第三腰椎骨骼肌质量指数对慢加急性肝衰竭患者预后的预测价值

韩冶文; 李京; 赵凝慧; 姚佳; 王娟

doi:10.12449/JCH250415

第三腰椎骨骼肌质量指数对慢加急性肝衰竭患者预后的预测价值

DOI: 10.12449/JCH250415

韩冶文¹,
李京²,
赵凝慧²,
姚佳²,
王娟^3, , ,

1.
太原市人民医院普外科，太原 030012
2.
山西白求恩医院消化内科，太原 030032
3.
河南省直第三人民医院感染性疾病科，郑州 450000

基金项目:

山西省基础研究项目 (202103021224341);

山西省基础研究项目 (202203021222342);

山西省基础研究项目 (202303021212328);

山西省卫生健康委科技指导项目 (2021XM42);

山西省内分泌与代谢疾病重点实验室 (202104010910009)

伦理学声明： 本研究方案于2022年10月1日经由山西白求恩医院伦理委员会审批，批号：YXLL-2022-109。

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：韩冶文负责课题设计，资料分析，撰写论文；李京和赵凝慧参与收集数据，修改论文；王娟和姚佳负责拟定研究方向及写作思路，指导文章撰写、修改及定稿。

详细信息

通信作者:
王娟， 2647146563@qq.com （ORCID： 0000-0002-0406-8585）

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出版历程
- 收稿日期: 2024-08-19
- 录用日期: 2024-10-15
- 出版日期: 2025-04-25

Value of third lumbar skeletal muscle mass index in predicting the prognosis of patients with acute-on-chronic liver failure

Yewen HAN¹,
Jing LI²,
Ninghui ZHAO²,
Jia YAO²,
Juan WANG^{3
, ,
,}

1.
Department of General Surgery，Taiyuan People’s Hospital，Taiyuan 030012，China
2.
Department of Gastroenterology，Shanxi Bethune Hospital，Taiyuan 030032，China
3.
Department of Infectious Diseases，The Third People’s Hospital of Henan Province，Zhengzhou 450000，China

Research funding:

Shanxi Province Basic Research Program (202103021224341);

Shanxi Province Basic Research Program (202203021222342);

Shanxi Province Basic Research Program (202303021212328);

Shanxi Provincial Healthy Commission Guiding Science and Technology Project (2021XM42);

Endocrine and Metabolic Diseases Key Laboratory of Shanxi Province (202104010910009)

More Information

Corresponding author: WANG Juan， 2647146563@qq.com （ORCID： 0000-0002-0406-8585）

摘要

摘要: 目的探讨第三腰椎骨骼肌质量指数（L3-SMI）对慢加急性肝衰竭（ACLF）患者长期预后的预测价值，为ACLF患者的预后评分提供实用的工具。方法回顾性纳入2017年12月—2021年12月在山西白求恩医院接受腹部CT检查并确诊为ACLF的126例患者，收集患者临床、生化指标以及计算终末期肝病模型（MELD）评分等指标，计算L3-SMI。符合正态分布的计量资料两组间比较采用成组t检验；不符合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。应用受试者操作特征曲线（ROC曲线）评估L3-SMI和其他变量如MELD评分和Child-Pugh评分的诊断价值，ROC曲线下面积（AUC）的比较使用Delong检验。结果 126例ACLF患者中有44例（35%）在2年内死亡，82例（65%）存活。死亡组患者年龄、腹水发生率、国际标准化比值、MELD评分、Child-Pugh评分均显著高于存活组（P值均<0.05），L3-SMI显著低于存活组［38.40（35.95～46.29） cm²/m² vs 44.19（40.20～48.58） cm²/m²，Z=-2.855， P=0.004］。L3-SMI预测ACLF患者2年病死率的AUC为0.720，敏感度为63.6%，特异度为80.5%；L3-SMI+MELD评分+Child-Pugh评分联合预测的AUC优于MELD评分+Child-Pugh评分二者联合预测的AUC（0.809 vs 0.757，Z=2.015， P<0.05）。结论 L3-SMI对ACLF患者的预后有一定的预测作用，且L3-SMI+MELD评分+Child-Pugh评分联合预测ACLF患者预后的价值更高，将L3-SMI或肌肉减少症包括在ACLF患者常规预后的评分中，可能会提高预测疾病进展的能力。
- 慢加急性肝功能衰竭 /
- 第三腰椎骨骼肌质量指数 /
- 肌减少症
Abstract: Objective To investigate the value of third lumbar skeletal muscle mass index （L3-SMI） in predicting the long-term prognosis of patients with acute-on-chronic liver failure （ACLF）， and to provide a useful tool for prognostic scoring of ACLF patients. Methods A retrospective analysis was performed for the data of 126 patients who underwent abdominal computed tomography （CT） scanning and were diagnosed with ACLF in Shanxi Bethune Hospital from December 2017 to December 2021， including clinical indicators， biochemical parameters， and model for end-stage liver disease （MELD） score， and L3-SMI was calculated. The independent-samples t test was used for comparison of normally distributed continuous data between groups， and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between groups； the chi-square test was used for comparison of categorical data between groups. The receiver operating characteristic （ROC） curve was used to assess the diagnostic value of L3-SMI and other variables （MELD score and Child-Pugh score）， and the DeLong test was used for comparison of the area under the ROC curve （AUC）. Results Among the 126 patients enrolled， 44 （35%） died within 2 years and 82 （65%） survived. Compared with the survival group， the death group had significantly higher age， incidence rate of ascites， international normalized ratio， MELD score， and Child-Pugh score （all P<0.05） and a significantly lower value of L3-SMI ［38.40 （35.95‍ ‍—‍ ‍46.29） cm²/m² vs 44.19 （40.20‍ ‍—‍ ‍48.58） cm²/m²， Z=-2.855， P=0.004］. L3-SMI had an AUC of 0.720 in predicting 2-year mortality in ACLF patients， with a sensitivity of 63.6% and a specificity of 80.5%， and a combination of L3-SMI， MELD score， and Child-Pugh score had a significantly better AUC than a combination of MELD score and Child-Pugh score in predicting 2-year mortality （0.809 vs 0.757， Z=2.015， P<0.05）. Conclusion L3-SMI has a high predictive value for the prognosis of ACLF patients， and the combination of L3-SMI、MELD score and Child-Pugh score has a higher predictive value for ACLF patients， and the inclusion of L3-SMI or sarcopenia in the conventional prognostic scores of ACLF patients may increase the ability to predict disease progression.
- Acute-On-Chronic Liver Failure /
- the Third Lumbar Skeletal Muscle Mass Index /
- Sarcopenia

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图 1 L3-SMI、MELD评分、Child-Pugh评分预测ACLF患者预后的ROC曲线

Figure 1. ROC curve of L3-SMI， MELD score， and Child-Pugh score in predicting ACLF patients

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图 2 L3-SMI、MELD评分、Child-Pugh评分联合预测ACLF患者预后的ROC曲线

Figure 2. ROC curve of L3-SMI， MELD score， and Child-Pugh score combined to predict ACLF patients

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表 1 ACLF存活与非存活患者的基线特征

Table 1. Baseline characteristics of patients who survived and did not survive acute-on-chronic liver failure

项目	死亡组（n=44）	存活组（n=82）	统计值	P值
性别［例（%）］			χ²=1.244	0.571
男	30（68.2）	50（61.0）
女	14（31.8）	32（39.0）
年龄（岁）	55.05±10.20	47.59±10.81	t=3.299	0.010
体质量（kg）	62.94±7.45	65.37±11.68	t=-0.514	0.443
BMI（kg/m²）	22.74±3.53	23.22±3.74	t=-0.230	0.658
病因［例（%）］
HBV	16（36.4）	40（48.8）	χ²=0.894	0.344
酒精相关性	20（45.5）	16（19.5）	χ²=4.722	0.030
自身免疫性	4（9.1）	8（9.8）	χ²=0.007	0.932
其他	4（9.1）	18（22.0）	χ²=1.643	0.302
RBC（×10¹²/L）	3.17±0.85	3.60±0.88	t=-1.766	0.062
WBC（×10⁹/L）	7.05（4.40～10.90）	6.30（4.75～9.00）	Z=-1.348	0.531
Hb（g/L）	108.14±20.87	118.24±24.75	t=-1.500	0.109
PLT（×10⁹/L）	84.50（50.50～113.25）	113.00（78.00～150.50）	Z=-1.752	0.068
TBil（μmol/L）	323.00（251.70～487.93）	285.20（193.25～408.10）	Z=-1.384	0.235
Alb（g/L）	27.62±4.67	29.54±5.83	t=-1.839	0.188
Cr（μmol/L）	106.95（65.65～179.00）	77.25（68.75～121.35）	Z=-2.251	0.117
INR	2.23（1.89～2.87）	1.82（1.60～2.42）	Z=-2.733	0.008
Child-Pugh评分（分）	12.00（10.00～13.00）	11.00（9.00～12.00）	Z=-2.799	0.007
MELD评分（分）	27.54±8.11	22.82±7.09	t=3.192	0.020
腹水［例（%）］	40（90.9）	52（63.4）	χ²=5.493	0.019
肝性脑病［例（%）］	16（36.4）	16（19.5）	χ²=2.146	0.219
肝肾综合征［例（%）］	6（13.6）	4（4.9）	χ²=1.503	0.333
L3-SMI（cm²/m²）	38.40（35.95～46.29）	44.19（40.20～48.58）	Z=-2.855	0.004
注：INR，国际标准化比值。

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表 2 各项指标及联合指标的诊断效能

Table 2. Diagnostic efficacy of individual indicators and combined indicators

指标	AUC	95%CI	截断值	敏感度（%）	特异度（%）	P值	Z值^1）	P值^1）
L3-SMI	0.720	0.577～0.862	39.52	63.6	80.5	0.004	1.145	0.145
Child-Pugh评分	0.712	0.574～0.846	11.50	54.5	78.0	0.006	2.038	0.040
MELD评分	0.728	0.592～0.864	25.34	63.6	75.6	0.003	1.749	0.080
L3-SMI+MELD评分	0.771	0.633～0.906	0.63	68.2	85.4	<0.001	1.228	0.219
L3-SMI+Child-Pugh评分	0.783	0.659～0.906	0.56	63.6	87.8	<0.001	0.898	0.369
L3-SMI+MELD评分+Child-Pugh评分	0.809	0.691～0.927	0.60	68.2	82.9	<0.001
MELD+Child-Pugh评分	0.757	0.630～0.884	0.56	59.1	85.4	<0.001	2.015	0.046
注：1）与L3-SMI+MELD评分+Child-Pugh评分比较。

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