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

doi:10.3969/j.issn.1001-5256.2021.09.016

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

昆明医科大学第二附属医院消化内科，昆明 650101

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。

详细信息

通信作者:
胥莹，xuying_0505@163.com

中图分类号: R575.2
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出版历程
- 收稿日期: 2021-01-12
- 录用日期: 2021-01-27
- 出版日期: 2021-09-20

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

Department of Gastroenterology, The Second Affiliated Hospital of Kunming Medical University, Kunming 650101, China

摘要

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。
- 肝硬化 /
- 预后 /
- 血清白蛋白 /
- 国际标准化比值
Abstract: Objective To investigate the value of prothrombin time-international normalized ratio to albumin ratio (PTAR) in evaluating the prognosis of patients with decompensated cirrhosis. Methods A retrospective analysis was performed for the clinical data of 172 patients with decompensated cirrhosis who were admitted to The Second Affiliated Hospital of Kunming Medical University from April 2016 to April 2017, including sex, age, etiology, complications, and first examination of laboratory markers after admission. With death as the outcome event, the patients were divided into survival group with 98 patients and death group with 74 patients according to the outcome of the disease after 2 years of follow-up. The influencing factors for prognosis were analyzed, and the value of PTAR in predicting the prognosis of patients with decompensated cirrhosis were evaluated. The t-test or the Mann-Whitney U test was used for comparison of continuous data between groups, and the chi-square test or the Fisher's exact test was used for comparison of categorical data between groups. Univariate and multivariate Cox regression analyses were performed for related variables. The receiver operating characteristic (ROC) curve was plotted and the area under the ROC curve (AUC) was calculated, and the optimal cut-off value was determined according to the sensitivity and specificity of the ROC curve. The Kaplan-Meier survival curve analysis was performed to compare 2-year survival rate between patients with different values of PTAR, indocyanine green retention rate at 15 minutes (ICGR15), and Model for End-Stage Liver Disease (MELD) score, and the log-rank test was used for comparison between groups. Results Compared with the survival group, the death group had significantly higher PTAR (Z=-7.823, P < 0.001), ICGR15 (t=3.458, P=0.001), and MELD score (t=5.921, P < 0.001). PTAR, ICGR15, and MELD score had optimal cut-off values of 0.05, 41.00%, and 37.25, respectively, in predicting 2-year prognosis, with AUCs of 0.849, 0.651, and 0.724, respectively. The survival analysis showed that the high-PTAR (PTAR≥0.05) group had a significantly lower survival rate than the low-PTAR (PTAR < 0.05) group (χ²=60.07, P < 0.001). The multivariate Cox regression analysis showed that PTAR ≥0.05 was an independent risk factor for death within 2 years (hazard ratio = 2.564, 95% confidence interval: 1.276-5.151, P=0.008). Conclusion PTAR ≥0.05 can be used as an independent predictive factor for death within 2 years in patients with decompensated cirrhosis, and PTAR has a relatively high value in predicting the prognosis of patients with decompensated cirrhosis.
- Liver Cirrhosis /
- Prognosis /
- Serum Albumin /
- International Normalized Ratio

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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

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

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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值
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

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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

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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
指标	B值	P值	HR	95%CI	B值	P值	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

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