Evaluation value of hepatic venous pressure gradient on gastrointestinal bleeding in decompensated cirrhosis patients
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摘要: 目的 探讨肝静脉压力梯度对肝硬化失代偿期患者消化道出血的评估价值。方法 纳入2020年1月—2021年6月在我院就诊的112例肝硬化失代偿期患者作为研究对象，分析肝静脉压力梯度与患者临床特征的相关性，所有患者按随访1年内是否发生消化道出血分为消化道出血组和无消化道出血组，比较两组患者的临床资料以及肝静脉压力梯度；多因素logistic回归分析获得肝硬化失代偿期患者消化道出血的独立预测因素，重点分析肝静脉压力梯度与患者消化道出血的相关性；基于多因素分析结果建立预测肝硬化失代偿期患者消化道出血风险的列线图模型，绘制校准曲线以验证列线图模型的预测效能。结果 肝静脉压力梯度与肝硬化失代偿期患者性别、食管胃底静脉曲张程度、Child-Pugh分级以及终末期肝病模型(model for end-stage liver disease，MELD)评分有一定的相关性(P < 0.05)；消化道出血组男性占比、重度食管胃底静脉曲张占比、凝血酶原活动度≤75%、Child-Pugh分级C级占比、MELD评分>14分占比以及肝静脉压力梯度明显高于无消化道出血组(P < 0.05)；多因素logistic回归分析显示，食管胃底静脉曲张程度、Child-Pugh分级、MELD评分以及肝静脉压力梯度为肝硬化失代偿期患者发生消化道出血的独立预测因素(P < 0.05)；基于多因素分析结果获得的独立预测因素为：食管胃底静脉曲张程度、Child-Pugh分级、MELD评分以及肝静脉压力梯度，结合各自影响权重建立预测肝硬化失代偿期患者消化道出血风险的列线图模型，校准曲线显示，肝硬化失代偿期患者消化道出血风险的预测值与实际观测值符合度良好(P>0.05)。结论 肝静脉压力梯度可用于准确评估肝硬化失代偿期患者消化道出血风险，基于独立预测因素建立的列线图模型具有较高的预测价值。Abstract: Objective To explore the value of hepatic venous pressure gradient in the evaluation of gastrointestinal bleeding in decompensated cirrhosis patients.Methods One hundred and twelve decompensated liver cirrhosis patients who were treated in our hospital from January 2020 to June 2021 were included as the study subjects. The correlation between the hepatic venous pressure gradient and the clinical characteristics of the patients was analyzed. All patients were divided into the digestive tract bleeding group and the no digestive tract bleeding group according to whether digestive tract bleeding occurred within the follow-up one year. The general clinical data and hepatic venous pressure gradient of patients between the two groups were compared. Multivariate logistic regression analysis was used to obtain independent predictors of digestive tract bleeding in decompensated cirrhosis patients, the analysis was focused on the correlation between hepatic venous pressure gradient and digestive tract bleeding. A nomogram model was established to predict the risk of digestive tract bleeding in decompensated cirrhosis patients based on the results of multivariate analysis, and a calibration curve was drawn to verify the predictive efficiency of the nomogram model.Results There was a certain correlation between the hepatic venous pressure gradient and the sex, the degree of esophageal and gastric fundus varices, Child-Pugh grade and model for end-stage liver disease(MELD) score of decompensated cirrhosis patients(P < 0.05). The proportion of male, severe esophageal and gastric varices, prothrombin activity =75%, Child-Pugh grade C, MELD score>14, and hepatic venous pressure gradient of patients in the gastrointestinal bleeding group were significantly higher than those in the non gastrointestinal bleeding group(P < 0.05). Multivariate logistic regression analysis showed that the degree of esophageal and gastric fundus varices, Child-Pugh grade, MELD score and hepatic vein pressure gradient were independent predictors of gastrointestinal bleeding in decompensated cirrhosis patients(P < 0.05). The degree of esophageal and gastric fundus varices, Child-Pugh grade, MELD score and hepatic vein pressure gradient, a nomogram model for predicting the risk of gastrointestinal bleeding in decompensated cirrhosis patients was established in combination with their respective influence weights based on independent predictors obtained from the results of multivariate analysis. The calibration curve showed that the predicted value of the risk of gastrointestinal bleeding in decompensated cirrhosis patients was in good agreement with the actual observation value(P>0.05).Conclusion Hepatic venous pressure gradient can be used to accurately assess the risk of gastrointestinal bleeding in decompensated cirrhosis patients. The nomogram model has a high predictive value based on independent predictors.
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表 1 肝静脉压力梯度与肝硬化失代偿期患者临床特征的相关性
X±S 临床特征 例数(n=112) 肝静脉压力梯度/mmHga) t P 年龄/岁 0.957 0.276 ≤55 45 15.7±4.6 >55 67 16.0±4.2 性别 2.787 0.018 男 76 16.7±4.5 女 36 15.2±4.2 肝硬化病因 1.617 0.196 病毒性 79 16.2±4.7 非病毒性 33 15.6±4.3 腹水 0.854 0.348 是 80 16.2±4.8 否 32 15.7±4.6 食管胃底静脉曲张程度 5.788 <0.001 轻度 23 14.7±3.8 中度 40 16.2±4.1 重度 49 17.9±4.8 白蛋白/(g/L) 1.657 0.134 ≤28 67 16.3±4.7 >28 45 15.8±4.6 总胆红素/(mmol/L) 1.094 0.234 ≤41 48 15.7±4.5 >41 63 16.2±4.7 凝血酶原活动度/% 1.876 0.094 ≤75 76 16.1±4.3 >75 36 15.7±4.3 Child-Pugh分级 4.974 <0.001 B级 69 15.5±4.3 C级 43 17.5±4.9 MELD评分/分 3.789 <0.001 ≤14 57 15.4±4.6 >14 55 16.9±4.9 注：a)1 mmHg=0.133 kPa。 
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表 2 两组患者的临床资料比较
例，X ± s 临床资料 消化道出血组(n=42) 无消化道出血组(n=70) t/χ2 P 临床资料 消化道出血组(n=42) 无消化道出血组(n=70) t/χ2 P 年龄/岁 1.644 0.298 白蛋白/(g/L) 1.945 0.239 ≤55 16 29 ≤28 21 46 > 55 26 41 > 28 21 24 性别 5.789 0.024 总胆红素/(mmol/L) 1.243 0.365 男 20 56 ≤41 16 32 女 22 14 > 41 26 38 肝硬化病因 1.879 0.254 凝血酶原活动度/% 4.674 0.041 病毒性 25 54 ≤75 35 41 非病毒性 17 16 > 75 7 29 腹水 0.876 0.467 Child-Pugh分级 9.967 0.002 是 30 50 B级 12 57 否 12 20 C级 30 13 食管胃底静脉曲张程度 7.899 0.004 MELD评分/分 7.895 0.007 轻度 2 21 ≤14 15 44 中度 12 28 > 14 27 26 重度 28 21 肝静脉压力梯度/ mmHg 17.7±4.9 13.4±3.3 5.668 < 0.001
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表 3 影响肝硬化失代偿期患者消化道出血的多因素logistic回归分析
自变量 β S.E. Wald χ2 P OR 95%CI 肝静脉压力梯度 1.378 0.337 11.677 <0.001 4.136 1.563~7.663 食管胃底静脉曲张程度(中度) 0.483 0.118 6.221 0.013 1.568 1.135~3.869 食管胃底静脉曲张程度(重度) 1.287 0.356 13.875 <0.001 3.967 1.768~6.774 MELD评分 0.895 0.127 4.234 0.038 2.645 1.078~4.889 Child-Pugh分级 1.145 0.238 7.488 0.011 3.859 1.248~7.865
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