术后首次MELD评分及其衍生评分对肝衰竭患者肝移植术后早期生存率的预测价值

赖曼; 王鑫; 姚勤伟; 刘海霞; 许瀛; 何莉; 栗光明

doi:10.3969/j.issn.1674-7445.2022.04.012

术后首次MELD评分及其衍生评分对肝衰竭患者肝移植术后早期生存率的预测价值

doi: 10.3969/j.issn.1674-7445.2022.04.012

100069 首都医科大学附属北京佑安医院重症医学科

基金项目:

北京市医院管理中心重点医学专业发展计划 ZYLX202124

详细信息

作者简介:

通讯作者:
栗光明，男，1967年生，博士，主任医师，研究方向为肝移植、活体肝移植，Email: liguangming917@163.com

中图分类号: R617, R512.6+2
计量
- 文章访问数: 252
- HTML全文浏览量: 115
- PDF下载量: 69
- 被引次数: 0
出版历程
- 收稿日期: 2022-02-14
- 网络出版日期: 2022-07-14
- 刊出日期: 2022-07-15

Predictive value of the initial MELD score and its derivative scores for early survival rate after liver transplantation in patients with liver failure

Department of Critical Care Medicine, Beijing You'an Hospital, Capital Medical University, Beijing 100069, China

More Information

Corresponding author: Li Guangming, Email: liguangming917@163.com

摘要

摘要: 目的探讨术后首次终末期肝病模型(MELD)评分及其衍生评分MELD联合血清钠(MELD-Na)评分、MELD联合血乳酸(MELD-Lac)评分对于肝衰竭患者肝移植术后早期生存率的预测能力。方法回顾性分析135例肝衰竭肝移植受者的临床资料，根据术后28 d的生存情况分为早期生存组(110例)和早期死亡组(25例)，比较两组患者的临床资料，采用受试者工作特征(ROC)曲线确定MELD评分、MELD-Na评分与MELD-Lac评分对肝衰竭患者肝移植术后早期生存率预测的最佳截取值，以评价不同评分预测肝衰竭患者肝移植术后早期生存率的能力。结果两组患者术后首次MELD评分、MELD-Na评分、MELD-Lac评分比较，差异均有统计学意义(均为P < 0.05)。术后首次MELD评分、MELD-Na评分、MELD-Lac评分预测肝衰竭患者肝移植术后早期生存率的AUC分别为0.653 [95%可信区间(CI) 0.515~0.792]、0.648(95% CI 0.514~0.781)、0.809 (95% CI 0.718~0.900)，最佳截取值分别为18.09、18.09、19.97，约登指数分别为0.398、0.380、0.525，灵敏度分别为0.680、0.680、0.840，特异度分别为0.720、0.700、0.690。MELD-Lac评分预测肝衰竭患者肝移植术后早期生存率的AUC大于MELD评分和MELD-Na评分，差异均有统计学意义(均为P < 0.05)。结论术后首次MELD评分及MELD-Na评分对于肝衰竭患者肝移植术后早期生存率预测能力一般，而术后首次MELD-Lac评分是肝衰竭患者肝移植术后早期生存率更为可靠的预测指标。
- 肝衰竭 /
- 肝移植 /
- 终末期肝病模型(MELD)评分 /
- 终末期肝病模型联合血清钠(MELD-Na)评分 /
- 终末期肝病模型联合血乳酸(MELD-Lac)评分 /
- 受试者工作特征(ROC)曲线 /
- 早期预后 /
- 预测价值
Abstract: Objective To explore the predictive values of the initial model for end-stage liver disease (MELD) score, MELD combined with serum sodium (MELD-Na) score and MELD combined with serum lactic acid (MELD-Lac) score for early survival rate after liver transplantation in patients with liver failure. Methods Clinical data of 135 recipients undergoing liver transplantation for liver failure were retrospectively analyzed. All patients were divided into the early survival group (n=110) and early death group (n=25) according to the survival at postoperative 28 d. Clinical data were compared between two groups. The optimal cut-off values of MELD, MELD-Na and MELD-Lac scores for predicting early survival rate after liver transplantation in patients with liver failure were determined by the receiver operating characteristic (ROC) curve. The predictive values of different scores for early survival rate after liver transplantation in patients with liver failure were evaluated. Results Significant differences were observed in the initial MELD, MELD-Na and MELD-Lac scores after liver transplantation between two groups (all P < 0.05). For the initial MELD, MELD-Na and MELD-Lac scores in predicting early survival rate after liver transplantation in patients with liver failure, the AUC were 0.653 [95% confidence interval (CI) 0.515-0.792], 0.648 (95%CI 0.514-0.781) and 0.809 (95%CI 0.718-0.900), the optimal cut-off values were 18.09, 18.09 and 19.97, Youden's indexes were 0.398, 0.380 and 0.525, the sensitivity was 0.680, 0.680 and 0.840, and the specificity was 0.720, 0.700 and 0.690, respectively. The AUC of MELD-Lac score was higher than those of MELD and MELD-Na scores, and the differences were statistically significant (both P < 0.05). Conclusions Compared with the initial MELD and MELD-Na scores after liver transplantation, the initial MELD-Lac score is a more reliable index for predicting early survival rate after liver transplantation in patients with liver failure.

HTML全文

下载: 全尺寸图片幻灯片

图 1 三种评分预测肝衰竭患者肝移植术后早期生存率的ROC曲线

Figure 1. ROC curves of three scores for predicting early survival rate after liver transplantation in patients with liver failure

下载: 全尺寸图片幻灯片

表 1 两组患者临床资料比较

Table 1. Comparison of clinical data of patients between the two groups

指标	早期生存组(n=110)	早期死亡组(n=25)	统计值	P值
一般资料
年龄(x±s，岁)	46±11	51±12	1.911	0.058
BMI(x±s，kg/m²)	24±4	24±7	0.431	0.667
肝硬化[n(%)]	80(73)	18(72)	0.005	0.941
原发病[n(%)]			4.694	0.320
乙肝	59(54)	15(60)
丙肝	7(6)	4(16)
酒精性肝病	25(23)	3(12)
药物性肝病	7(6)	2(8)
其他	12(11)	1(4)
术前资料
ALT[M(P₂₅, P₇₅)，U/L]	33(20，88)	53(34，110)	1.626	0.104
AST[M(P₂₅, P₇₅)，U/L]	68(43，118)	95(68，135)	1.912	0.056
TB[M(P₂₅, P₇₅)，μmol/L]	286(142，529)	446(187，605)	1.654	0.098
血红蛋白(x±s，g/L)	91±20	90±17	0.308	0.759
血小板[M(P₂₅, P₇₅)，×10⁹/L]	46(29，68)	42(31，63)	0.079	0.937
PTA(x±s，%)	27±12	26±15	0.512	0.613
PT-INR[M(P₂₅, P₇₅)]	2.8(2.2，3.7)	2.5(2.0，5.7)	0.251	0.802
血尿素氮[M(P₂₅, P₇₅)，mmol/L]	5.5(3.7，8.8)	6.6(3.4，16.4)	1.464	0.143
血清肌酐[M(P₂₅, P₇₅)，μmol/L]	58(43，82)	72(50，92)	1.708	0.088
MELD评分(x±s，分)	27±8	29 ±10	0.948	0.350
术后资料
MELD评分(x±s，分)	16±7	20±7	2.408	0.017
MELD-Na评分(x±s，分)	16±7	20±7	2.086	0.039
MELD-Lac评分(x±s，分)	18±5	25±7	4.800	< 0.001

下载: 导出CSV

参考文献(32)

[1]	中华医学会器官移植学分会围手术期管理学组. 肝衰竭肝移植围手术期管理中国专家共识(2021版)[J]. 中华消化外科杂志, 2021, 20(8): 835-840. DOI: 10.3760/cma.j.cn115610-20210626-00312. Perioperative Management Group of Branch of Organ Transplantation of Chinese Medical Association. Chinese expert consensus on perioperative management of liver transplantation in patients with liver failure (2021 edition)[J]. Chin J Dig Surg, 2021, 20(8): 835-840. DOI: 10.3760/cma.j.cn115610-20210626-00312.
[2]	CZIGANY Z, SCHERER MN, PRATSCHKE J, et al. Technical aspects of orthotopic liver transplantation-a survey-based study within the Eurotransplant, Swisstransplant, Scandiatransplant, and British Transplantation Society networks[J]. J Gastrointest Surg, 2019, 23(3): 529-537. DOI: 10.1007/s11605-018-3915-6.
[3]	中华医学会感染病学分会肝衰竭与人工肝学组, 中华医学会肝病学分会重型肝病与人工肝学组. 肝衰竭诊治指南(2018年版)[J]. 临床肝胆病杂志, 2019, 35(1): 38-44. DOI: 10.3969/j.issn.1001-5256.2019.01.007. Liver Failure and Artificial Liver Group, Chinese Society of Infectious Diseases, Chinese Medical Association, Severe Liver Disease and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association. Guideline for diagnosis and treatment of liver failure (2018)[J]. J Clin Hepatol, 2019, 35(1): 38-44. DOI: 10.3969/j.issn.1001-5256.2019.01.007.
[4]	张冬青, 郑瑞丹, 林明华, 等. HBV相关慢加急性肝衰竭患者90天预后影响因素分析[J]. 临床肝胆病杂志, 2021, 37(10): 2316-2319. DOI: 10.3969/j.issn.1001-5256.2021.10.011. ZHANG DQ, ZHENG RD, LIN MH, et al. Influencing factors for the 90-day prognosis of patients with HBV-related acute-on-chronic liver failure[J]. J Clin Hepatol, 2021, 37(10): 2316-2319. DOI: 10.3969/j.issn.1001-5256.2021.10.011.
[5]	CARDOSO NM, SILVA T, BASILE-FILHO A, et al. A new formula as a predictive score of post-liver transplantation outcome: postoperative MELD-lactate[J]. Transplant Proc, 2014, 46(5): 1407-1412. DOI: 10.1016/j.transproceed.2013.12.067.
[6]	BELLI LS, DUVOUX C, ARTZNER T, et al. Liver transplantation for patients with acute-on-chronic liver failure (ACLF) in Europe: results of the ELITA/EF-CLIF collaborative study (ECLIS)[J]. J Hepatol, 2021, 75(3): 610-622. DOI: 10.1016/j.jhep.2021.03.030.
[7]	YOON JU, YOO YM, BYEON GJ, et al. The impact of pretransplant hepatic encephalopathy, model for end-stage liver disease (MELD) scale on long-term survival following deceased donor liver transplantation: a retrospective study[J]. Ann Palliat Med, 2021, 10(5): 5171-5180. DOI: 10.21037/apm-21-21.
[8]	RAMZAN M, IQBAL A, MURTAZA HG, et al. Comparison of CLIF-C ACLF score and MELD score in predicting ICU mortality in patients with acute-on-chronic liver failure[J]. Cureus, 2020, 12(2): e7087. DOI: 10.7759/cureus.7087.
[9]	VERMA R, JAIN N, ARORA A, et al. Beyond MELD predictors of post TIPSS acute liver failure the lesson learned[J]. Indian J Radiol Imaging, 2021, 31(3): 618-622. DOI: 10.1055/s-0041-1736403.
[10]	BOECKER J, CZIGANY Z, BEDNARSCH J, et al. Potential value and limitations of different clinical scoring systems in the assessment of short- and long-term outcome following orthotopic liver transplantation[J]. PLoS One, 2019, 14(3): e0214221. DOI: 10.1371/journal.pone.0214221.
[11]	KLEIN KB, STAFINSKI TD, MENON D. Predicting survival after liver transplantation based on pre-transplant MELD score: a systematic review of the literature[J]. PLoS One, 2013, 8(12): e80661. DOI: 10.1371/journal.pone.0080661.
[12]	ACAR Ş, AKYILDIZ M, GÜRAKAR A, et al. Delta MELD as a predictor of early outcome in adult-to-adult living donor liver transplantation[J]. Turk J Gastroenterol, 2020, 31(11): 782-789. DOI: 10.5152/tjg.2020.18761.
[13]	GOUDSMIT BFJ, BRAAT AE, TUSHUIZEN ME, et al. Joint modeling of liver transplant candidates outperforms the model for end-stage liver disease: the effect of disease development over time on patient outcome[J]. Am J Transplant, 2021, 21(11): 3583-3592. DOI: 10.1111/ajt.16730.
[14]	KIM JD, CHOI JY, KWON JH, et al. Performance of posttransplant model for end-stage liver disease (MELD) and delta-MELD scores on short-term outcome after living donor liver transplantation[J]. Transplant Proc, 2009, 41(9): 3766-3768. DOI: 10.1016/j.transproceed.2009.10.006.
[15]	POMMERGAARD HC, DAUGAARD TR, ROSTVED AA, et al. Model for end-stage liver disease score predicts complications after liver transplantation[J]. Langenbecks Arch Surg, 2021, 406(1): 55-65. DOI: 10.1007/s00423-020-02018-3.
[16]	KHANDOGA A, ISKANDAROV E, ANGELE M, et al. Model for end-stage liver disease score in the first 3 weeks after liver transplantation as a predictor for long-term outcome[J]. Eur J Gastroenterol Hepatol, 2016, 28(2): 153-158. DOI: 10.1097/MEG.0000000000000505.
[17]	WAGENER G, RAFFEL B, YOUNG AT, et al. Predicting early allograft failure and mortality after liver transplantation: the role of the postoperative model for end-stage liver disease score[J]. Liver Transpl, 2013, 19(5): 534-542. DOI: 10.1002/lt.23634.
[18]	KAMATH PS, KIM WR, Advanced Liver Disease Study Group. The model for end-stage liver disease (MELD)[J]. Hepatology, 2007, 45(3): 797-805. DOI: 10.1002/hep.21563.
[19]	SACLEUX SC, SAMUEL D. A critical review of MELD as a reliable tool for transplant prioritization[J]. Semin Liver Dis, 2019, 39(4): 403-413. DOI: 10.1055/s-0039-1688750.
[20]	KIM Y, KIM K, JANG I. Analysis of mortality prognostic factors using model for end-stage liver disease with incorporation of serum-sodium classification for liver cirrhosis complications: a retrospective cohort study[J]. Medicine (Baltimore), 2019, 98(45): e17862. DOI: 10.1097/MD.0000000000017862.
[21]	SHARMA P, SCHAUBEL DE, GOODRICH NP, et al. Serum sodium and survival benefit of liver transplantation[J]. Liver Transpl, 2015, 21(3): 308-313. DOI: 10.1002/lt.24063.
[22]	GOUDSMIT BFJ, PUTTER H, TUSHUIZEN ME, et al. Validation of the model for end-stage liver disease sodium (MELD-Na) score in the Eurotransplant region[J]. Am J Transplant, 2021, 21(1): 229-240. DOI: 10.1111/ajt.16142.
[23]	KRAMER A, AL AGHA S, BÖHM L, et al. Lactate in emergency medicine[J]. Anaesthesist, 2020, 69(11): 826-834. DOI: 10.1007/s00101-020-00819-1.
[24]	VITIN AA, AZAMFIREI L, TOMESCU D, et al. Perioperative management of lactic acidosis in end-stage liver disease patient[J]. J Crit Care Med (Targu Mures), 2017, 3(2): 55-62. DOI: 10.1515/jccm-2017-0014.
[25]	AGRAWAL T, MAIWALL R, RAJAN V, et al. Higher circulating natural killer cells and lower lactate levels at admission predict spontaneous survival in non-acetaminophen induced acute liver failure[J]. Clin Immunol, 2021, 231: 108829. DOI: 10.1016/j.clim.2021.108829.
[26]	CARDOSO FS, ABRALDES JG, SY E, et al. Lactate and number of organ failures predict intensive care unit mortality in patients with acute-on-chronic liver failure[J]. Liver Int, 2019, 39(7): 1271-1280. DOI: 10.1111/liv.14083.
[27]	SARMAST N, OGOLA GO, KOUZNETSOVA M, et al. Model for end-stage liver disease-lactate and prediction of inpatient mortality in patients with chronic liver disease[J]. Hepatology, 2020, 72(5): 1747-1757. DOI: 10.1002/hep.31199.
[28]	MAHMUD N, ASRANI SK, KAPLAN DE, et al. The predictive role of model for end-stage liver disease-lactate and lactate clearance for in-hospital mortality among a national cirrhosis cohort[J]. Liver Transpl, 2021, 27(2): 177-189. DOI: 10.1002/lt.25913.
[29]	POPESCU M, DIMA S, BRASOVEANU V, et al. High perioperative lactate levels and decreased lactate clearance are associated with increased incidence of posthepatectomy liver failure[J]. Hepatobiliary Pancreat Dis Int, 2021, 20(6): 592-594. DOI: 10.1016/j.hbpd.2021.03.005.
[30]	GOLSE N, GUGLIELMO N, EL METNI A, et al. Arterial lactate concentration at the end of liver transplantation is an early predictor of primary graft dysfunction[J]. Ann Surg, 2019, 270(1): 131-138. DOI: 10.1097/SLA.0000000000002726.
[31]	FERNÁNDEZ-SARMIENTO J, WILCHES-CUADROS MA, HERNANDEZ-SARMIENTO R, et al. Association between serum lactate and unsatisfactory outcomes in critically ill children in the immediate post-operative period of liver transplantation[J]. Front Pediatr, 2022, 9: 796504. DOI: 10.3389/fped.2021.796504.
[32]	MARTINS RM, TEODORO JS, FURTADO E, et al. Evaluation of bioenergetic and mitochondrial function in liver transplantation[J]. Clin Mol Hepatol, 2019, 25(2): 190-198. DOI: 10.3350/cmh.2018.0087.