Angermayr B, Luca A, König F, Bertolini G, Ploner M, Gridelli B, Ulbrich G, Reiberger T, Bosch J, Peck-Radosavljevic M
Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
Eur J Clin Invest. 2009 Jan;39(1):65-71. doi: 10.1111/j.1365-2362.2008.02063.x.
Originally, aetiology of liver disease has been incorporated into the computation of the Model of End-stage Liver Disease (MELD) score. Clinical observations prompted us to hypothesize that patients with viral and alcoholic cirrhosis may differ in predicted survival rates. Until now, no large representative studies evaluated the impact of aetiology on long-term survival predicted by the Child-Pugh and MELD scores.
Four hundred and ninety-three patients who underwent transjugular intrahepatic portosystemic shunt implantation in Vienna, Austria, and Palermo, Italy, were included in this retrospective study. The main analyses were a logistic regression model and a Cox proportional hazards regression model calculating the interaction of the aetiology with the scores.
Both groups had similar survival rates (median 1377 and 1721 days for viral and alcoholic cirrhosis, respectively; P = 0.58), but patients with viral cirrhosis had significantly lower MELD scores (P = 0.002). In the Cox analysis, aetiology had a significant impact on the prediction of overall survival by MELD score. For 3-month survival, MELD score was adequately predictive for both groups. For 1-year survival, aetiology had a significant impact on survival, indicating that patients with identical scores but different aetiologies differed in survival rates. When stratifying patients into high- and low-risk patients (MELD < 16 vs. MELD >or= 16), aetiology of cirrhosis had no impact on the predictive value for low-risk patients; high-risk-patients (MELD >or= 16) with viral cirrhosis had significantly lower survival rates than patients with alcoholic cirrhosis and identical scores. With regard to Child-Pugh Score, no significant differences between the two patient groups and in the prediction of 3-month and 1-year survival could be observed.
Our study suggests that aetiology of cirrhosis has an impact on 1-year survival predicted by the MELD score. This becomes more apparent in patients with advanced stage of liver disease (MELD >or= 16). Since MELD score is used for ranking patients for liver transplantation and waiting times are regularly longer than 3 months, our observations suggest that with increasing time on the waiting list and severity of disease, patients with viral cirrhosis may have a disadvantage in the current allocation policy.
最初，肝病病因已被纳入终末期肝病模型（MELD）评分的计算中。临床观察促使我们推测，病毒性和酒精性肝硬化患者的预测生存率可能存在差异。到目前为止，尚无大型代表性研究评估病因对Child-Pugh和MELD评分预测长期生存的影响。
本回顾性研究纳入了在奥地利维也纳和意大利巴勒莫接受经颈静脉肝内门体分流术植入的493例患者。主要分析是计算病因与评分相互作用的逻辑回归模型和Cox比例风险回归模型。
两组生存率相似（病毒性和酒精性肝硬化患者的中位生存期分别为1377天和1721天；P = 0.58），但病毒性肝硬化患者的MELD评分显著更低（P = 0.002）。在Cox分析中，病因对MELD评分预测总体生存有显著影响。对于3个月生存率，MELD评分对两组均有充分的预测性。对于1年生存率，病因对生存有显著影响，表明评分相同但病因不同的患者生存率存在差异。将患者分为高风险和低风险患者（MELD < 16 vs. MELD≥16）时，肝硬化病因对低风险患者的预测价值无影响；病毒性肝硬化的高风险患者（MELD≥16）与酒精性肝硬化且评分相同的患者相比，生存率显著更低。关于Child-Pugh评分，两组患者之间以及在3个月和1年生存率的预测方面均未观察到显著差异。
我们的研究表明，肝硬化病因对MELD评分预测的1年生存有影响。这在肝病晚期患者（MELD≥16）中更为明显。由于MELD评分用于对肝移植患者进行排名，且等待时间通常超过3个月，我们的观察结果表明，随着等待名单上时间的增加和疾病严重程度的加重，病毒性肝硬化患者在当前分配政策中可能处于劣势。
