Fejfar T, Safka V, Hůlek P, Vanásek T, Krajina A, Jirkovský V
II. interní klinika Lékarské fakulty UK a FN Hradec Kralové.
Vnitr Lek. 2006 Sep;52(9):771-6.
Transjugular Intrahepatic Portosystemic Shunt (TIPS) is now well established in the treatment of complications of symptomatic portal hypertension such as acute or recurrent variceal bleeding, refractory ascites and Budd-Chiari syndrome. In some patients with refractory ascites who belong to group C according to Child-Pugh classification (score around 12), the indication of the procedure could be very questionable and early mortality is quite high. However, in some cases, the subgroup of such risky patients can profit from TIPS. Child-Pugh classification is used for the stratification of the patients routinely. During the last decade other scoring systems occured to bring a better prognostic value. MELD (Model for End stage Liver Disease) score, based only on laboratory values is one of them. Comparison of these two scoring systems in patients treated by TIPS in previous trials brought certain discrepancy, but MELD score seems to be better in predicting early mortality. The aim of our study was to determine retrospectively the predictive accuracy of MELD score for the early mortality in comparison to Child-Pugh score in patients treated for refractory ascites by TIPS.
We evaluated 110 patients (mean age 55 years) with liver cirrhosis (61% of patients with alcoholic etiology), who underwent TIPS for refractory ascites in our center from September 1992 to December 2003. MELD and Child-Pugh score was calculated and then compared between groups with early (one month), three month and one year mortality, and those who survived over this period (one, three and twelve months), comparing MELD and Child-Pugh score (ROC analysis and Student's T test were used).
Mean follow up was 23 months. Average MELD score in the whole group was (16). In patients, who died within one month the score before TIPS was 21, three months 20 and 18 one year. Comparing MELD score between subgroups and then Child-Pugh score, only for MELD score there was a statistically significant difference (p < 0.05) in one month. Using ROC (AUC) analysis, discriminant power of MELD score was superior to Child-Pugh score for one (0.73 vs 0.63) and three month (0.73 vs 0.67) mortality. The discriminant power for one year mortality was low in both scores.
MELD scoring system is a better tool to predict the risk of early mortality in patients with refractory ascites treated by TIPS than Child-Pugh classification. The discriminant power was low in both scores in one year horizon.
经颈静脉肝内门体分流术（TIPS）目前在治疗有症状的门静脉高压并发症方面已得到广泛应用，如急性或复发性静脉曲张出血、顽固性腹水和布加综合征。在一些根据Child-Pugh分类属于C组（评分约为12）的顽固性腹水患者中，该手术的适应证可能存在很大疑问，且早期死亡率相当高。然而，在某些情况下，这类高危患者亚组可从TIPS中获益。Child-Pugh分类通常用于对患者进行分层。在过去十年中，出现了其他评分系统以提供更好的预后价值。基于实验室值的终末期肝病模型（MELD）评分就是其中之一。在以往试验中接受TIPS治疗的患者中，比较这两种评分系统存在一定差异，但MELD评分在预测早期死亡率方面似乎更好。我们研究的目的是回顾性确定在因顽固性腹水接受TIPS治疗的患者中，与Child-Pugh评分相比，MELD评分对早期死亡率的预测准确性。
我们评估了110例肝硬化患者（平均年龄55岁）（61%的患者病因是酒精性），这些患者于1992年9月至2003年12月在我们中心因顽固性腹水接受了TIPS治疗。计算MELD和Child-Pugh评分，然后比较有早期（1个月）、3个月和1年死亡率的组与在此期间存活（1个月、3个月和12个月）的组之间的评分，比较MELD和Child-Pugh评分（使用ROC分析和Student's T检验）。
平均随访23个月。整个组的平均MELD评分为（16）。在1个月内死亡的患者中，TIPS术前评分为21，3个月时为20，1年时为18。在亚组之间比较MELD评分，然后比较Child-Pugh评分，仅MELD评分在1个月时有统计学显著差异（p<0.05）。使用ROC（AUC）分析，MELD评分对1个月（0.73对0.63）和3个月（0.73对0.67）死亡率的判别能力优于Child-Pugh评分。两种评分对1年死亡率的判别能力都较低。
对于因顽固性腹水接受TIPS治疗的患者，MELD评分系统在预测早期死亡风险方面比Child-Pugh分类是更好的工具。两种评分在1年时间范围内的判别能力都较低。
