간경변증 환자의 생존율 예측에 있어 ΔMELD 측정의 유용성
Clinical Usefulness of ΔMELD to Predict the Survival of Patients with Liver Cirrhosis
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목적: MELD 점수는 기존의 Child-Pugh(CP) 점수의 단점을 보완하여 만성 간질환 환자의 예후 판정에 유용하다고 알려져 있다. 최근 시간 경과에 따른 MELD 점수의 변화(ΔMELD) 역시 예후 판정의 유용한 예측 인자가 될 수 있음이 제시되고 있어 본 연구에서는 간경변증 환자의 생존율 예측에 있어 ΔMELD의 유용성을 확인하고, CP 점수 및 MELD 점수와 비교하고자 하였다. 대상과 방법: 간경변증으로 진단된 환자 중 최소 2개월 이상의 간격으로 2회 이상 연속 MELD 점수의 측정이 가능했던 120명의 입원환자를 대상으로 의무기록을 통해 ΔMELD에 영향을 주는 인자들을 분석하였다. C-통계값을 구하여 간경변증 환자의 6, 12, 24개월 사망 예측에 있어 최초 CP 점수, MELD 점수 및 ΔMELD 간의 유용성을 비교하였고, 최초 CP 점수, MELD 점수 및 ΔMELD/month에 따른 6, 12, 24개월 생존율을 비교 분석하였다. 결과: MELD 점수의 증가는 생화학검사 수치의 악화 및 간뇌증의 발생과 정맥류 출혈의 발생과 유의한 연관성을 보였다. ΔMELD/month의 6개월, 12개월, 24개월 사망률에 대한 AUC 값은 각각 0.928, 0.727, 0.693으로 CP 점수와 MELD 점수보다 우수하였다. ΔMELD/month가 1.0 이상인 경우 6개월, 12개월 및 24개월 생존율이 유의하게 감소하였다. ΔMELD/ month는 간경변증 환자의 사망률에 대한 독립적인 위험 인자로서 ΔMELD/month가 1 증가시 사망률은 각각 68% 증가하였다(위험비 1.679, 95% CI: 1.381-2.042, p<0.001). 결론: 시간 경과에 따른 MELD 점수의 변화는 간경변증 환자의 예후 판정에 초기 CP 점수 또는 MELD 점수보다 더 유용한 지표가 될 수 있을 것으로 생각한다.
Abstract
The change of MELD (Model for End-stage Liver Disease) score over time (ΔMELD) has been proposed as a tool to predict the survival in cirrhotic patients. The aims of the study were to assess ability of the ΔMELD to predict the survival and compare them with the initial MELD and CP score. Methods: MELD score was serially determined at least twice with more than two-month interval in 120 cirrhotic patients. We analyzed the clinical factors associated with the variation of MELD score. The predictive power of 6, 12 and 24 months mortality for ΔMELD, initial MELD and CP score was compared by c-statistics. Patient survival was also compared at 6, 12 and 24 months according to the cut off values of ΔMELD/month, initial MELD and CP score. Results: Increased MELD score was associated with biochemical and clinical parameters such as esophageal variceal bleeding and onset of hepatic encephalopathy. The area under receiver operating characteristic (ROC) curve for ΔMELD/month was 0.928 (P<0.001) compared with 0.575 for MELD score and 0.636 for CP score at 6 month-mortality; the area was 0.727, 0.594 and 0.657 at 12 month-mortality; 0.693, 0.587 and 0.639 at 24 month-mortality, respectively. The patients with ΔMELD/month more than 1.0 had resulted in the higher mortality at 6, 12 and 24 months. The ΔMELD/month was associated with mortality and was an independent prognostic predictor with a risk ratio of 1.679 (95% CI: 1.381-2.042, P<0.001). Conclusions: Determination of ΔMELD could be better prognostic predictor for patients with liver cirrhosis than initial MELD and CP score.
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