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凝血酶原国际标准化比值/白蛋白对失代偿期肝硬化患者预后的预测价值

孟淑慧 胥莹 邹松龙 张雪 吴杰芳

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凝血酶原国际标准化比值/白蛋白对失代偿期肝硬化患者预后的预测价值

DOI: 10.3969/j.issn.1001-5256.2021.09.016
利益冲突声明:本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明:胥莹、孟淑慧负责课题设计,资料分析;孟淑慧负责收集数据,撰写论文;邹松龙、张雪、吴杰芳参与数据采集及工作支持;胥莹负责拟定写作思路,指导撰写文章,修改论文,并最后定稿。
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    通信作者:

    胥莹,xuying_0505@163.com

  • 中图分类号: R575.2

Value of prothrombin time-international normalized ratio to albumin ratio in predicting the prognosis of patients with decompensated cirrhosis

  • 摘要:   目的  探讨凝血酶原国际标准化比值/白蛋白(PTAR)评估失代偿期肝硬化患者预后的临床价值。  方法  回顾性分析2016年4月—2017年4月昆明医科大学第二附属医院收治的172例失代偿期肝硬化患者的临床资料,包括性别、年龄、病因、并发症、入院后首次的实验室指标检测等。以死亡为终点事件,根据随访2年的疾病转归情况将所纳入患者分为生存组(n=98)和死亡组(n=74)。分析影响预后的相关因素,并评估PTAR对失代偿期肝硬化患者预后的预测价值。计量资料两组间比较采用t检验或Mann-Whitney U检验。计数资料两组间比较采用χ2检验或Fisher确切概率法。对相关变量行单因素和多因素Cox回归分析。绘制受试者工作特征曲线(ROC曲线),计算曲线下面积(AUC),并根据ROC曲线的敏感度和特异度确定最佳临界值。运用Kaplan-Meier生存曲线分析不同PTAR、吲哚菁绿15 min滞留率(ICGR15)、MELD评分患者的2年生存率,并采用log-rank检验比较组间差异。  结果  死亡组患者的PTAR(Z=-7.823,P<0.001)、ICGR15(t=3.458,P=0.001)及MELD评分(t=5.921,P<0.001)均明显高于生存组。PTAR、ICGR15、MELD评分预测患者2年预后的最佳临界值分别为0.05、41.00%、37.25分,AUC分别为0.849、0.651、0.724。生存分析提示高水平PTAR组(PTAR≥0.05)患者生存率显著低于低水平PTAR组(PTAR<0.05)(χ2=60.07,P<0.001)。多因素Cox回归分析结果显示,PTAR≥0.05是患者2年死亡的独立危险因素(HR=2.564,95%CI:1.276~5.151,P=0.008)。  结论  PTAR≥0.05可作为失代偿期肝硬化患者2年死亡的独立预测因子,PTAR对失代偿肝硬化患者预后有较高的预测价值。

     

  • 图  1  3种指标预测失代偿期肝硬化患者2年死亡的ROC曲线

    图  2  不同PTAR、ICGR15、MELD评分患者的Kaplan-Meier生存曲线

    表  1  纳入研究的两组患者临床基线特征比较

    指标 死亡组(n=74) 生存组(n=98) 统计值 P
    年龄(岁) 54.81±13.64 50.51±12.44 t=2.154 0.033
    男/女(例) 58/16 66/32 χ2=2.550 0.110
    Alb(g/L) 26.48±4.28 33.39±5.35 t=-9.126 <0.001
    ALT(U/L) 49.50(26.00~134.25) 36.00(20.50~70.00) Z=-2.787 0.005
    AST(U/L) 94.00(52.75~260.75) 52.00(34.50~79.00) Z=-4.776 <0.001
    GGT(U/L) 94.50(41.50~201.25) 73.00(33.50~133.00) Z=-1.761 0.078
    ALP(U/L) 156.50(109.75~233.75) 121.00(92.50~157.00) Z=-3.257 0.001
    TBil(μmol/L) 152.15(56.45~331.40) 74.10(35.50~160.40) Z=-3.906 <0.001
    SCr(μmol/L) 74.50(61.00~90.50) 68.00(53.50~77.50) Z=-2.479 0.013
    TC(mol/L) 2.33(1.76~3.60) 3.33(2.38~4.27) Z=-3.345 0.001
    Na(mol/L) 137.70(133.38~139.35) 139.00(137.95~140.90) Z=-3.221 0.001
    PT(s) 19.70(17.05~24.83) 15.70(13.95~17.35) Z=-6.183 <0.001
    INR 1.80(1.42~2.26) 1.28(1.15~1.54) Z=-6.201 <0.001
    WBC(×109/L) 6.09(3.65~7.98) 4.74(3.36~7.33) Z=-1.553 0.121
    Hb(g/L) 109.36±25.87 117.66±25.26 t=-2.111 0.036
    中性粒细胞计数(×109/L) 4.43(2.10~5.64) 2.79(2.05~4.97) Z=-1.803 0.071
    PTAR 0.06(0.05~0.09) 0.04(0.03~0.05) Z=-7.823 <0.001
    ICGR15(%) 47.58±16.86 37.96±18.91 t=3.458 0.001
    MELD评分(分) 38.15±9.04 31.11±6.56 t=5.921 <0.001
    静脉曲张[例(%)] 47(63.5) 67(68.4) χ2=0.444 0.505
    静脉曲张破裂出血[例(%)] 28(37.8) 19(19.4) χ2=7.227 0.007
    肝性脑病[例(%)] 14(18.9) 9(9.2) χ2=3.450 0.063
    腹腔积液[例(%)] 62(83.8) 49(50.0) χ2=21.026 <0.001
    细菌感染[例(%)] 34(45.9) 41(41.8) χ2=0.290 0.591
    肝肾综合征[例(%)] 3(4.1) 2(2.0) 0.653
    下载: 导出CSV

    表  2  3种指标预测失代偿期肝硬化患者2年内死亡的诊断效能比较

    指标 AUC 95% CI 敏感度 特异度 最佳临界值 约登指数
    PTAR 0.849 0.791~0.906 0.797 0.786 0.05 0.583
    ICGR15 0.651 0.569~0.733 0.770 0.561 41.00% 0.331
    MELD评分 0.724 0.646~0.802 0.568 0.827 37.25分 0.395
    三者联合 0.851 0.795~0.907 0.784 0.796 0.41 0.580
    下载: 导出CSV

    表  3  单因素及多因素Cox回归分析

    指标 单因素分析 多因素分析
    B P HR 95%CI B P HR 95%CI
    年龄 0.019 0.051 1.019 1.000~1.039
    ICGR15 0.021 0.001 1.021 1.009~1.034
    MELD评分 0.070 <0.001 1.073 1.047~1.099
    Hb -0.010 0.044 0.990 0.981~1.000
    Alb -0.177 <0.001 0.838 0.799~0.878 -0.121 <0.001 0.886 0.835~0.939
    PTAR≥0.05 1.923 <0.001 6.839 3.861~12.114 0.941 0.008 2.564 1.276~5.151
    ALT 0.002 <0.001 1.002 1.001~1.002
    AST 0.002 <0.001 1.002 1.001~1.003 0.001 <0.001 1.001 1.001~1.002
    ALP 0.001 0.020 1.001 1.000~1.001
    TBil 0.004 <0.001 1.004 1.002~1.005
    SCr 0.002 0.082 1.002 1.000~1.004
    TC -0.210 0.025 0.811 0.675~0.974
    PT 0.096 <0.001 1.101 1.070~1.132
    INR 0.813 <0.001 2.255 1.768~2.876
    静脉曲张破裂出血 0.623 0.009 1.865 1.165~2.984
    腹腔积液 1.301 <0.001 3.647 1.977~6.829
    下载: 导出CSV
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  • 收稿日期:  2021-01-12
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