不同评分模型对肝硬化患者经...门体分流术后生存的预测价值_刘钰懿.pdf

肝纤维化及肝硬化DOI:10 3969/j issn1001 5256 2023 03 016不同评分模型对肝硬化患者经颈静脉肝内门体分流术后生存的预测价值刘钰懿1，慕之勇1，胡辂1，王军1，熊伟2，胡鸿3，刘爱民4，安选5，许愈强6，余灏东7，王金能8，文良志1，陈东风11 陆军军医大学陆军特色医学中心(大坪医院)消化内科，消化系统肿瘤精准防治重庆市重点实验室，重庆 400042;2 重庆医科大学第三附属医院 消化内科，重庆 400042;3 川北医学院附属南充市中心医院 介入放射科，四川 南充 637000;4 重庆大学附属涪陵医院 消化内科，重庆 408000;5 重庆大学附属三峡医院 肝病科，重庆 404100;6 乐山市人民医院 消化内科，四川 乐山 614000;7 重庆大学附属黔江医院 消化内科，重庆 409000;8 重庆市第九人民医院 消化内科，重庆 400042通信作者:陈东风，chendf1981126 com(OCID:0000 0001 5514 7358)摘要:目的探讨 Child Pugh 评分、终末期肝病模型(MELD)评分、联合血清钠离子的终末期肝病模型(MELD Na)评分、慢性肝衰竭联盟 急性失代偿(CLIF C AD)评分和经颈静脉肝内门体分流术(TIPS)术后生存 Freiburg 指数(FIPS)评分对肝硬化患者生存的预测价值。方法回顾性分析 2014 年 1 月2021 年 2 月我国西南地区多家医院行TIPS 治疗的 447 例肝硬化患者的临床资料，其中生存组 306 例，死亡组 62 例。计算五种评分模型分值，并基于五种评分模型分别对患者进行生存分析。正态分布的计量资料组间比较采用独立样本的 t 检验;不符合正态分布的计量资料组间比较采用非参数 Mann Whitney U 检验;计数资料组间比较采用 Pearson 2检验;采用 Cox 回归分析各评分模型对 TIPS 患者预后的影响;Kaplan Meier 法分析不同评分水平的患者死亡风险的差异，并采用 Log rank 检验。各模型预测能力采用受试者工作特征曲线下面积(AUC)、不同时间点 C 指数及决策曲线进行评估。结果生存组患者年龄(Z=2 884)低于死亡组，Alb(t=3 577)、Na+(Z=3 756)均高于死亡组，而酒精性肝硬化患者比例(2=22.674)、AST(Z=2.141)、PT(Z=2 486)、IN(Z=2 429)、TBil(Z=3 754)、腹水严重程度(2=14 186)及五种模型评分均低于死亡组(P 值均 0 05)。生存分析显示，各评分模型均能有效对 TIPS 患者预后进行风险分层。对各评分模型不同时间点 C 指数比较发现，Child Pugh 评分对术后生存预测能力较高，其次为 MELD Na 评分、MELD 评分和 CLIF C AD评分，而 FIPS 评分预测能力相对较差，此外，随时间延长，各评分预测效能均减弱。Child Pugh 评分术后 1 年生存率的预测效能最大(AUC=0 832)，MELD Na 评分术后 3 年生存率的预测效能最大(AUC=0 726)，而FIPS 评分术后在 1 年和 3 年生存预测能力比较中均较差。结论五种评分模型均可作为肝硬化 TIPS 术后患者生存的预测方法，且都可为肝硬化 TIPS 患者提供有效的预后风险分层。在短期预测上 Child Pugh 评分生存预测能力更好，长期预测上 MELD Na 评分生存预测能力更好，而 FIPS 评分预测能力均相对较差。关键词:肝硬化;门静脉高压;门体分流术，经颈静脉肝内基金项目:国家自然科学基金(82170594)Value of different scoring models in predicting the survival of patients with liver cirrhosis after transjugularintrahepatic portosystemic shuntLIU Yuyi1，MU Zhiyong1，HU Lu1，WANG Jun1，XIONG Wei2，HU Hong3，LIU Aimin4，AN Xuan5，XU Yuqiang6，YUHaodong7，WANG Jinneng8，WEN Liangzhi1，CHEN Dongfeng1(1 Department of Gastroenterology，Chongqing Key Labora-tory of Digestive Malignancies，Army Specialized Medical Center of Army Medical University Daping Hospital，Chongqing095临床肝胆病杂志第39 卷第3 期2023 年3 月J Clin Hepatol，Vol39 No3，Mar2023400042，China;2 Department of Gastroenterology，The Third Affiliated Hospital of Chongqing Medical University，Chongqing400042，China;3 Department of Interventional adiology，Nanchong Central Hospital，North Sichuan Medical College，Nan-chong，Sichuan 637000，China;4Department of Gastroenterology，Chongqing University Fuling Hospital，Chongqing408000，China;5 Department of Hepatology，Chongqing University Three Gorges Hospital，Chongqing 404100，China;6.Department of Gastroenterology，The People s Hospital of Leshan，Leshan，Sichuan 614000，China;7 Department of Gas-troenterology，Chongqing University Qianjiang Hospital，Chongqing 409000，China;8 Department of Gastroenterology，TheNinth People s Hospital of Chongqing，Chongqing 400042，China)Corresponding author:CHEN Dongfeng，chendf1981126 com(OCID:0000 0001 5514 7358)Abstract:ObjectiveTo compare the value of Child Pugh score，Model for End Stage Liver Disease(MELD)score，MELD combined with serum sodium concentration(MELD Na)score，CLIF Consortium Acute Decompensation(CLIF CAD)score，and Freiburg index of post transjugular intrahepatic portosystemic shunt(TIPS)survival(FIPS)score in predic-ting the survival of patients undergoing TIPS MethodsA retrospective analysis was performed for the clinical data of 447 pa-tients with liver cirrhosis who underwent TIPS in several hospitals in southwest China，among whom there were 306 patients inthe survival group and 62 in the death group The scores of the above five models were calculated，and a survival analysis wasperformed based on these models The independent samples t test was used for comparison of normally distributed continuousdata between groups，and the non parametric Mann Whitney U test was used for comparison of non normally distributedcontinuous data between groups;the Pearson chi square test was used for comparison of categorical data between groups;amultivariate Cox regression analysis was used for correction analysis of known influencing factors with statistical significancewhich were not included in the scoring models;the Kaplan Meier method was used to evaluate the discriminatory ability ofeach model in identifying risks in the surgical population，and the log rank test was used for analysis The area under the re-ceiver operating characteristic curve(AUC)，C index at different time points，and calibration curve were used to evaluate thepredictive ability of each scoring model esultsCompared with the death group，the survival group had significantly lowerage(Z=2 884，P 0 05)，higher albumin(t=3 577，P 0 05)，and Na+(Z=3 756，P 0 05)and significantlylower proportion of patients with alcoholic cirrhosis(2=22 674，P 0 05)，aspartate aminotransferase(Z=2 141，P 0.05)，prothrombin time(Z=2 486，P 0 05)，international normalized ratio(Z=2 429，P 0 05)，total bilirubin(Z=3 754，P 0 05)，severity of ascites(2=14 186，P 0 05)，and scores of the five models(all P 0 05)Survivalanalysis showed that all scoring models effectively stratified