Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea.
Department of Internal Medicine, Seoul National University College of Medicine, Seoul, Korea.
Korean J Intern Med. 2019 Nov;34(6):1233-1243. doi: 10.3904/kjim.2018.120. Epub 2019 Feb 18.
BACKGROUND/AIMS: Non-selective β-blockers (NSBBs) are used for primary prevention of esophageal variceal hemorrhage (VH) in patients with portal hypertension, but a significant number of patients develop VH while on NSBB therapy. In this study, we sought to determine whether liver volume can predict the risk of primary prophylaxis failure in cirrhotic patients on NSBB therapy.
A retrospective cohort of 309 patients on prophylactic propranolol was analyzed. Liver volume was measured in portal venous phase images of multidetector computed tomography. Predictors of VH were assessed using a Cox proportional hazards model with competing-risks analysis. A nomogram was developed for estimation of the risk of primary prophylaxis failure.
During a median follow-up of 36 months, 37 patients on propranolol developed VH. Liver volume index, the ratio of measured-to-expected liver volume, was an independent predictor of VH (adjusted hazard ratio [HR], 2.70; 95% confidence interval [CI], 1.37 to 5.33; p = 0.004) as were the presence of large varices and the absence of ascites. A nomogram-based volume score of > 0.6 was predictive of prophylaxis failure (HR, 7.54; 95% CI, 2.88 to 19.73; p < 0.001). Time-dependent receiver operating characteristic curve analysis revealed that a nomogram-based risk score had significantly better discriminatory power than the North Italian Endoscopy Club index in predicting prophylaxis failure at 6 and 8 years.
Liver volume index is an independent predictor of first VH and a nomogram-based volume score stratifies the VH risk in cirrhotic patients on propranolol prophylaxis.
背景/目的：非选择性β受体阻滞剂（NSBBs）用于门静脉高压症食管静脉曲张出血（VH）的一级预防，但仍有相当数量的患者在 NSBB 治疗期间发生 VH。本研究旨在确定肝体积能否预测 NSBB 治疗的肝硬化患者一级预防失败的风险。
分析了 309 例接受预防性普萘洛尔治疗的患者的回顾性队列。使用多排 CT 门静脉期图像测量肝体积。使用竞争风险分析的 Cox 比例风险模型评估 VH 的预测因素。开发了一个列线图来估计一级预防失败的风险。
在中位随访 36 个月期间，37 例普萘洛尔患者发生 VH。肝体积指数（实测肝体积与预期肝体积之比）是 VH 的独立预测因素（调整后的危险比[HR]，2.70；95%置信区间[CI]，1.37 至 5.33；p = 0.004），大静脉曲张的存在和腹水的不存在也是如此。基于列线图的>0.6 体积评分可预测预防失败（HR，7.54；95%CI，2.88 至 19.73；p<0.001）。时间依赖性受试者工作特征曲线分析显示，基于列线图的风险评分在预测 6 年和 8 年时的预防失败方面具有明显优于北意大利内镜俱乐部指数的区分能力。
肝体积指数是首次 VH 的独立预测因素，基于列线图的体积评分可对接受普萘洛尔预防的肝硬化患者的 VH 风险进行分层。
