基于终末期肝病评分模型对91例乙型肝炎病毒相关性慢加急肝衰竭患者预后的评估及死亡危险因素分析

采用9种终末期肝病预后评分模型对乙型肝炎病毒相关性慢加急肝衰竭(hepatitis B virus-related acute-on-chronic liver failure，HBV-ACLF)患者进行预后评估，分析引起HBV-ACLF患者死亡的危险因素。连续收集2014年7月-2018年7月复旦大学附属华山医院确诊的HBV-ACLF患者，通过评估受试者工作特征曲线的曲线下面积(area under receiver operating characteristic curve，AUROC)，判断目前9种终末期肝病预后评分模型预测HBV-ACLF患者预后的准确性。采用多因素Logistic回归分析，探讨HBV-ACLF患者死亡的危险因素。共纳入91例HBV-ACLF患者，死亡46例。COSSH-ACLFs评分对轻度、重度患者的短期和中期预后具有最佳预测能力(总体死亡率AUROC：28 d为 0.946，90 d为 0.920；按器官衰竭数量分级，0～1级：28 d为 0.900，90 d为 0.846；2～3级：28 d为 0.957，90 d为 0.917)；确定COSSH-ACLFs评分的最佳临界点为 6.245，生存曲线分析显示评分>6.245 的患者生存率明显低于评分≤6.245 的患者(10.7% vs. 81.8%，P<0.000 1)。年龄、总胆红素、血小板计数、凝血系统衰竭、肝性脑病是HBV-ACLF患者死亡的独立危险因素。死亡组患者血小板计数显著低于生存组(P<0.002 2)，血小板计数≤63×109/L与HBV-ACLF患者病情严重程度及预后显著相关。本研究证实COSSH-ACLFs评分模型预测HBV-ACLF患者预后的能力较其他评分模型更为准确，血小板计数与HBV-ACLF患者病情严重程度及预后显著相关。

Assessment of various prognostic model and analysis of predictors for 91 patients with hepatitis B virus-related acute-on-chronic liver failure

Nine prognostic models for end-stage liver diseases were used to assess the prognosis of the patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) and the influencing factors of mortality were analyzed. A total of 91 HBV-ACLF patients who received treatment in Huashan Hospital, Fudan University, from July 2014 to July 2018 were selected. The predictive value of nine prognostic models was assessed by the areas under receiver operating characteristic curves (AUROCs), and the influencing factors of mortality were analyzed by logistic regression model. Among 91 patients with HBV-ACLF, 46 died within 90 d. COSSH-ACLF score model presented the best predictive value (AUROC: 0.946 for 28-day mortality and 0.920 for 90-day mortality). AUROCs of the patients graded by the number of organ failure were: grades 0-1: 0.900 for 28-day mortality and 0.846 for 90-day mortality; grades 2-3: 0.957 for 28-day mortality and 0.917 for 90-day mortality. The cutoff of COSSH-ACLF score was 6.245. The survival rate of the patients with COSSH-ACLF score >6.245 was significantly lower than those ≤6.245 (10.7% vs. 81.8%, P<0.000 1). The independent predictors of mortality were age, total bilirubin, coagulation failure, hepatic encephalopathy and platelet count. The platelet count in the survival group was significantly higher than that in the death group (P<0.002 2). The results suggest that COSSH-ACLF score model is clinically practical for the prognosis of HBV-ACLF patients, and platelet count is associated with the severity and prognosis of HBV-ACLF patients.