정맥류 초출혈을 한 간경변증 환자의 사망률 예측에서 ΔMELD/월의 유용성: 초기 CTP, MELD 점수 및 ΔCTP/월과의 비교
Usefulness of ΔMELD/month for Prediction of the Mortality in the First Episode of Variceal Bleeding Patients with Liver Cirrhosis: Comparison with CTP, MELD score and ΔCTP/month
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목적: 비대상간경변증 합병증 중 식도정맥류 초출혈 환자들만을 대상으로 단기 및 장기 사망률 예측 인자로서 CTP 점수, MELD 점수 및 이들 점수 변화(ΔCTP, ΔMELD)들의 유용성을 알아보고 어떤 인자가 가장 유용하게 임상에서 적용될 수 있는지 알아보고자 하였다. 대상과 방법: 간경변증에 의한 식도정맥류 초출혈로 입원한 환자 중 2회 이상 연속적인 MELD 및 CTP 점수의 측정이 가능했던 71명을 대상으로 후향 분석을 하였다. C-통계값과 logistic regression을 통해 6개월 단기 및 1년 이상의 장기 사망률 예측에 최초 CTP 및 MELD 점수 및 ΔCTP/월, ΔMELD/월 간의 유용성을 비교하였고 사망률에 관련된 위험비(hazard ratio)는 Cox proportional hazard model 분석방법으로 구하였다. 결과: 6개월 내의 단기 사망률 예측에는 출혈 당시의 MELD 점수, CTP 점수 및 ΔCTP/월, ΔMELD/월 점수 모두가 유용하게 이용될 수 있으며, 1년 이상의 사망률 예측에는 초기 CTP 점수 및 ΔMELD/월이 유용하였다. 이 중 ΔMELD/월이 6개월 내의 단기 및 1년 이상의 사망률 예측에 가장 높은 C-통계값을 보였는데 (6개월: 1, 1년: 0.81), 0.27점 이상인 경우 이하인 경우에 비해서 6개월 40.1배, 1년 14.1배의 높은 사망 위험도를 보였다. 또한 6개월 내에 사망한 모든 환자들의 ΔMELD/월 값은 0.27이상이었다. 사망 위험비에서 ΔMELD/월 점수만이 6개월, 1년 사망률에 독립적인 위험 인자였다. 결론: 식도정맥류 초출혈을 한 간경변증 환자들의 사망률 예측에 ΔMELD/월이 CTP 점수, MELD 점수와 더불어 유용한 지표가 될 수 있을 것으로 생각한다. 앞으로 보다 정확한 예후 인자 간의 유용성 비교를 위해서는 전향 연구가 필요할 것으로 생각한다.
Abstract
Background/Aims: There are many models for predicting prognosis of liver cirrhosis including Child Turcotte Pugh (CTP), the model for end-stage liver disease (MELD) score and its changes over time (ΔCTP and ΔMELD/month). We investigated the ability of these models to predict the mortality of liver cirrhosis patients with the first episode of variceal bleeding and which model can be usefully applied in practice. Methods: Seventy-one liver cirrhosis patients hospitalized for the first episode of esophageal variceal bleeding were retrospectively analyzed. The predictive power of initial CTP, MELD score, ΔCTP and ΔMELD/month was compared through c-statistics and multiple logistic regression. Results: All of the prognostic predictors measured higher in patients who survived than in those who died. The area under the receiver operating characteristic (ROC) curve for ΔMELD/month in 6 months was 1, a higher value than 0.81 for initial CTP, 0.75 for initial MELD, and 0.84 for ΔCTP/month; the area of ΔMELD/month in 12 months was 0.81, also showing a higher value than others. ΔMELD/month > 0.27 was a strong significant prognostic predictor in 6 (odds ratio: 40.1, p=0.001) and 12 months (odds ratio: 14.1, p<0.001). Only the ΔMELD/month was an independent prognostic predictor with a risk ratio of 1.604 (95% CI: 1.119-2.302, p=0.01) in 6 months and 1.627 (95% CI: 1.294-2.047, p<0.001) in 12 months. Conclusions: The ΔMELD/month is superior to initial CTP, MELD and ΔCTP/month to predict 6 and 12 months mortality in liver cirrhosis patients with the first episode of variceal bleeding.
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