者：钱珍[1] 辛雪萍 张威 张帆 尹丹丹 王帅[1] QIAN Zhen;XIN Xue-ping;ZHANG Wei;WANG Shuai(Gastroenterology Department,The First Affiliated Hospital,and College of Clinical Medicine of Henan University of Science and Technology(Luoyang Henan,471003),China)

机构地区：[1]河南科技大学临床医学院河南科技大学第一附属医院消化内科,河南洛阳471003 [2]河南科技大学第三附属医院消化内科

出　　处：《中西医结合肝病杂志》2025年第2期183-188,共6页Chinese Journal of Integrated Traditional and Western Medicine on Liver Diseases

基　　金：北京肝胆相照公益基金会人工肝专项基金(No.RGGJJ-2021-003)。

摘　　要：目的:探讨终末期肝病血清钠年龄模型(iMELD)对慢加急性肝衰竭预后的评估及在人工肝干预时机选择中的作用。方法:149例乙型肝炎慢加急性肝衰竭患者按照亚太肝脏研究协会建议,分为早(n=59)、中(n=46)、晚(n=44)3期,其中75例行人工肝治疗(人工肝组),74例行内科药物治疗(非人工肝组)。入院时患者均检查血常规、肝功能、肾功能、凝血功能、血氨、C-反应蛋白(CRP)、乙型肝炎病毒(HBV)血清学标志物、HBV DNA载量、血清电解质等,计算iMELD分值。单因素生存分析采用Log rank检验;多因素模型采用Cox比例风险模型分析;ROC曲线表示模型的区分度,约登指数最大法确定截断值,决策曲线采用R4.0.3中Rmda软件包绘制。结果:人工肝组和非人工肝患者的生存率为分别是76.0%和60.8%(P<0.05);iMELD评分每增加1分,死亡的风险增加1.085倍;中期和晚期患者死亡的风险分别是早期的3.545和4.063倍,人工肝组患者死亡风险是非人工肝组的0.235倍;人工肝组iMELD评分峰值为(46.06±9.15)分,非人工肝组iMELD评分峰值为(40.93±12.34)分,差异有统计学意义(P<0.05);是否行人工肝治疗和iMELD的ROC曲线截断值为43.538;DCA决策曲线阈值概率(Pt)为23%~58%时,基于iMELD评分决定是否应用人工肝治疗,净获益高于“全治疗”策略,相当于每100例患者中可减少不必要的人工肝治疗最多达12例。结论:iMELD评分越高,死亡风险越高,当iMELD>43.538分时建议积极人工肝治疗,iMELD评分对临床选择合适病例进行人工肝治疗具有指导意义。Objective:Investigation the role of iMELD in the assessment of prognosis of acute-on-chronic liver failure and in the selection of the timing of artificial liver intervention.Methods:One hundred and forty-nine patients with hepatitis B virus related acute-on-chronic liver failure meeting the diagnostic criteria were classified according to Acute-on-chronic liver failure:consensus recommendations of the Asian Pacific association for the study of the liver(APASL):an update classified them into 3 stages:early(n=59),intermediate(n=46),and late(n=44).Among them,75 cases were treated with artificial liver(artificial liver group),and 74 cases underwent internal medicine drug treatment(nonartificial liver group).Upon admission,all patients underwent tests including complete blood count,liver function,kidney function,coagulation function,blood ammonia,C-reactive protein(CRP),hepatitis B virus(HBV)serological markers,HBV DNA load,serum electrolytes,and the iMELD score was calculated.Univariate survival analysis was performed using the Log-rank test.The multivariate model was analyzed using the Cox proportional hazards model.The ROC curve was used to represent the discriminative ability of the model,with the optimal cutoff value determined by the Youden index.The decision curve was plotted using the rmda package in R 4.0.3.Results:The survival rates of the artificial liver therapy group and non-artificial liver therapy group were 76.0%and 60.8%,respectively(P<0.05).The risk of death increased 1.085 times for every 1-point increase in iMELD score.The risk of death was 3.545 and 4.063 times higher in the middle and late stage patients than in the early stage,respectively,and the risk of death for patients in the artificial liver therapy group was 0.235 times higher on average than that in the non-artificial liver therapy group.The peak iMELD score in the artificial liver therapy group was 46.06±9.15,while the peak iMELD score in the non-artificial liver therapy group was 40.93±12.34,(P<0.05).The ROC curve cut-off value for

关 键 词：乙型病毒性肝炎 慢加急性肝衰竭 人工肝 终末期肝病血清钠年龄模型 截断值 

分 类 号：R575[医药卫生—消化系统]