COSSH-ACLF Ⅱ评分对HBV相关慢加急性肝衰竭合并肝性脑病患者短期预后的预测价值

黄彤; 赵昱博; 杨玲

doi:10.12449/JCH250821

COSSH-ACLF Ⅱ评分对HBV相关慢加急性肝衰竭合并肝性脑病患者短期预后的预测价值

DOI: 10.12449/JCH250821

黄彤¹,
赵昱博²,
杨玲^3, , ,

1.
山西医科大学第一医院感染病科，太原 030001
2.
山西医科大学第一医院肝胆外科，太原 030001
3.
山西医科大学第一医院麻醉科，太原 030001

基金项目:

北京肝胆相照公益基金会 (iGandanF-1082023-RGG010)

伦理学声明：本研究方案于2023年9月14日经由山西医科大学医院伦理委员会审批，批号：KYLL-2023-208。

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：黄彤负责设计论文框架，起草论文；赵昱博负责数据收集，统计学分析、绘制图表；杨玲负责拟定写作思路，论文修改，指导撰写文章并最后定稿。

详细信息

通信作者:
杨玲， 2777673937@qq.com （ORCID： 0009-0002-3656-8776）

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出版历程
- 收稿日期: 2024-12-26
- 录用日期: 2025-01-20
- 出版日期: 2025-08-25

Value of Chinese Group on the Study of Severe Hepatitis B-acute-on-chronic liver failure Ⅱ score in predicting the short-term prognosis of patients with acute-on-chronic liver failure comorbid with hepatic encephalopathy

Tong HUANG¹,
Yubo ZHAO²,
Ling YANG^{3
, ,
,}

1.
Department of Infectious Diseases The First Hospital of Shanxi Medical University，Taiyuan 030001，China
2.
Department of Hepatobiliary Surgery The First Hospital of Shanxi Medical University，Taiyuan 030001，China
3.
Department of Anesthesiology The First Hospital of Shanxi Medical University，Taiyuan 030001，China

Research funding:

Beijing Gando Charity Foundation (iGandanF-1082023-RGG010)

More Information

Corresponding author: YANG Ling， 2777673937@qq.com （ORCID： 0009-0002-3656-8776）

摘要

摘要: 目的探讨中国重症乙型肝炎研究学组-慢加急性肝衰竭评分（COSSH-ACLFⅡ）对HBV相关慢加急性肝衰竭（HBV-ACLF）合并肝性脑病（HE）患者短期预后的预测价值。方法回顾性分析2019年1月—2024年10月山西医科大学第一医院收治并确诊的134例HBV-ACLF合并HE患者，根据随访90 d患者的生存状态分为生存组（n=60）和死亡组（n=74）。分别计算COSSH-ACLFⅡ评分、COSSH-ACLF评分、终末期肝病模型（MELD）评分、终末期肝病模型联合血清钠（MELD-Na）评分和MELD 3.0评分，比较两组基础临床资料、实验室指标、并发症及各模型评分等。计数资料两组间比较采用χ²检验；计量资料两组间比较采用成组t检验或者Mann-Whitney U检验。采用受试者操作特征曲线（ROC曲线）分析各评分对HBV-ACLF合并HE患者预后预测的临床效能。结果死亡组年龄［（56.09±10.52）岁］明显大于生存组［（49.23±11.57）岁］（t=2.720，P=0.007）。死亡组中并发症发生率（上消化道出血、腹水）、实验室指标（白细胞计数、中性粒细胞计数、总胆红素、国际标准化比值、血肌酐、血尿素氮）均明显高于生存组（P值均<0.05）。死亡组COSSH-ACLFⅡ、COSSH-ACLF、MELD、MELD-Na和MELD 3.0评分均高于生存组（P值均<0.001）。将患者以COSSH-ACLFⅡ评分危险分层的3个区间分为低危组、中危组和高危组，比较发现，COSSH-ACLFⅡ评分分值越高，患者病死率越高（χ²=44.371，P<0.001）。根据ROC曲线分析结果，COSSH-ACLFⅡ评分评价HBV-ACLF合并HE患者90 d死亡的ROC曲线下面积（AUC）为0.883，95%CI为0.837～0.919。截断值为7.25时，敏感度90.5%，特异度78.7%，预测准确度85.07%。COSSH-ACLFⅡ的AUC（0.883）优于COSSH-ACLF（0.841）、MELD 3.0（0.733）、MELD-Na（0.723）、MELD（0.716）（P值均<0.05）。结论采用COSSH-ACLF Ⅱ评分可提高预测HBV-ACLF合并HE患者90 d预后的准确度，COSSH-ACLFⅡ危险分层有助于简化患者病情分级。
- 乙型肝炎病毒 /
- 慢加急性肝功能衰竭 /
- 肝性脑病 /
- 预后
Abstract: Objective To investigate the value of Chinese Group on the Study of Severe Hepatitis B-acute-on-chronic liver failure Ⅱ （COSSH-ACLF Ⅱ） score in predicting the short-term prognosis of patients with hepatitis B virus-related acute chronic liver failure （HBV-ACLF） comorbid with hepatic encephalopathy （HE）. Methods A retrospective analysis was performed for 134 patients who were admitted to The First Hospital of Shanxi Medical University from January 2019 to October 2024 and were diagnosed with HBV-ACLF and HE， and according to the survival status of the patients on day 90 of follow-up， they were divided into survival group with 60 patients and death group with 74 patients. Related scores were calculated， including COSSH-ACLF Ⅱ score， COSSH-ACLF score， Model for End-Stage Liver Disease （MELD） score， MELD combined with serum sodium concentration （MELD-Na） score， and MELD 3.0 score， and the two groups were compared in terms of basic clinical data， laboratory markers， complications， and the scores of each model. The chi-square test was used for comparison of categorical data between two groups， and the t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups. The receiver operating characteristic （ROC） curve was used to assess the performance of each score in predicting the prognosis of patients with comorbidity of HBV-ACLF and HE. Results The death group had a significantly higher age than the survival group （56.09±10.52 years vs 49.23±11.57 years， t=2.720， P=0.007）. Compared with the survival group， the death group had significantly higher incidence rate of complications （upper gastrointestinal bleeding and ascites） and laboratory markers （white blood cell count， neutrophil count， total bilirubin， international normalized ratio， serum creatinine， and blood urea nitrogen）（all P<0.05）. The death group had significantly higher COSSH-ACLF Ⅱ， COSSH-ACLF， MELD， MELD-Na， and MELD 3.0 scores than the survival group （all P<0.001）. The patients were stratified into low-， moderate-， and high-risk groups based on COSSH-ACLF Ⅱs score， and comparison between groups showed that the mortality rate of patients increased with the increase in COSSH-ACLF Ⅱ score （χ²=44.371， P<0.001）. The ROC curve analysis showed that COSSH-ACLF Ⅱ score had an area under the ROC curve （AUC） of 0.883 （95% confidence interval： 0.837‍ ‍—‍ ‍0.919） in predicting the 90-day mortality of patients with comorbidity of HBV-ACLF and HE， with a sensitivity of 90.5%， a specificity of 78.7%， and a predictive accuracy of 85.07% at the cut-off value of 7.25. COSSH-ACLF Ⅱ score had a better performance than COSSH-ACLF （AUC=0.841， P<0.05）， MELD 3.0 （AUC=0.733， P<0.05）， MELD-Na （AUC=0.723， P<0.05）， and MELD （AUC=0.716， P<0.05）. Conclusion COSSH-ACLF Ⅱ score can improve the accuracy of predicting 90-day prognosis in patients with comorbidity of HBV-ACLF and HE， and COSSH-ACLF Ⅱ risk stratification can help to simplify the grading of patients.
- Hepatitis B Virus /
- Acute-on-Chronic Liver Failure /
- Hepatic Encephalopathy /
- Prognosis

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图 1 90 d不同评分预后判断的ROC曲线

Figure 1. ROC curves for prognostic assessment at 90 days with different scores

下载: 全尺寸图片幻灯片

表 1 两组患者基线特征及预后评分比较

Table 1. Comparison of baseline characteristics and prognostic scores between the two groups

指标	生存组（n=60）	死亡组（n=74）	统计值	P值
年龄（岁）	49.23±11.57	56.09±10.52	t=2.720	0.007
男［例（%）］	55（91.67）	61（82.43）	χ²=0.182	0.669
基础疾病［例（%）］
肝硬化	47（78.33）	62（83.78）	χ²=0.527	0.462
高血压	8（13.33）	14（18.91）	χ²=0.935	0.333
糖尿病	5（8.33）	8（10.81）	χ²=0.081	0.774
并发症［例（%）］
上消化道出血	16（26.67）	56（75.68）	χ²=41.518	<0.001
腹水	40（66.67）	60（81.08）	χ²=4.331	0.035
实验室指标
白细胞计数（×10⁹/L）	6.43（4.01～8.11）	8.30（4.57～10.73）	Z=-4.134	<0.001
NEUT（×10⁹/L）	3.78（2.73～5.37）	6.53（3.03～8.72）	Z=-5.512	<0.001
血小板计数（×10⁹/L）	109（82～143）	90（62～115）	Z=-1.962	0.051
INR	1.82（1.65～2.06）	2.36（1.75～2.88）	Z=-4.121	<0.001
TBil（μmol/L）	228.70（113.81～362.71）	294.45（241.72～365.15）	Z=-2.233	0.023
丙氨酸转氨酶（U/L）	490（192～981）	391（119～995）	Z=-0.127	0.882
白蛋白（g/L）	29.28（26.91～32.34）	29.14（27.67～33.93）	Z=-0.049	0.972
血肌酐（μmol/L）	63（52～78）	75（60～108）	Z=-3.172	0.001
血尿素氮（mmol/L）	4.08（3.02～6.64）	7.64（5.43～12.06）	Z=-6.371	<0.001
血清钠（mmol/L）	137（135～142）	138（132～141）	Z=-0.271	0.272
MELD评分（分）	22.31±6.02	25.98±8.58	t=-5.431	<0.001
MELD-Na评分（分）	24.15±5.67	27.03±7.11	t=-5.633	<0.001
MELD 3.0评分（分）	23.97±5.57	27.19±8.12	t=-5.720	<0.001
COSSH-ACLF评分（分）	4.33（3.73～4.27）	6.09（4.66～7.32）	Z=-6.498	<0.001
COSSH-ACLFⅡ评分（分）	6.32（5.72～7.33）	7.64（7.11～8.68）	Z=-8.472	<0.001

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表 2 不同预后评分对HBV-ACLF合并HE患者90 d死亡的预测效能分析

Table 2. Analysis of the predictive efficacy of different prognostic scores for 90-days mortality in patients with HBV-ACLF complicated by HE

预后评分	AUC	95%CI	截断值	敏感度	特异度	预测准确度（%）	P值
COSSH-ACLFⅡ	0.883	0.837～0.919	7.25	0.905	0.787	85.07	<0.001
COSSH-ACLF	0.841^1）	0.786～0.876	6.79	0.881	0.693	79.85	<0.001
MELD 3.0	0.733^1）2）	0.670～0.789	29.40	0.873	0.621	76.12	<0.001
MELD-Na	0.723^1）2）	0.663～0.773	28.21	0.807	0.673	74.43	<0.001
MELD	0.716^1）2）	0.650～0.768	21.63	0.793	0.588	70.15	<0.001
注：1）与COSSH-ACLFⅡ比较，P<0.05；2）与COSSH-ACLF比较，P<0.05。

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