| Background and ObjectiveHepatorenal syndrome (HRS) is a serious complication of the end-stage liver diseases and portal hypertension, characterized by renal dmage, reduction of renal blood flow and the abnormality of endogenous vascular activity.The disease progresses rapidly and has the high mortality.Therefore,to determine early the prognosis of outcome of the HRS can help improve clinical outcome and reduce motality. At present, the clinical scoring system to evaluate the prognosis of the severe liver disease are several, such as the Child-Pugh, end-stage liver disease (Meld) score and so on. Child-Pugh is a recognized scoring system, but there are subjective factors,such as no uniform quantitative criteria. Meld score has more objective factors, but not include indicators that can reflect the renal function,such as Scr,BUN and so on. The clinical features of HRS include azotemia, hypoproteinemia,dilutional hyponatremia, electrolyte disturbance and so on, hypoproteinemia and hyponatremia are very prominent, while the existing evaluation methods is sidedness and limitations as not include these two factors. The plasma colloid osmotic pressure and crystal osmotic pressure is an important indicator to reflect the body functions of patients,the blood sodium is the main components in composing the crystal osmotic pressure, the albumin is the main components in composing the colloid osmotic pressure, therefore the score composed by osmotic pressure should have the relationship between the prognosis of patients with HRS. In this study, we establish a scoring system with the plasma crystal osmotic pressure and colloid osmotic pressure as the main parameters,it composed by the plasma effective crystal osmotic pressure score,the plasma colloid osmotic pressure score and the plasma osmotic pressure comprehensive score, to predict the prognosis of the patients with HRS,and compare with the MELD score, Child-Pugh score, in order to assess the prognosis of HRS briefly and accuratly.MethodsThe subjects were the patients diagnosed live cirrosis with HRS in our hospital from January2008to July2010. In the106enrolled cases,88were male and18were female. Male vs female was4.89:1. There ages range from32to68years, with an average of37.6±17.8. The diagnostic criteria is consistent with the diagnostic criteria newly established by the international ascites research team in2007. Clinical data was collected since the day when HRS was confirmed. The enrolled patients were divided into survival group and death group according to the prognosis during the three-month follow up.The plasma osmotic pressure score:the effective crystal osmotic pressure (mmol/L)=2×[serum sodium (mmol/L)+potassium (mmol/L)]+glucose (mmol/L). To score according to osmotic pressure from upper to lower,≥280mmol/L (the lower limits of normal) note0as the baseline,with each decressde20mmol/L as a gradient noted2,10is the maximum. Plasma colloid osmotic pressure (mmHg)=6.89×(albumin+fibrinogen)(g/dl)-5.68, note by the osmotic pressure from upper to lower,≥25mmHg (the lower limits of normal)note0as the baseline,with each decressde5mmol/L as a gradient noted2,10is the maximum.The effective crystal osmotic pressure score plus the plasma colloid osmotic pressure score is comprehensive plasma osmotic pressure score.Statistical software SPSS13.0was used for statistical analysis. Measurement data noted as x±s. T-test was used to do group differences. Compare the predictive ability of scoring method using receiver operating characteristic (ROC) area under the curve (AUC). According to the ROC curve to determine the optimal diagnostic threshold, and determine the sensitivity and specificity of the threshold, calculate Youden index.Result1.Out of the106patients, only1case had normal plasma effective crystal osmotic pressure, and another case had normal plasma colloid osmotic pressure. The others’plasma effective crystal osmolality and colloid osmotic pressure all decreased significantly.87.7%patients’plasma effective crystal osmotic pressures were lower than260mmol/L, and94.3%patients’plasma colloid osmotic pressure were lower than20.0mmHg. Single scoring value is more than4points.2.Plasma colloid osmotic pressure single score, plasma osmotic pressure comprehensive score, MELD score and Child-Pugh score of the patients with HRS in the death group were all significantly higher than those of the survival group (P <0.01). Plasma effective crystal osmotic pressure score showed no significant difference between the two groups (P=0.067).3.The AUC of the scoring systems from low to high are plasma effective crystal osmotic pressure single score, colloid osmotic pressure single score, Child-Pugh score, MELD score and plasma osmotic pressure comprehensive score. The AUC of Child-Pugh score, MELD score and plasma osmotic pressure comprehensive score were all more than0.7. Plasma osmotic pressure comprehensive score had the highest Youden index, followed by MELD score and Child-Pugh score. We compared the AUC of plasma osmotic pressure comprehensive score, Child-Pugh score and MELD score using normality Z test. It showed that there were significant differences between the plasma osmotic pressure comprehensive score and Child-Pugh scores (Z=2.01, P <0.05), and there was no significant difference for MELD score (Z=1.02, P>0.05).Conclusions1. In this study, plasma osmotic comprehensive scoring system meet the pathophysiologic characteristics of the HRS, and has the relevance, practicality and operability comparing with other scoring systems.2. When the cut-off of the plasma osmotic pressure comprehensive score is11.00, the sensitivity is75.9%and specificity is80.7%in forecasting the risk of death in3months for patients with HRS. 3. Child-Pugh score and MELD score have clinical predictive value,but the sensitivity and the specificity are lower than the plasma osmotic comprehensive score,it has significant statistical difference.4. The plasma effective crystal osmotic pressure score and colloid osmotic pressure score have no clinical significance in predicting HRS prognosis. |
