急性心力衰竭患者肝肾功能损害及肝纤维化的预后价值
Prognostic value of impaired hepato-renal function and liver fibrosis in patients admitted for acute heart failure.
作者信息
Kawahira Masatsugu, Tamaki Shunsuke, Yamada Takahisa, Watanabe Tetsuya, Morita Takashi, Furukawa Yoshio, Kawasaki Masato, Kikuchi Atsushi, Kawai Tsutomu, Seo Masahiro, Nakamura Jun, Kayama Kiyomi, Kimura Takanari, Ueda Kunpei, Sakamoto Daisuke, Kogame Takehiro, Ito Shota, Chang Yongchol, Fukunami Masatake
机构信息
Division of Cardiology, Osaka General Medical Center, 3-1-56, Mandai-Higashi, Sumiyoshi-ku, Osaka, 558-8558, Japan.
出版信息
ESC Heart Fail. 2021 Apr;8(2):1274-1283. doi: 10.1002/ehf2.13195. Epub 2021 Jan 20.
AIMS
Cardiohepatic interactions have been a focus of attention in heart failure (HF). The model for end-stage liver disease excluding international normalized ratio (MELD-XI) score has been shown to be useful for predicting poor outcomes in patients with acute decompensated HF (ADHF). Furthermore, the fibrosis-4 (FIB-4) index, a simple marker to assess liver fibrosis, predicts adverse prognoses in patients with HF as well. However, there is little information available on the prognostic significance of the combination of the MELD-XI score and FIB-4 index in patients with ADHF and its association with left ventricular ejection fraction (LVEF) subgroup.
METHODS AND RESULTS
We prospectively studied 466 consecutive patients who were admitted for ADHF [HF with reduced LVEF (LVEF < 40%): n = 164, HF with mid-range LVEF (40% ≤ LVEF < 50%): n = 104, and HF with preserved LVEF (LVEF ≥ 50%): n = 198]. We calculated the MELD-XI score and FIB-4 indices at discharge. The primary endpoint was all-cause death (ACD). During the mean follow-up period of 2.8 years, 143 patients had ACD. In the multivariate Cox analysis, the MELD-XI score and FIB-4 index were independently associated with ACD. Patients were stratified into the following three groups according to the median value of MELD-XI score (=11) and FIB-4 index (=2.13): Group 1 had both a low MELD-XI score and a low FIB-4 index; Group 2 had either a high MELD-XI score (MELD-XI score ≥11) or a high FIB-4 index (FIB-4 index ≥2.13); and Group 3 had both a high MELD-XI score and a high FIB-4 index. Kaplan-Meier analysis revealed that Group 2 and Group 3 had a significantly greater risk of ACD than Group 1 [Group 2 vs. Group 1: adjusted hazard ratio, 2.48 (95% confidence interval: 1.75-3.53), P < 0.0001; Group 3 vs. Group 1: adjusted hazard ratio, 7.03 (95% confidence interval: 3.95-13.7), P < 0.0001]. In addition, the patients with both a higher MELD-XI score and FIB-4 index showed a significantly higher risk of ACD also in the patients with HF with reduced LVEF, HF with mid-range LVEF, and HF with preserved LVEF (all P < 0.0001).
CONCLUSIONS
The combination of MELD-XI score and FIB-4 index may be useful for stratifying patients at risk for ACD in patients with ADHF, irrespective of LVEF.
目的
心肝相互作用一直是心力衰竭（HF）领域的关注焦点。终末期肝病模型排除国际标准化比值（MELD-XI）评分已被证明有助于预测急性失代偿性心力衰竭（ADHF）患者的不良预后。此外，纤维化-4（FIB-4）指数作为评估肝纤维化的一个简单标志物，也能预测HF患者的不良预后。然而，关于MELD-XI评分与FIB-4指数联合应用于ADHF患者的预后意义及其与左心室射血分数（LVEF）亚组的关系，目前所知甚少。
方法与结果
我们对466例因ADHF连续入院的患者进行了前瞻性研究[射血分数降低的HF（LVEF < 40%）：n = 164，射血分数中等范围的HF（40%≤LVEF < 50%）：n = 104，射血分数保留的HF（LVEF≥50%）：n = 198]。我们在出院时计算了MELD-XI评分和FIB-4指数。主要终点是全因死亡（ACD）。在平均2.8年的随访期内，143例患者发生了ACD。在多因素Cox分析中，MELD-XI评分和FIB-4指数与ACD独立相关。根据MELD-XI评分（=11）和FIB-4指数（=2.13）的中位数，将患者分为以下三组：第1组MELD-XI评分和FIB-4指数均低；第2组MELD-XI评分高（MELD-XI评分≥11）或FIB-4指数高（FIB-4指数≥2.13）；第3组MELD-XI评分和FIB-4指数均高。Kaplan-Meier分析显示，第2组和第3组发生ACD的风险显著高于第1组[第2组与第1组：调整后风险比为2.48（95%置信区间：1.75 - 3.53），P < 0.0001；第3组与第1组：调整后风险比为7.03（95%置信区间：3.95 - 13.7），P < 0.0001]。此外，在射血分数降低的HF、射血分数中等范围的HF和射血分数保留的HF患者中，MELD-XI评分和FIB-4指数均较高的患者发生ACD的风险也显著更高（所有P < 0.0001）。
结论
MELD-XI评分与FIB-4指数联合应用可能有助于对ADHF患者中存在ACD风险的患者进行分层，而与LVEF无关。
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