前白蛋白与总胆红素比值对HBV相关慢加急性肝衰竭患者短期预后的预测价值

李文娟; 赵卫峰; 黄小平

doi:10.12449/JCH251112

前白蛋白与总胆红素比值对HBV相关慢加急性肝衰竭患者短期预后的预测价值

DOI: 10.12449/JCH251112

苏州大学附属第一医院感染病科，江苏苏州 215000

基金项目:

“十三五”国家科技重大专项 (2017ZX10203201002-002);

中国肝炎防治基金会专项 (TGQB20180371)

伦理学声明：本研究方案由苏州大学附属第一医院伦理委员会审批，批号：（2025）伦审批第534号。

利益冲突声明：本文不存在任何利益冲突。

作者贡献声明：李文娟负责资料查找，撰写论文；黄小平负责修改论文；赵卫峰指导修改文章并最终定稿。

详细信息

通信作者:
黄小平， grehxp@163.com （ORCID： 0000-0003-0916-2885）

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出版历程
- 收稿日期: 2025-04-25
- 录用日期: 2025-07-16
- 出版日期: 2025-11-25

Value of prealbumin-to-total bilirubin ratio in predicting the short-term prognosis of patients with HBV-related acute-on-chronic liver failure

Department of Infectious Diseases，The First Affiliated Hospital of Soochow University，Suzhou，Jiangsu 215000，China

Research funding:

National Key Science and Technology Special Project for the 13th Five-Year Plan (2017ZX10203201002-002);

China Hepatitis Prevention and Control Foundation Special Project (TGQB20180371)

More Information

Corresponding author: HUANG Xiaoping， grehxp@163.com （ORCID： 0000-0003-0916-2885）

摘要

摘要: 目的评估入院时前白蛋白与总胆红素比值（PA/TBil）对HBV相关慢加急性肝衰竭（HBV-ACLF）患者90天死亡或肝移植的预测价值，并分析其与MELD评分联合后对短期预后预测效能的影响。方法回顾性分析2020年4月—2025年5月苏州大学附属第一医院感染病科收住入院的216例HBV-ACLF患者的临床资料，对患者随访3个月，根据结局将患者分为生存组（n=104）和死亡/移植组（n=112）。采用Kolmogorov-Smirnov检验分析计量资料是否符合正态分布，符合正态分布的计量资料两组间比较采用成组t检验，偏态资料两组间比较采用Mann-Whitney U检验；计数资料两组间比较采用χ²检验；采用单因素及多因素二元Logistic回归分析影响预后的因素；采用受试者操作特征曲线分析各指标对ACLF预后的预测效能，计算曲线下面积（AUC），并使用Delong检验对AUC进行比较。结果 216例患者90天生存率为48.15%（104/216），生存组PLT、淋巴细胞计数、Alb、PA/TBil水平均显著高于死亡/移植组（P值均<0.05）；年龄、WBC、中性粒细胞计数、PT、国际标准化比值、AST、TBil、肌酐、MELD评分均显著低于死亡/移植组（P值均<0.05）。多因素Logistic回归分析显示，年龄（OR=1.05，95%CI：1.02～1.09，P<0.001）、PA/TBil（OR=0.16，95%CI：0.05～0.46，P<0.001）、MELD评分（OR=1.09，95%CI：1.01～1.17，P=0.024）是HBV-ACLF患者90天预后的独立影响因素。PA/TBil、MELD评分及二者联合预测HBV-ACLF患者预后的AUC分别为0.760、0.779、0.811；PA/TBil联合MELD评分预测的AUC优于单一指标AUC（Z值分别为-2.058、2.017，P值均<0.05）。结论血清PA/TBil、MELD评分均可以有效预测HBV-ACLF患者的预后，二者联合对患者的预后预测效果明显优于单独使用MELD评分，这为临床风险分层管理和及时干预提供了重要参考。
- 乙型肝炎病毒 /
- 慢加急性肝功能衰竭 /
- 预后 /
- 前白蛋白 /
- 胆红素 /
- MELD评分
Abstract: Objective To investigate the value of prealbumin-to-total bilirubin （PA/TBil） ratio on admission in predicting 90-day mortality or liver transplantation in patients with HBV-related acute-on-chronic liver failure （HBV-ACLF）， as well as the effect of its combination with Model for End-Stage Liver Disease （MELD） score on the predictive performance for short-term prognosis. Methods A retrospective analysis was performed for the clinical data of 216 HBV-ACLF patients who were admitted to Department of Infectious Diseases in the First Affiliated Hospital of Soochow University from April 2020 to May 2025， and the patients were followed up for 3 months. According to the outcome， the patients were divided into survival group with 104 patients and death/transplantation group with 112 patients. The Kolmogorov-Smirnov test was used to check whether the continuous data was in accordance with the normal distribution； the two-independent-samples t test was used for comparison of normally distributed continuous data between two groups， while the Mann-Whitney U test was used for comparison of continuous data with skewed distribution between two groups. The chi-square test was used for comparison of categorical data between two groups. Univariate and multivariate binary Logistic regression analyses were used to investigate the influencing factors for prognosis， and the receiver operating characteristic （ROC） curve was used to analyze the performance of each indicator in predicting the prognosis of ACLF. The area under the ROC curve （AUC） was calculated， and the Delong test was used for comparison of AUC. Results A total of 216 patients were enrolled in this study， with a 90-day survival rate of 48.15% （104/216）. Compared with the death/transplantation group， the survival group had significantly higher platelet count， lymphocyte count， albumin， and PA/TBil ratio （all P<0.05） and significantly lower age， white blood cell count， neutrophil count， prothrombin time， international normalized ratio， aspartate aminotransferase， total bilirubin， creatinine， and MELD score （all P<0.05）. The multivariate Logistic regression analysis showed that age （odds ratio ［OR］=1.05， 95% confidence interval ［CI］： 1.02 — 1.09， P<0.001）， PA/TBil ratio （OR=0.16， 95%CI： 0.05 — 0.46， P<0.001）， and MELD score （OR=1.09， 95%CI： 1.01 — 1.17， P=0.024） were independent influencing factors for 90-day prognosis in HBV-ACLF patients. PA/TBil ratio and MELD score used alone or in combination had an AUC of 0.760， 0.779， and 0.811， respectively， in predicting the prognosis of HBV-ACLF patients， and PA/TBil ratio combined with MELD score had a better AUC than PA/TBil ratio or MELD score used alone （Z=-2.058 and 2.017， both P<0.05）. Conclusion Both serum PA/TBil ratio and MELD score can effectively predict the prognosis of patients with HBV-ACLF， and a combination of the two indicators had a better predictive performance than MELD score alone， which provides an important reference for clinical risk stratification management and timely intervention.
- Hepatitis B Virus /
- Acute-on-Chronic Liver Failure /
- Prognosis /
- Prealbumin /
- Bilirubin /
- MELD Score

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图 1 PA/TBil和MELD评分以及二者联合预测HBV-ACLF患者预后的ROC曲线

Figure 1. ROC curves of PA/TBil， MELD score， and their combination in predicting prognosis of HBV-ACLF patients

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表 1 生存组和死亡/移植组HBV-ACLF患者的临床指标比较

Table 1. Comparison of clinical indicators between survival and death groups in HBV-ACLF patients

变量	合计（n=216）	生存组（n=104）	死亡/移植组（n=112）	统计值	P值
年龄（岁）	55.0（49.0～64.0）	53.0（45.5～61.0）	58.0（51.0～67.0）	Z=-3.07	0.002
性别（男/女，例）	174/42	83/21	91/21	χ²=0.07	0.789
WBC（×10⁹/L）	7.75（4.92～11.33）	7.31（4.77～9.29）	8.34（5.33～12.68）	Z=-2.20	0.028
淋巴细胞计数（×10⁹/L）	0.84（0.54～1.19）	0.93（0.75～1.29）	0.67（0.46～1.15）	Z=-3.71	<0.001
中性粒细胞计数（×10⁹/L）	5.95（3.56～9.20）	5.16（3.33～7.61）	7.09（3.79～10.84）	Z=-3.07	0.002
PLT（×10⁹/L）	76.50（48.75～131.00）	89.50（56.75～135.75）	66.50（38.75～107.75）	Z=-2.97	0.003
Hb（g/L）	111.24±25.10	113.98±26.73	108.69±23.32	t=1.55	0.122
PT（s）	19.00（16.20～24.30）	18.10（15.85～21.68）	21.55（16.78～28.40）	Z=-3.99	<0.001
INR	1.68（1.40～2.22）	1.59（1.36～1.89）	1.92（1.46～2.61）	Z=-4.21	<0.001
ALT（U/L）	115.65（42.30～222.73）	99.20（34.83～306.50）	117.55（49.90～218.73）	Z=-0.52	0.603
AST（U/L）	119.40（62.60～263.32）	88.50（55.08～216.90）	133.75（81.15～308.57）	Z=-2.43	0.015
TBil（μmol/L）	194.95（86.97～365.97）	121.75（71.25～232.62）	284.65（147.75～439.70）	Z=-6.06	<0.001
Alb（g/L）	30.01±5.33	31.41±5.15	28.72±5.19	t=3.83	<0.001
Cr（μmol/L）	65.05（52.70～88.00）	58.35（49.65～73.90）	76.05（56.10～99.80）	Z=-4.29	<0.001
PA/TBil	0.19（0.09～0.45）	0.33（0.16～0.96）	0.13（0.05～0.24）	Z=-6.59	<0.001
MELD评分（分）	13.17（7.80～18.61）	9.96（4.76～13.83）	16.31（12.50～22.74）	Z=-7.09	<0.001

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表 2 HBV-ACLF患者90天预后相关Logistic回归分析

Table 2. Logistic regression analysis of 90-day prognosis in HBV-ACLF patients

变量	单因素分析			多因素分析
变量	β值	OR（95%CI）	P值	β值	OR（95%CI）	P值
年龄（岁）	0.04	1.04（1.01～1.06）	0.002	0.05	1.05（1.02～1.09）	<0.001
WBC（×10⁹/L）	0.06	1.06（1.01～1.12）	0.019	0.01	1.01（0.90～1.13）	0.877
淋巴细胞计数（×10⁹/L）	0.02	1.02（0.91～1.14）	0.788
中性粒细胞计数（×10⁹/L）	0.09	1.09（1.03～1.16）	0.005	0.04	1.04（0.92～1.18）	0.512
PLT（×10⁹/L）	-0.01	0.99（0.99～0.99）	0.018	0.00	1.00（0.99～1.00）	0.755
PT（s）	0.10	1.11（1.05～1.16）	<0.001	-0.20	0.82（0.62～1.10）	0.189
INR	1.06	2.89（1.74～4.81）	<0.001	2.04	7.72（0.45～131.90）	0.158
AST（U/L）	0.00	1.00（1.00～1.00）	0.620
TBil（μmol/L）	0.01	1.01（1.01～1.01）	<0.001
Alb（g/L）	-0.10	0.90（0.85～0.95）	<0.001	-0.02	0.98（0.92～1.05）	0.640
Cr（μmol/L）	0.01	1.01（1.01～1.02）	0.001
PA/TBil	-2.35	0.10（0.04～0.25）	<0.001	-1.84	0.16（0.05～0.46）	<0.001
MELD评分（分）	0.15	1.17（1.11～1.23）	<0.001	0.08	1.09（1.01～1.17）	0.024

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表 3 PA/TBil、MELD评分、PA/TBil联合MELD评分对90天预后的预测价值

Table 3. Comparison of predictive value for 90-day prognosis among PA/TBil， MELD score， and PA/TBil combined with MELD score

模型	AUC	95%CI	灵敏度（%）	特异度（%）	Youden指数	Cut-off值	P值
PA/TBil	0.760	0.697～0.823	61.5	80.4	0.419	0.266	<0.001
MELD评分	0.779	0.719～0.840	79.5	63.5	0.430	12.000	<0.001
PA/TBil-MELD评分	0.811	0.755～0.867	67.9	79.8	0.477	0.596	<0.001

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