Value of Charlson comorbidity index in predicting the prognosis of patients with acute-on-chronic liver failure

Fuchun WANG; Wanjie ZHANG; Ziyi LI; Yongwu MAO; Aiping TIAN; Xiaorong MAO; Junfeng LI

doi:10.3969/j.issn.1001-5256.2023.05.015

Volume 39 Issue 5

May 2023

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Article Navigation > Journal of Clinical Hepatology > 2023 > 39(5): 1098-1104

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Value of Charlson comorbidity index in predicting the prognosis of patients with acute-on-chronic liver failure

DOI: 10.3969/j.issn.1001-5256.2023.05.015

Fuchun WANG¹,
Wanjie ZHANG¹,
Ziyi LI¹,
Yongwu MAO^2a,
Aiping TIAN^2a,
Xiaorong MAO^{2a
,
,
,},
Junfeng LI^{2a, 2b
,
,
,}

1.
The First Clinical Medical College of Lanzhou University, Lanzhou 730000, China
2a.
Department of Hepatology, The First Hospital of Lanzhou University, Lanzhou 730000, China
2b.
Research Office of Infectious Diseases, The First Hospital of Lanzhou University, Lanzhou 730000, China

Research funding:

National Natural Science Foundation of China (81800528);

Natural Science Foundation of Gansu Province (20JR5RA364);

Hospital Fund of the First Hospital of Lanzhou University (ldyyyn2020-02);

Hospital Fund of the First Hospital of Lanzhou University (ldyyyn2020-14);

Key Research and Development Project of Gansu Province (21YF5FA121);

Gansu Clinical Medical Research Center of Infection & Liver Diseases (21JR7RA392)

More Information

Corresponding author: MAO Xiaorong, mxr2013@126.com (ORCID: 0000-0003-1952-1554); LI Junfeng, junfenglee@126.com (ORCID: 0000-0002-5638-706X)
Received Date: 2022-10-13
Accepted Date: 2022-11-15
Published Date: 2023-05-20

Abstract

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.
- Acute-On-Chronic Liver Failure,
- Prognosis,
- Charlson Comorbidity Index

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全世界约有一半新诊断的肝细胞癌(hepatocellular cell carcinoma，HCC)病例发生在我国，其中HBV感染是主要危险因素，占全球HCC病例的50%~80%^[1]。HBV通过多种机制在宿主细胞中持续存在，从而导致慢性HBV感染^[2]，并且诱导HCC发生^[3]。超过80%的HCC在肝硬化基础上发展，这表明肝硬化在肝癌前环境中起着重要作用^[4]。因此慢性HBV感染和肝硬化是肝癌发生的高风险因素。由于缺乏明显的症状和有效的筛查策略，80%的HCC患者被诊断时已为中晚期，其中仅有30%~40%患者符合当前有效治疗方案的条件^[5]，故在早期将慢性HBV感染、肝硬化与HCC区分诊断是延长患者生存期甚至根治HCC的关键。现急需一种检测方式能够在患有良性肝病的肝癌高危人群中早期筛查出HCC，从而降低病死率。影像学检查作为有效筛查方法被应用于临床，但是受限于设备以及检测人员。实验室检测则更能筛查大量人群，目前主要的早期实验室筛查方法为检测患者血清AFP，但单一指标检测的敏感度与特异度存在限制。考虑联合指标检测能够提高诊断效率，本文将探究AFP与GGT/AST联合检测在良性肝病和HCC区别诊断中发挥的作用，以期为临床诊断提供新的参考依据。

1. 资料与方法

1.1 研究对象

选取2019年1月15日—6月15日于本院诊治的慢性乙型肝炎患者(CHB组)、乙型肝炎肝硬化患者(LC组)、HBV相关HCC患者(HCC组)，另选取同期健康体检者作为对照(HC组)。纳入标准：(1)HCC组患者HBsAg为阳性且诊断完全符合《原发性肝癌诊疗规范(2017年版)》^[6]; (2)HCC组、CHB组和LC组患者均为首次诊断，在接受治疗前收集生化指标; (3)临床资料完整。排除标准：(1)排除HCC之外的恶性肿瘤; (2)排除HBV以外的其他肝炎病毒感染; (3)排除患有严重糖尿病、甲状腺亢进以及心血管疾病等患者; (4)排除妊娠患者。研究对象均自愿参与本项研究。

1.2 研究方法

采集所有研究对象空腹6~8 h后的静脉血5 ml，以转速3500 r/min(离心半径=16 cm)离心5 min，分离血清后-80 ℃冷冻备用。采用Siemens公司ADVIACENTUAR XP全自动化学发光免疫分析仪及配套试剂盒检测血清AFP水平，参考区间为0~8.0 ng/ml。使用Siemens公司ADVIA2400全自动生化分析仪检测AST、ALT、GGT水平，参考区间分别为15~40、5~40、10~60 U/L。以上操作严格依据说明书进行，所有检测均在试剂盒说明书规定时间内完成，且严格遵守试验相关操作规程。

1.3 伦理学审查

本研究方案经由武汉大学人民医院临床研究伦理委员会审批，批号：WDRY2018-K047。

1.4 统计学方法

采用SPSS 23.0软件、GraphPad Prism 6.0和MedCalc 18.2.1对数据进行统计分析。正态分布计量资料以x±s表示，多组间比较采用方差分析，进一步两两比较采用LSD-t检验。偏态分布计量资料以M(P₂₅~P₇₅)表示，多组间比较采用Kruskal-Wallis H检验，进一步两两比较采用Nemenyi检验。计数资料组间比较采用χ²检验。通过二元logistic回归分析，计算出预测变量，并绘制AFP、GGT/AST以及预测变量单独或联合检测的受试者工作特征曲线(ROC曲线)，计算曲线下面积(AUC)及敏感度、特异度，采用Z检验对AUC进行比较。P＜0.05为差异有统计学意义。

2. 结果

2.1 一般资料

共纳入研究对象352例，其中HC组86例，男42例，女44例，年龄23~82岁，平均(55.90±15.19)岁; CHB组68例，男38例，女30例，年龄22~77岁，平均(51.40±10.59)岁，HBV DNA阳性50例; LC组69例，男34例，女35例，年龄28~79岁，平均(53.49±11.35)岁，HBV DNA阳性36例，Child-Pugh A级25例，B级32例，C级12例; HCC组129例，男70例，女59例，年龄24~78岁，平均(54.60±11.17)岁，HBV DNA阳性50例，Child-Pugh A级79例，B级41例，C级9例，BCLC分期A期21例，B期31例，C期77例。4组研究对象年龄(F=1.455，P=0.227)与性别分布(χ²=1.346，P=0.718)差异均无统计学意义。

2.2 各指标检测结果比较

HCC组与HC组、CHB组、LC组之间患者的AFP、GGT/AST、GGT比较差异均有统计学意义(P值均＜0.05)(表 1)。

表 1 各组AFP、GGT、AST及GGT/AST血清学水平比较

组别	例数	AFP(ng/ml)	GGT/AST	GGT(U/L)	AST(U/L)
HC组	86	3.35(2.20~4.70)	0.98(0.71~1.36)	20.00(15.00~27.00)	21.00(18.00~24.00)
CHB组	68	4.35(2.35~15.75)	0.82(0.46~1.25)	51.00(23.75~140.75)¹⁾	61.00(34.25~125.00)¹⁾
LC组	69	8.60(2.70~54.20)¹⁾	0.97(0.55~1.81)	69.00(27.00~113.00)¹⁾	47.00(31.00~88.00)¹⁾
HCC组	129	157.10(9.90~6126.40)¹⁾²⁾³⁾	2.00(1.19~3.11)¹⁾²⁾³⁾	98.00(45.00~207.00)¹⁾²⁾³⁾	46.00(29.00~88.00)¹⁾²⁾
H值		124.018	70.202	126.282	135.987
P值		＜0.001	＜0.001	＜0.001	＜0.001
注：与HC组比较，1)P＜0.05;与CHB组比较，2)P＜0.05;与LC组比较，3)P＜0.05。

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2.3 ROC曲线分析AFP与GGT/AST单独或联合检测诊断HCC的价值

采用二元logistic回归分析得到不同组别之间两种指标的联合回归模型，然后进一步绘制其ROC曲线(图 1)，计算AUC(表 2)，结果显示，在HCC组与LC组、HCC组与HC组+CHB组+LC组、HCC组与CHB组+LC组中，AFP与GGT/AST联合诊断的AUC均显著高于AFP单独诊断的AUC(Z值分别为2.684、2.241、2.415，P值分别为0.007、0.025、0.016)。

图 1 AFP与GGT/AST单独或联合检测诊断HCC的ROC曲线

注：a，HCC组与CHB组; b，HCC组与LC组; c，HCC组与HC组+CHB组+LC组; d，HCC组与CHB组+LC组。

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表 2 AFP与GGT/AST单独或联合检测在辅助HCC诊断中的价值

分组	标志物	AUC	95%CI	敏感度(%)	特异度(%)	P值
HCC组vs CHB组	AFP	0.803	0.742~0.864	72.9	72.1	＜0.05
	GGT/AST	0.789	0.717~0.861	67.4	83.8	＜0.05
	联合	0.846	0.790~0.910	79.8	77.9	＜0.05
HCC组vs LC组	AFP	0.760	0.693~0.826	55.8	84.1	＜0.05
	GGT/AST	0.727	0.650~0.803	90.7	46.4	＜0.05
	联合	0.802	0.741~0.862	48.1	97.1	＜0.05
HCC组vs HC组+CHB组+LC组	AFP	0.835	0.791~0.879	86.0	68.2	＜0.05
	GGT/AST	0.768	0.718~0.817	67.4	74.9	＜0.05
	联合	0.843	0.802~0.885	73.6	78.5	＜0.05
HCC组vs CHB组+LC组	AFP	0.781	0.727~0.835	55.8	85.4	＜0.05
	GGT/AST	0.758	0.700~0.815	67.4	77.5	＜0.05
	联合	0.823	0.775~0.871	81.4	66.4	＜0.05

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3. 讨论

HCC的发生通常伴有前期的慢性HBV感染和肝硬化，在慢性HBV感染以及患有肝硬化的高危人群中，利用有效的筛查方式早期发现HCC至关重要，是患者可能获得根治的关键^[7]。本文纳入352例研究对象，基于相关纳排标准将其分为4组，统计分析结果发现HCC组与HC组、CHB组、LC组AFP和GGT/AST比较，差异均有统计学意义(P值均＜0.05)，此结果与以往研究结果^[8]相符。

AFP作为最早被发现的蛋白肿瘤标志物之一^[9]，其可反映肝功能情况，因此广泛用于实验室检查。综合全球多种指南，AFP在我国可作为良好的血清学指标^[10]，但其特异度低，易引起误判^[11]。在CHB、LC患者中AFP水平也会升高，因此鉴别诊断HBV相关HCC患者时，AFP具有一定局限性，且部分HBV相关HCC患者的AFP水平并未达到筛查标准，因此容易漏查^[12]。

GGT在哺乳动物组织中广泛分布，是一种质膜结合蛋白，血清中的GGT主要来源于肝胆系统^[13]。已有研究^[14]表明GGT通过诱导DNA损伤来促进肿瘤进展和不良预后，释放活性氧以激活与入侵相关的信号通路，与HCC发展关联密切。AST主要分布于肝细胞线粒体内，当肝脏严重病变坏死时，血清中AST水平会显著升高^[15]，作为肝功能检查常用生化指标，GGT与AST在临床中应用广泛^[16]。本研究计算GGT/AST比值并发现其单独或联合AFP时在HBV相关HCC的诊断中具有一定价值，且该指标计算简单，不用另增检验项目，便于在HCC诊断过程中应用。

本研究ROC曲线分析结果显示，在HCC组与LC组中，GGT/AST联合AFP后AUC明显提高，表明GGT/AST与AFP联合在鉴别HCC与LC时有良好的诊断效果; 在HCC组与HC组+CHB组+LC组以及CHB组+LC组分别区别诊断时，二者联合的AUC均明显高于AFP单独诊断的AUC，进一步说明GGT/AST联合AFP在鉴别HCC与良性肝病患者中有较好的诊断价值。

综上所述，本研究表明GGT/AST联合AFP在HBV相关HCC的临床诊断中具有一定价值，提高了AFP的单独诊断效率。由于本研究样本量较小，因此相关研究结果仍需未来增加样本量予以验证。

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DOI: 10.3969/j.issn.1001-5256.2023.05.015