白蛋白-胆红素评分对肝硬化食管胃静脉曲张出血患者预后的预测价值

李德钊; 李健; 郭晓林

doi:10.3969/j.issn.1001-5256.2021.05.022

白蛋白-胆红素评分对肝硬化食管胃静脉曲张出血患者预后的预测价值

DOI: 10.3969/j.issn.1001-5256.2021.05.022

吉林大学第一医院肝病科，长春 130000

基金项目:

国家重点研发计划“精准医学研究”专项 (2017YFC0908104)

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：李德钊负责课题设计，资料分析，撰写论文；李德钊、李健参与收集数据，修改论文；郭晓林负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

作者简介:
李德钊(1994—)，男，主要从事肝脏相关疾病的研究

通信作者:
郭晓林，guoxl@jlu.edu.cn

中图分类号: R575.2
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出版历程
- 收稿日期: 2020-10-28
- 录用日期: 2020-12-04
- 出版日期: 2021-05-20

Value of albumin-bilirubin score in predicting the prognosis of patients with liver cirrhosis and esophagogastric variceal bleeding

Department of Hepatology, The First Hospital of Jilin University, Changchun 130000, China

摘要

摘要: 目的探讨白蛋白-胆红素评分(ALBI)评估肝硬化食管胃静脉曲张出血患者预后的价值，并与Child-Turcotte-Pugh(CTP)评分和终末期肝病模型联合Na评分(MELD-Na)进行比较。方法回顾性分析2018年8月—2019年4月吉林大学第一医院确诊的肝硬化食管胃静脉曲张出血患者155例。根据随访1年的疾病转归情况将所纳入的患者分为生存组(n=98)和死亡组(n=57)。分析影响预后的相关因素，并评估ALBI评分对患者预后的预测价值。正态分布的计量资料两组间比较采用t检验; 非正态分布的计量资料两组间比较采用Mann-Whitney U检验，计数资料两组间比较采用χ²检验。采用Spearman相关分析评估两变量间的相关性。采用多因素logistic回归分析患者1年死亡的独立影响因素，绘制受试者工作特征(ROC)曲线，计算ROC曲线下面积(AUC)，并根据约登指数确定最佳临界值。各评分系统之间AUC的比较采用Z捡验。结果生存组和死亡组患者在首次出血量(U=1994.5，P=0.002)、有无肝性脑病(χ²=14.154，P＜0.001)、腹水严重程度(χ²=10.537，P=0.005)、TBil(U=1694.0，P＜0.001)、Alb(t=-6.633，P＜0.001)、AST(U=2223.5，P=0.035)、Na(U=1859.5，P=0.001)、INR(U=1259.5，P＜0.001)、PT(U=1331.5，P＜0.001)、WBC (U=2008.5，P=0.004)、RBC (t=-2.633，P=0.009)、RDW(U=1719.5，P＜0.001)、Hb(U=2150.0，P=0.017)、ALBI分级(χ²=48.732，P＜0.001)、CTP分级(χ²=34.646，P＜0.001)等方面差异均有统计学意义。死亡组入院时ALBI评分为-1.11±0.59，明显高于生存组(-1.79±0.44)(t=7.618，P＜0.001)；MELD-Na评分为18.0(14.5~24.0)，高于生存组的12.0(10.0~16.0)(U=1176.0，P＜0.001)；CTP评分为9.0(8.0~11.0)，高于生存组的7.0(6.0~8.0)(U=1078.0，P＜0.001)。Spearman相关分析显示ALBI评分与CTP评分、MELD-Na评分均呈正相关(r值分别为0.753、0.668，P值均＜0.001)。多因素logistic回归分析后显示ALBI评分(OR=8.349，95%CI：2.658~26.232)、CTP评分(OR=1.586，95%CI：1.157~2.175)及MELD-Na评分(OR=1.188，95%CI：1.062~1.328)是影响患者1年死亡的独立危险因素。ALBI评分、CTP评分及MELD-Na评分预测患者1年预后最佳临界值分别为-1.485、8.5、17.5，AUC分别为0.818、0.807、0.789。3种评分系统预测1年病死率比较，差异无统计学意义(P值均＞0.05)。结论 ALBI评分与CTP评分和MELD-Na评分对于肝硬化食管胃静脉曲张出血患者1年死亡预测的预后表现相当，ALBI评分具有良好的评估能力。
- 肝硬化 /
- 食管和胃静脉曲张 /
- 白蛋白-胆红素评分 /
- 预后
Abstract: Objective To investigate the value of albumin-bilirubin (ALBI) score in evaluating the prognosis of patients with liver cirrhosis and esophagogastric variceal bleeding, and to compare it with Child-Turcotte-Pugh (CTP) score and Model for End-stage Liver Disease combined with serum sodium concentration (MELD-Na) score. Methods A retrospective analysis was performed for the clinical data of 155 patients who were diagnosed with liver cirrhosis and esophagogastric variceal bleeding in The First Hospital of Jilin University from August 2018 to April 2019, and according to disease outcome after 1 year of follow-up, these patients were divided into survival group with 98 patients and death group with 57 patients. The influencing factors for prognosis were analyzed, and the value of ALBI score in predicting prognosis was assessed. The t-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups. A Spearman correlation analysis was performed to investigate the correlation between two variables. A multivariate logistic regression analysis was used to investigate independent influencing factors for death within 1 year. The receiver operating characteristic (ROC) curve was plotted, and the area under the ROC curve (AUC) was calculated; the optimal cut-off value was determined based on Youden index. The Z test was used for comparison of AUC between these three scoring systems. Results There were significant differences between the survival group and the death group in initial blood loss (U=1994.5, P=0.002), presence or absence of hepatic encephalopathy (χ²=14.154, P < 0.001), severity of ascites (χ²=10.537, P=0.005), total bilirubin (U=1694.0, P < 0.001), albumin (t=-6.633, P < 0.001), aspartate aminotransferase (U=2223.5, P=0.035), Na (U=1859.5, P=0.001), international normalized ratio (U=1259.5, P < 0.001), prothrombin time (U=1331.5, P < 0.001), white blood cell count (U=2008.5, P=0.004), red blood cell count (t=-2.633, P=0.009), red blood cell volume distribution width (U=1719.5, P < 0.001), hemoglobin (U=2150.0, P=0.017), ALBI grade (χ²=48.732, P < 0.001), and CTP class (χ²=34.646, P < 0.001). The death group had a significantly higher ALBI score on admission than the survival group (-1.11±0.59 vs -1.79±0.44, t=7.618, P < 0.001), as well as significantly higher MELD-Na score (18.0[14.5-24.0] vs 12.0[10.0-16.0], U=1176.0, P < 0.001) and CTP score (9.0[8.0-11.0] vs 7.0[6.0-8.0], U=1078.0, P < 0.001). The Spearman correlation analysis showed that ALBI score was positively correlated with CTP score and MELD-Na score (r=0.753 and 0.668, both P < 0.001). The multivariate logistic regression analysis showed that ALBI score (odds ratio [OR]=8.349, 95% confidence interval [CI]: 2.658-26.232), CTP score (OR=1.586, 95%CI: 1.157-2.175), and MELD-Na score (OR=1.188, 95%CI: 1.062-1.328) were independent risk factors for predicting death within 1 year. The optimal cut-off value was -1.485 for ALBI score, 8.5 for CTP score, and 17.5 for MELD-Na score in predicting the 1-year prognosis of patients, with an AUC of 0.818, 0.807, and 0.789, respectively. There was no significant difference between the three scoring systems in predicting the 1-year mortality rate (P > 0.05). Conclusion The performance of ALBI score is comparable to that of CTP and MELD-Na scores in predicting the risk of death within 1 year in patients with liver cirrhosis and esophagogastric variceal bleeding, and ALBI score has a good evaluation ability.
- Liver Cirrhosis /
- Esophageal and Gastric Varices /
- Albumin-Bilirubin Score /
- Prognosis

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图 1 ALBI评分与CTP评分及MELD-Na评分的相关性分析

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图 2 ALBI评分、MELD-Na评分及CTP评分对肝硬化食管胃静脉曲张出血患者1年预后评估的ROC曲线

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表 1 纳入研究的两组患者基线临床特征比较

指标	生存组(n=98)	死亡组(n=57)	统计值	P值
年龄(岁)	54.15±10.59	55.95±12.07	t=0.966	0.336
性别(男/女)	69/29	44/13	χ²=0.840	0.359
首次出血量(ml)	200(175~300)	500(200~775)	U=1994.5	0.002
EVL或EIS治疗频次(1次/2次)	78/20	48/9	χ²=0.505	0.477
再次出血(有/无)	33/65	16/41	χ²=0.523	0.469
肝性脑病(有/无)	8/90	18/39	χ²=14.154	＜0.001
腹水(无/轻度/中重度)	41/37/20	12/21/24	χ²=10.537	0.005
TBil(μmol/L)	22.20(13.40~30.05)	29.10(20.90~90.80)	U=1694.0	＜0.001
Alb(g/L)	31.40±4.88	25.76±5.57	t=-6.633	＜0.001
AST(U/L)	29.95(24.58~42.45)	35.20(24.70~90.95)	U=2223.5	0.035
ALT(U/L)	21.75(15.3~36.53)	24.40(14.35~42.50)	U=2572.5	0.413
GGT(U/L)	37.25(22.45~68.76)	29.40(16.00~118.00)	U=2755.0	0.888
ALP(U/L)	61.15(49.50~79.68)	58.00(39.80~91.55)	U=2637.5	0.564
Cr(μmol/L)	61.05(50.65~73.13)	66.20(54.95~87.25)	U=2308.5	0.072
Na(mmol/L)	136.95(134.60~140.10)	135.00(131.10~137.55)	U=1859.5	0.001
PT(s)	14.55(13.40~16.40)	16.90(15.60~20.70)	U=1331.5	＜0.001
INR	1.24(1.15~1.39)	1.48(1.34~1.76)	U=1259.5	＜0.001
WBC(×10⁹/L)	4.16(2.79~6.19)	5.90(3.63~10.21)	U=2008.5	0.004
RBC(×10¹²/L)	2.90±0.69	2.60±0.65	t=-2.633	0.009
Hb(g/L)	80.0(66.25~100.50)	72.00(59.00~88.00)	U=2150.0	0.017
PLT(×10⁹/L)	72.50(51.75~113.00)	68.00(43.00~106.50)	U=2454.0	0.208
RDW(%)	15.80(14.68~17.83)	17.60(15.95~20.35)	U=1719.5	＜0.001
CTP评分(分)	7.0(6.0~8.0)	9.0(8.0~11.0)	U=1078.0	＜0.001
CTP分级(A/B/C，例)	34/55/9	4/26/27	χ²=34.646	＜0.001
MELD-Na评分(分)	12.0(10.0~16.0)	18.0(14.5~24.0)	U=1176.0	＜0.001
ALBI评分(分)	-1.79±0.44	-1.11±0.59	t=7.618	＜0.001
ALBI分级(1/2/3，例)	2/79/17	0/15/42	χ²=48.732	＜0.001

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表 2 多因素logistic回归分析肝硬化食管胃静脉曲张出血患者预后的影响因素

回归模型	B值	SE	Wald	P值	OR	95%CI
回归模型1
AST	0.001	0.001	0.661	0.416	1.001	0.999~1.003
WBC	0.043	0.055	0.604	0.437	1.044	0.937~1.163
RDW	0.133	0.098	1.831	0.176	1.142	0.942~1.386
RBC	0.662	0.786	0.709	0.400	1.938	0.415~9.050
Na	-0.027	0.042	0.423	0.515	0.973	0.897~1.056
INR	1.381	0.893	2.392	0.122	3.979	0.691~22.895
Hb	-0.030	0.025	1.507	0.220	0.970	0.924~1.018
ALBI评分	2.122	0.584	13.201	＜0.001	8.349	2.658~26.232
回归模型2
AST	0.001	0.001	1.313	0.252	1.001	0.999~1.003
WBC	0.020	0.054	0.143	0.705	1.020	0.919~1.134
RDW	0.191	0.095	4.018	0.045	1.210	1.004~1.458
RBC	-0.228	0.618	0.136	0.713	0.797	0.237~2.673
Hb	-0.013	0.021	0.403	0.526	0.987	0.948~1.028
PT	0.048	0.078	0.380	0.538	1.050	0.900~1.224
MELD-Na评分	0.172	0.057	9.062	0.003	1.188	1.062~1.328
回归模型3
AST	0.001	0.001	0.801	0.371	1.001	0.999~1.003
WBC	0.017	0.054	0.104	0.747	1.018	0.916~1.131
RDW	0.179	0.094	3.631	0.057	1.197	0.995~1.439
RBC	-0.059	0.664	0.008	0.929	0.942	0.256~3.465
Hb	-0.014	0.022	0.401	0.527	0.986	0.945~1.029
INR	1.457	0.871	2.796	0.095	4.293	0.778~23.681
Na	-0.025	0.042	0.344	0.558	0.976	0.899~1.059
CTP评分	0.461	0.161	8.208	0.004	1.586	1.157~2.175

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表 3 ALBI评分、MELD-Na评分及CTP评分预测肝硬化食管胃静脉曲张出血患者1年内死亡的ROC曲线结果

指标	AUC	95% CI	cut-off值	敏感度(%)	特异度(%)	约登指数	P值
ALBI评分	0.818	0.744~0.893	-1.485	78.9	76.5	0.555	＜0.001
CTP评分	0.807¹⁾	0.736~0.878	8.5	68.4	80.6	0.490	＜0.001
MELD-Na评分	0.789¹⁾²⁾	0.713~0.866	17.5	56.1	87.8	0.439	＜0.001
注：与ALBI评分比较，1) Z=0.359，P=0.719；Z=0.826，P=0.409；与CTP评分比较，2) Z=0.470，P=0.638。

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