Division of Gastroenterology and Hepatology, University of Michigan.
Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI.
Hepatology. 2018 Oct;68(4):1498-1507. doi: 10.1002/hep.29628. Epub 2018 May 14.
Over 40% of patients with cirrhosis will develop hepatic encephalopathy (HE). HE is associated with decreased survival, falls, motor vehicle accidents, and frequent hospitalization. Accordingly, we aimed to develop a tool to risk-stratify patients for HE development. We studied a population-based cohort of all patients with cirrhosis without baseline HE (n = 1,979) from the Veterans Administration from Michigan, Indiana, and Ohio (January 1, 2005-December 31, 2010) using demographic, clinical, laboratory, and pharmacy data. The primary outcome was the development of HE. Risk scores were constructed with both baseline and longitudinal data (annually updated parameters) and validated using bootstrapping. The cohort had a mean age of 58.0 ± 8.3 years, 36% had hepatitis C, and 17% had ascites. Opiates, benzodiazepines, statins, and nonselective beta-blockers were taken at baseline by 24%, 13%, 17%, and 12%, respectively. Overall, 863 (43.7%) developed HE within 5 years. In multivariable models, risk factors (hazard ratio, 95% confidence interval) for HE included higher bilirubin (1.07, 1.05-1.09) and nonselective beta-blocker use (1.34, 1.09-1.64), while higher albumin (0.54, 0.48-0.59) and statin use (0.80, 0.65-0.98) were protective. Other clinical factors, including opiate and benzodiazepine use, were not predictive. The areas under the receiver operating characteristics curve for HE using the four significant variables in baseline and longitudinal models were 0.68 (0.66-0.70) and 0.73 (0.71-0.75), respectively. Model effects were validated and converted into a risk score. A score ≤0 in our longitudinal model assigns a 6% 1-year probability of HE, while a score >20 assigns a 38% 1-year risk.
Patients with cirrhosis can be stratified by a simple risk score for HE that accounts for changing clinical data; our data also highlight a role for statins in reducing cirrhosis complications including HE. (Hepatology 2017).
超过 40%的肝硬化患者会发生肝性脑病（HE）。HE 与生存率降低、跌倒、机动车事故和频繁住院有关。因此，我们旨在开发一种工具来对 HE 发展的患者进行风险分层。
我们研究了密歇根州、印第安纳州和俄亥俄州退伍军人事务部（VA）的一组来自人群的无基线 HE 的肝硬化患者（n=1979），使用人口统计学、临床、实验室和药房数据。主要结局是 HE 的发生。使用基线和纵向数据（每年更新参数）构建风险评分，并使用自举法进行验证。
该队列的平均年龄为 58.0±8.3 岁，36%患有丙型肝炎，17%有腹水。基线时分别有 24%、13%、17%和 12%的患者服用阿片类药物、苯二氮䓬类药物、他汀类药物和非选择性β受体阻滞剂。总体而言，863 例（43.7%）在 5 年内发生 HE。在多变量模型中，HE 的危险因素（危险比，95%置信区间）包括胆红素升高（1.07，1.05-1.09）和非选择性β受体阻滞剂的使用（1.34，1.09-1.64），而白蛋白升高（0.54，0.48-0.59）和他汀类药物的使用（0.80，0.65-0.98）则具有保护作用。其他临床因素，包括阿片类药物和苯二氮䓬类药物的使用，并没有预测作用。在基线和纵向模型中使用四个显著变量的 HE 受试者工作特征曲线下面积分别为 0.68（0.66-0.70）和 0.73（0.71-0.75）。模型效果得到验证并转化为风险评分。在我们的纵向模型中，评分≤0 时，1 年 HE 的概率为 6%，而评分>20 时，1 年风险为 38%。
可以根据 HE 的简单风险评分对肝硬化患者进行分层，该评分考虑了不断变化的临床数据；我们的数据还突出了他汀类药物在减少包括 HE 在内的肝硬化并发症方面的作用。（Hepatology 2017）
