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查尔森共病指数对慢加急性肝衰竭患者预后的评估价值
DOI: 10.3969/j.issn.1001-5256.2023.05.015
伦理学声明：本研究方案于2022年6月6日经由兰州大学第一医院伦理委员会审批，批号：LDYYLL2022-336。
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：王富春、李子怡、张万洁、毛永武及田爱平参与了数据收集，数据分析，文献检索，起草文章初稿；王富春、毛小荣及李俊峰对文章的思路和设计有关键贡献，并参与修改文章关键内容。
Value of Charlson comorbidity index in predicting the prognosis of patients with acute-on-chronic liver failure
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摘要:
目的 评估查尔森共病指数(CCI)对慢加急性肝衰竭(ACLF)患者短期和长期死亡风险的预测价值。 方法 纳入2016年12月1日—2021年12月1日就诊于兰州大学第一医院的ACLF患者317例。按照患者预后结局分为死亡组(n=169)和存活组(n=148)，分析基线临床资料及随访数据。计量资料两组间比较采用成组t检验或Mann-Whitney U检验。计数资料两组间比较采用χ2检验。使用单因素和多因素Cox风险比例模型分析ACLF患者预后的影响因素。通过Kaplan-Meier法绘制生存曲线，Log-rank检验比较不同CCI评分患者的生存时间差异，并采用受试者工作特征曲线(ROC曲线)评估CCI等指标对ACLF患者预后的评价效能。 结果 317例ACLF患者中，男225例(71.0%)。死亡组和存活组患者基线资料比较，年龄、Hb、WBC、TBil、Alb、MELD评分、PTA、CCI、年龄校正的查尔森共病指数(ACCI)以及随访时间差异均有统计学意义(P值均＜0.05)。多因素Cox回归分析结果显示，CCI(HR=1.351，95%CI：1.112~1.641，P=0.002)、ACCI(HR=1.200，95%CI：1.011~1.423，P=0.037)和MELD评分(HR=1.076，95%CI：1.054~1.099，P＜0.001)是ACLF患者预后的独立危险因素。根据CCI评分将ACLF患者分为3组：CCI≤4分组(n=167)、CCI=5分组(n=64)、CCI≥6分组(n=86)，3组ACLF患者3年病死率分别为26.5%、83.2%和96.9%。随访3年和随访至2022年9月时，3组患者生存时间两两比较，差异均有统计学意义(P值均＜0.001)。CCI、ACCI和MELD评分预测ACLF患者预后的ROC曲线下面积分别为0.845、0.811、0.790。 结论 CCI和ACCI评分作为常用的共病评价指标，对评估ACLF患者短期及长期预后具有一定价值。 Abstract:Objective To investigate the value of Charlson comorbidity index (CCI) in predicting the short- and long-term risks of death in patients with acute-on-chronic liver failure (ACLF). Methods A total of 317 patients with ACLF who attended The First Hospital of Lanzhou University from December 1, 2016 to December 1, 2021 were enrolled, and according to their prognosis, they were divided into death group with 169 patients and survival group with 148 patients. The two groups were analyzed in terms of clinical data and follow-up data. The group t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. The univariate and multivariate Cox proportional-hazards regression model analyses were used to investigate the influencing factors for the prognosis of ACLF patients. The Kaplan-Meier method was used to plot survival curves, and the Log-rank test was used for comparison of survival time between patients with different CCI scores. The receiver operating characteristic (ROC) curve was used to evaluate the performance of CCI and other indices in assessing the prognosis of ACLF patients. Results Among the 317 patients, there were 225 (71.0%) male patients. There were significant differences between the death group and the survival group in age, hemoglobin, white blood cell count, total bilirubin, albumin, Model for End-Stage Liver Disease (MELD) score, prothrombin time activity, CCI, age-adjusted Charlson co-morbidity index (ACCI), and follow-up time (all P < 0.05). The multivariate Cox regression analysis showed that the CCI (hazard ratio [HR]=1.351, 95% confidence interval [CI]: 1.112-1.641, P=0.002), ACCI (HR=1.200, 95%CI: 1.011-1.423, P=0.037), and MELD score (HR=1.076, 95%CI: 1.054-1.099, P < 0.001) were independent risk factors for the prognosis of ACLF patients. Based on CCI score, the patients were divided into CCI ≤4 group with 167 patients, CCI=5 group with 64 patients, and CCI ≥6 group with 86 patients, with a 3-year mortality rate of 26.5%, 83.2%, and 96.9%, respectively, and there was a significant difference in survival time between any two groups after 3 years of follow-up and at the time of follow-up till September 2022 (all P < 0.001). CCI, ACCI, and MELD scores had an area under the ROC curve of 0.845, 0.811, and 0.790, respectively, in predicting the prognosis of ACLF patients. Conclusion As commonly used comorbidity assessment indices, CCI and ACCI scores have certain value in evaluating the short- and long-term prognosis of ACLF patients. -
Key words:
- Acute-On-Chronic Liver Failure /
- Prognosis /
- Charlson Comorbidity Index
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图 2 不同CCI评分组患者生存时间的比较
注：a，随访3个月；b，随访3年；c，随访至2022年9月。
Figure 2. Comparison of survival time of patients in different CCI groups
图 3 CCI、ACCI及MELD评分预测ACLF患者总生存期的ROC曲线
Figure 3. ROC curves of CCI, ACCI and MELD scores in predicting overall survival of patients with ACLF
表 1 CCI中的共病加权指数
Table 1. Comorbidity weighting index in Charlson comorbidity index
共病 共病权重(分) 共病 共病权重(分) 心肌梗死 1 偏瘫 2 充血性心力衰竭 1 中重度肾病 2 外周血管疾病 1 糖尿病(伴有并发症) 2 脑血管疾病 1 实体瘤 2 痴呆 1 白血病 2 慢性肺病 1 淋巴瘤 2 结缔组织病 1 中/重度肝病 3 消化性溃疡病 1 转移性实体瘤 6 轻度肝病 1 获得性免疫缺陷综合征 6 糖尿病(无并发症) 1 注：计算ACCI时，年龄大于40岁者，每增加10岁加1分。 
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表 2 患者的基线资料
Table 2. Baseline data of the patients
指标 死亡组(n=169) 存活组(n=148) 统计值 P值 男[例(%)] 120(71.0) 105(70.9) χ2=0.000 0.991 年龄(岁) 52.1±11.9 48.1±13.2 t=2.821 0.005 BMI(kg/m2) 23.1±3.9 23.5±3.5 t=-0.920 0.385 Hb(g/L) 120.8±30.5 128.7±31.0 t=-2.291 0.023 WBC(×109/L) 6.4(4.4~9.4) 5.2(3.5~7.1) Z=-3.461 0.001 PLT(×109/L) 79.0(48.0~111.0) 91.5(52.0~135.5) Z=-1.869 0.062 ALT(U/L) 94.0(39.0~281.0) 127.5(42.3~507.8) Z=-1.614 0.107 TBil(μmol/L) 251.4(77.9~471.0) 164.0(60.4~334.9) Z=-3.201 0.001 Alb(g/L) 29.9±4.6 32.1±4.9 t=-4.008 ＜0.001 ALP(U/L) 148.1(104.2~183.5) 132.8(101.8~172.3) Z=-1.848 0.065 MELD评分 37.0±7.5 34.5±6.3 t=3.191 0.002 PTA(%) 37.1±11.9 43.6±16.8 t=-3.948 ＜0.001 AFP(IU/mL) 20.2(3.3~234.4) 36.0(4.2~167.2) Z=-0.264 0.792 CCI[例(%)] χ2=114.333 ＜0.001 ≤4分 43(25.4) 124(83.8) 5分 46(27.2) 18(12.2) ≥6分 80(47.3) 6(4.1) ACCI[例(%)] χ2=155.072 ＜0.001 ≤4分 24(14.2) 97(65.5) 5~6分 68(40.2) 39(26.4) ≥7分 77(45.6) 12(8.1) 随访时间(月) 7.0(3.5~12.0) 25.0(16.0~40.0) Z=-11.264 ＜0.001 注：PTA，凝血酶原活动度。
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表 3 ACLF患者生存时间的影响因素分析
Table 3. Univariate and multivariate analysis of influencing survival time of patients
指标 单因素分析 多因素分析 HR 95%CI P值 HR 95%CI P值 性别 1.012 0.726~1.411 0.944 年龄(岁) 1.023 1.011~1.035 ＜0.001 BMI(kg/m2) 0.970 0.930~1.011 0.153 Hb(g/L) 0.994 0.989~0.999 0.011 0.995 0.990~1.000 0.033 WBC(×109/L) 1.054 1.032~1.076 ＜0.001 PLT(×109/L) 0.998 0.995~1.001 0.210 ALT(U/L) 1.000 0.999~1.000 0.019 Alb(g/L) 0.946 0.917~0.976 ＜0.001 ALP(U/L) 1.002 1.001~1.004 0.006 MELD评分(分) 1.115 1.095~1.136 ＜0.001 1.076 1.054~1.099 ＜0.001 PTA(%) 0.969 0.959~0.980 ＜0.001 0.976 0.963~0.989 ＜0.001 AFP(IU/mL) 1.000 1.000~1.001 0.088 CCI(分) 1.764 1.635~1.903 ＜0.001 1.351 1.112~1.641 0.002 ACCI(分) 1.640 1.523~1.763 ＜0.001 1.200 1.011~1.423 0.037 注：性别以男性为对照组。
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表 4 ACLF患者不同时间的病死率
Table 4. Mortality in patients with ACLF at different times
CCI分组 例数 1个月 3个月 6个月 1年 3年 CCI≤4分组 167 0 1.8% 6.0% 9.6% 26.5% CCI=5分组 64 3.1% 4.7% 21.0% 63.9% 83.2% CCI≥6分组 86 4.9% 36.6% 61.0% 90.2% 96.9%
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表 5 CCI、ACCI、MELD评分、PTA及Hb预测ACLF患者总生存期的效能分析
Table 5. Efficacy analysis of CCI, ACCI, MELD score, PTA and Hb in predicting overall survival in patients with ACLF
指标 AUC 95%CI P值 敏感度(%) 特异度(%) 阳性预测值 阴性预测值 CCI 0.845 0.801~0.888 ＜0.001 83.78 74.56 0.74 0.84 ACCI 0.811 0.764~0.859 ＜0.001 65.54 85.80 0.80 0.74 MELD评分 0.790 0.741~0.839 ＜0.001 86.49 61.54 0.66 0.84 PTA 0.626 0.562~0.689 ＜0.001 37.84 86.39 0.72 0.61 Hb 0.580 0.517~0.643 ＜0.001 44.59 71.01 0.57 0.59
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[1] BAJAJ JS, O'LEARY JG, LAI JC, et al. Acute-on-chronic liver failure clinical guidelines[J]. Am J Gastroenterol, 2022, 117(2): 225-252. DOI: 10.14309/ajg.0000000000001595. [2] ARROYO V, MOREAU R, JALAN R. Acute-on-chronic liver failure[J]. N Engl J Med, 2020, 382(22): 2137-2145. DOI: 10.1056/NEJMra1914900. [3] CHARLSON ME, POMPEI P, ALES KL, et al. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation[J]. J Chronic Dis, 1987, 40(5): 373-383. DOI: 10.1016/0021-9681(87)90171-8. [4] CHARLSON M, SZATROWSKI TP, PETERSON J, et al. Validation of a combined comorbidity index[J]. J Clin Epidemiol, 1994, 47(11): 1245-1251. DOI: 10.1016/0895-4356(94)90129-5. [5] TAKEMURA K, TAKENAKA Y, ASHIDA N, et al. Age-adjusted Charlson Comorbidity Index predicts prognosis of laryngopharyngeal cancer treated with radiation therapy[J]. Acta Otolaryngol, 2017, 137(12): 1307-1312. DOI: 10.1080/00016489.2017.1362112. [6] BOAKYE D, WALTER V, JANSEN L, et al. Magnitude of the age-advancement effect of comorbidities in colorectal cancer prognosis[J]. J Natl Compr Canc Netw, 2020, 18(1): 59-68. DOI: 10.6004/jnccn.2019.7346. [7] BAGNI K, CHEN IM, JOHANSEN AZ, et al. Prognostic impact of Charlson's Age-Comorbidity Index and other risk factors in patients with pancreatic cancer[J]. Eur J Cancer Care (Engl), 2020, 29(3): e13219. DOI: 10.1111/ecc.13219. [8] SARICI A, AR MC, YOKUS O, et al. The impact of transfusion burden and comorbidities on the prognosis of patients with myelodysplastic syndromes[J]. Transfus Apher Sci, 2020, 59(5): 102845. DOI: 10.1016/j.transci.2020.102845. [9] QU WF, ZHOU PY, LIU WR, et al. Age-adjusted Charlson Comorbidity Index predicts survival in intrahepatic cholangiocarcinoma patients after curative resection[J]. Ann Transl Med, 2020, 8(7): 487. DOI: 10.21037/atm.2020.03.23. [10] GHABRIL M, GU J, YODER L, et al. Development and validation of a model consisting of comorbidity burden to calculate risk of death within 6 months for patients with suspected drug-induced liver injury[J]. Gastroenterology, 2019, 157(5): 1245-1252. DOI: 10.1053/j.gastro.2019.07.006. [11] SHINKAWA H, TANAKA S, TAKEMURA S, et al. Predictive value of the age-adjusted Charlson comorbidity index for outcomes after hepatic resection of hepatocellular carcinoma[J]. World J Surg, 2020, 44(11): 3901-3914. DOI: 10.1007/s00268-020-05686-w. [12] Liver Failure and Artificial Liver Group, Chinese Society of Infectious Diseases, Chinese Medical Association; Severe Liver Disease and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association. Guideline for diagnosis and treatment of liver failure(2018)[J]. J Clin Hepatol, 2019, 35(1): 38-44. DOI: 10.3969/j.issn.1001-5256.2019.01.007.中华医学会感染病学分会肝衰竭与人工肝学组, 中华医学会肝病学分会重型肝病与人工肝学组. 肝衰竭诊治指南(2018年版)[J]. 临床肝胆病杂志, 2019, 35(1): 38-44. DOI: 10.3969/j.issn.1001-5256.2019.01.007. [13] KAHL A, DU BOIS A, HARTER P, et al. Prognostic value of the age-adjusted Charlson comorbidity index (ACCI) on short- and long-term outcome in patients with advanced primary epithelial ovarian cancer[J]. Ann Surg Oncol, 2017, 24(12): 3692-3699. DOI: 10.1245/s10434-017-6079-9. [14] BECKER C, DAHLEM K, LANGE K, et al. Predictive value of comorbidity and anemia on outcome in patients with sinonasal carcinoma[J]. J Craniomaxillofac Surg, 2018, 46(8): 1373-1378. DOI: 10.1016/j.jcms.2018.05.009. [15] FORMIGA F, MORENO-GONZALEZ R, CHIVITE D, et al. High comorbidity, measured by the Charlson Comorbidity Index, associates with higher 1-year mortality risks in elderly patients experiencing a first acute heart failure hospitalization[J]. Aging Clin Exp Res, 2018, 30(8): 927-933. DOI: 10.1007/s40520-017-0853-1. [16] FRACCARO P, KONTOPANTELIS E, SPERRIN M, et al. Predicting mortality from change-over-time in the Charlson Comorbidity Index: A retrospective cohort study in a data-intensive UK health system[J]. Medicine (Baltimore), 2016, 95(43): e4973. DOI: 10.1097/MD.0000000000004973. [17] RATTANASOMPATTIKUL M, FEROZE U, MOLNAR MZ, et al. Charlson comorbidity score is a strong predictor of mortality in hemodialysis patients[J]. Int Urol Nephrol, 2012, 44(6): 1813-1823. DOI: 10.1007/s11255-011-0085-9. [18] LI H, ZHENG J, CHEN L, et al. The scoring systems in predicting short-term outcomes in patients with hepatitis B virus-related acute-on-chronic liver failure[J]. Ann Palliat Med, 2020, 9(5): 3048-3058. DOI: 10.21037/apm-20-608. [19] XU Y, HUANG XP, CHEN L, et al. Value of high-density lipoprotein cholesterol in evaluating the severity and prognosis of hepatitis B virus-associated acute-on-chronic liver failure[J]. J Clin Hepatol, 2021, 37(7): 1632-1635. DOI: 10.3969/j.issn.1001-5256.2021.07.030.徐英, 黄小平, 陈丽, 等. 高密度脂蛋白胆固醇对HBV相关慢加急性肝衰竭严重程度及预后的预测价值[J]. 临床肝胆病杂志, 2021, 37(7): 1632-1635. DOI: 10.3969/j.issn.1001-5256.2021.07.030. [20] XU X, HOU Z, XU Y, et al. The dynamic of platelet count as a novel and valuable predictor for 90-day survival of hepatitis B virus-related acute-on-chronic liver failure patients[J]. Clin Res Hepatol Gastroenterol, 2021, 45(2): 101482. DOI: 10.1016/j.clinre.2020.06.008. [21] CHAN TC, LUK JK, CHU LW, et al. Validation study of Charlson Comorbidity Index in predicting mortality in Chinese older adults[J]. Geriatr Gerontol Int, 2014, 14(2): 452-457. DOI: 10.1111/ggi.12129. -
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