Dynamic Evaluation Of The Prognosis Of Patients With Acute(Subacute)-on-Chronic Liver Failure Treated With Plasma Exchange By Lymphocyte Monocyte Ratio Combined With Decreased Level Of Total Bilirubin

Objective:To analyze the 28-day survival rate and prognostic risk factors of patients with Acute（subacute）-on-chronic liver failure（ACLF/SACLF）after plasmapheresis,and to establish a short-term prognostic evaluation model of ACLF/SACLF patients after plasmapheresis,so as to reflect the clinical course of ACLF/SACLF patients early and dynamically,so as to help to identify the beneficiaries of plasmapheresis.Methods:Using the method of retrospective analysis,the baseline levels of 115ACLF/SACLF patients in the Department of Infectious Diseases of Shengjing Hospital affiliated to China Medical University from January 2016 to November 2022 and the related medical history,clinical and laboratory data after three plasmapheresis treatments were collected.All patients received systematic and standardized routine medical treatment based on ascending PE treatment.Taking the day of admission as the starting point,the 28-day prognosis was divided into clinical improvement group and clinical ineffective group.Binary logistic regression was used to analyze the relationship between various factors and prognosis,and a new predictive model of lymphocyte monocyte ratio（LMR）combined with the decrease of total bilirubin was established.The receiver operating characteristic（ROC）curve was drawn,and the area under the ROC curve（AUC）and predictive value of the new predictive model were compared with those of the traditional end-stage liver disease model（MELD）and the integrated end-stage liver disease model（i MELD）.Results:From January 2016 to November 2022,a total of 115 patients were enrolled in this study,including 79 cases（68.7%）in the improvement group and 36 cases（31.3%）in the ineffective group.Compared with the improved group,the ineffective group had age,number of complications,infection and hepatic encephalopathy（HE）,lymphocyte count,platelet count,neutrophil lymphocyte ratio,LMR,D-dimer,MELD score,i MELD score,white blood cell count difference between PE treatment and baseline level,MELD score difference,MELD-Na score difference,i MELD score difference.There were significant differences in the decreasing level of total bilirubin and the decreasing rate of total bilirubin（P<0.05）.Binary logistic regression analysis showed that the lower the level of total bilirubin and the lower LMR were independent risk factors for 28-day prognosis in patients with ACLF/SACLF.LMR combined with total bilirubin level to establish a new predictive model,the new predictive model compared with the classical prognostic model MELD,i MELD ROC curve,the results showed that the new predictive model AUC was larger than MELD（Z=2.911,P=0.0036）and i MELD（Z=2.764,P=0.0057）,the difference was statistically significant（P<0.05）.Conclusion:The 28-day survival rate of ACLF/SACLF patients treated with plasma exchange was 68.7%.The lower the decrease level of total bilirubin（when the optimal diagnostic threshold was 194.2,the sensitivity was 51.9%,the specificity was 94.4%）,the lower the LMR（when the optimal diagnostic threshold was 1.397,the sensitivity was68.4%,the specificity was 69.4%）,is an independent risk factor for death of ACLF/SACLF patients within 28 days.A new predictive model(Logistic _LMR+TB=0.915×LMR+0.011×Total bilirubin decrease)was established by combining total bilirubin level with LMR,which can accurately predict the short-term prognosis of ACLF/SACLF patients after PE treatment.