Analyses of prognostic indices of chronic liver failure caused by hepatitis virus.

Abstract

To analyze the related indices about the prognoses of chronic liver failure caused by hepatitis virus.
Retrospectively reviewed 320 cases of chronic liver failure caused by hepatitis viruses. An improved group and an ineffective group (IG) were made to compare and analyze their clinical manifestations, laboratory examination indices and complications. Logistic regression was also carried out.
There were significant differences (P<0.05) between the improved group and the IG upon such indices as age, bilirubin, prothrombin time, albumin, alpha fetoprotein, the size of liver and complications (P<0.05). The regression formula was as follows: P = 1/(1+e(-y)) (y = 1.7262-0.0948X(1)+2.9846X(2)+0.6992X(3)+1.6019X(4)+ 2.0398X(5)). (Note: X(1)-Prothrombin activity; X(2)-digestive tract hemorrhage; X(3)-hepatic encephalopathy; X(4)-hepatorenal syndrome; X(5)-pulmonary infection.).
Laboratory examination such as bilirubin, prothrombin time and alpha fetoprotein can be regarded as indices of the prognoses of chronic liver failure caused by hepatitis. Moreover, the regression equation can evaluate prognoses more comprehensively and direct our treatments.

Full text

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• BRIEF REPORTS •
Analyses of prognostic indices of chronic liver failure caused by
hepatitis virus
Xiao-Mao Li, Lin Ma, Yue-Bo Yang, Zhong-Jie Shi, Shui-Sheng Zhou
ELSEVIER
PO Box 2345, Beijing 100023, China World J Gastroenterol 2005;11(18):2841-2843
www.wjgnet.com
wjg@wjgnet.com © 2005 The WJG Press and Elsevier Inc. All rights reserved.
World Journal of Gastroenterology ISSN 1007-9327
Xiao-Mao Li, Lin Ma, Yue-Bo Yang, Zhong-Jie Shi, Shui-Sheng
Zhou, Department of Obstetrics and Gynecology, Third Affiliated
Hospital, Sun Yat-Sen University, Guangzhou 510630, Guangdong
Province, China
Correspondence to: Professor Xiao-Mao Li, Department of
Obstetrics and Gynecology, Third Affiliated Hospital, Sun Yat-Sen
University, Guangzhou 510630, Guangdong Province,
China. tigerlee777@163.net
Telephone: +86-20-85515609 Fax: +86-20-87565575
Received: 2004-10-26 Accepted: 2004-12-21
Abstract Abstract
Abstract Abstract
Abstract
AIM: To analyze the related indices about the prognoses
of chronic liver failure caused by hepatitis virus.
METHODS: Retrospectively reviewed 320 cases of chronic
liver failure caused by hepatitis viruses. An improved group
and an ineffective group (IG) were made to compare
and analyze their clinical manifestations, laboratory
examination indices and complications. Logistic regression
was also carried out.
RESULTS: There were significant differences (P<0.05)
between the improved group and the IG upon such indices
as age, bilirubin, prothrombin time, albumin, alpha
fetoprotein, the size of liver and complications (P<0.05).
The regression formula was as follows: P = 1/(1+e-y)
(y = 1.7262-0.0948X1+2.9846X2+0.6992X3+1.6019X4+
2.0398X5). (Note: X1-Prothrombin activity; X2-digestive tract
hemorrhage; X3-hepatic encephalopathy; X4-hepatorenal
syndrome; X5-pulmonary infection.).
CONCLUSION: Laboratory examination such as bilirubin,
prothrombin time and alpha fetoprotein can be regarded
as indices of the prognoses of chronic liver failure caused
by hepatitis. Moreover, the regression equation can
evaluate prognoses more comprehensively and direct
our treatments.
© 2005 The WJG Press and Elsevier Inc. All rights reserved.
Key words: Chronic liver failure; Hepatitis; Prognostic
indices; Laboratory indices; Complications; Regression
equation
Li XM, Ma L, Yang YB, Shi ZJ, Zhou SS. Analyses of prognostic
indices of chronic liver failure caused by hepatitis virus. World
J Gastroenterol 2005; 11(18): 2841-2843
http://www.wjgnet.com/1007-9327/11/2841.asp
INTRODUCTIONINTRODUCTION
INTRODUCTIONINTRODUCTION
INTRODUCTION
Hepatitis B virus (HBV) infection is very common in
China[1-3]. Fulminant hepatitis (FH) refers to liver diseases that
have severe states and poor prognoses, with a mortality rate
of more than 50%[4]. In China, the majority of FH is chronic
liver failure caused by hepatitis virus (CLFHV) (accounting
for 85% of all FH), with the most common cause of HBV
infection[5]. Because of the chronic underlying pathological
changes (most commonly chronic hepatitis or liver cirrhosis),
when liver failure led by necrosis of mass liver cell develops,
treatments become more difficult. In order to improve our
knowledge about the judgment of the prognoses of CLFHV,
we conducted a retrospective study on the potential prognostic
influencial factors on 320 cases of CLFHV patients to investigate
into the ways of predicting the prognoses of CLFHV.
MAMA
MAMA
MATERIALS AND METHODS
TERIALS AND METHODS
TERIALS AND METHODS TERIALS AND METHODS
TERIALS AND METHODS
The 320 CLFHV patients who met the clinical diagnostic
grouping criteria made jointly by infectious diseases branch,
parasitic diseases branch and liver diseases branch of Chinese
Medical Association (2000, Xi’ an)[6] were admitted to our
hospital from January 2000 to June 2003. Two hundred
and eighty-eight cases were male (90%) and 32 were female
(10%), with an average age of 43.00±12.24 years (ranged
from 15 to 77 years). Three hundred and one cases were
single HBV infected, two were hepatitis E virus (HEV)
infected and one with undetermined cause. There were 16
cases who were multi-infected: three were HBV+hepatitis
C virus (HCV) infected, two were HBV+hepatitis D virus
(HDV) infected, 10 were HBV+HEV infected and one was
HBV+hepatitis A virus (HAV)+HDV infected.
We divided those 320 patients into two groups: 123 cases
were in the effective group (EG) (improved in symptoms
and signs on the whole or significantly, with liver function
rebuilt or significantly improved) and 197 cases were in the
ineffective group (IG) (discharged by themselves without
improving or died in hospital). We compared their laboratory
indices, B-ultrasonography, complications and such potential
prognoses-influencing factors. Among them, the value of
bilirubin was taken at the highest time in our hospital. The
results were analyzed by SPSS 10.0 software. It would be
significant if P<0.05.
RESUL RESUL
RESULRESUL
RESULTS
Age
TS
TS TS
TS
The average age in EG was 39.67±11.13 years and the
counterpart in IG was 45.02±12.50 years, with significant
difference (P<0.05).

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2842 ISSN 1007-9327 CN 14-1219/ R World J Gastroenterol May 14, 2005 Volume 11 Number 18
Laboratory indices
There were significant differences between those two groups
on such indices as bilirubin, serum albumin (ALB), blood
clotting functions, alpha fetoprotein (AFP), creatinine (Cr)
and blood ammonia (NH3), while there were no significant
differences on aminotransferase, cholesterol (CHOL) or
blood glucose (GLU) (Table 1).
Complications and the result of B-ultrasonography
There were more significant differences on complications
and liver size between the two groups (Tables 2 and 3).
Table 2 Comparison of complication distribution of two groups
Items Ineffective Effective P
group, n (%) group, n (%)
Alimentary tract hemorrhage
Hepatorenal syndrome
Primary peritonitis
Hepatic encephalopathy
Infection of biliary tract
Pulmonary infection
39 (19.8)
53 (26.9)
130 (66.0)
136 (69.0)
117 (59.4)
34 (17.1)
4 (3.3) <0.01
3 (2.4) <0.01
47 (38.2) <0.01
17 (13.8) <0.01
64 (52.0) >0.05
5 (4.1) <0.01
Table 3 Comparison of B-ultrasonography of two groups
Items Ineffective
group, n (%)
Effective
group, n (%)
P
Liver shrinkage
Enlarge of spleen
Ascites
105 (53.3)
125 (63.5)
159 (80.7)
39 (31.7)
76 (61.8)
89 (72.4)
<0.01
>0.05
>0.05
Analyses of influencing factors
We made Logistic Stepwise Regression about those variable
factors. We put together glutamate-pyruvate transaminase
(ALT)/glutamic-oxalacetic transaminase (AST), total bilirubin
(Tbil)/direct bilirubin (Dbil), prothrombin time (PT) and
prothrombin activity (PTA); blood urea nitrogen (BUN),
creatinine (Cr) and hepatorenal syndrome. Together with
age, ALB, CHOL, cholinesterase (CHE), AFP, liver size,
hemorrhage and hepatorenal syndrome, etc., we got 19
variables as regression factors. By Forward method, we got
the regression model as follows: P = 1/(1+e-y); (y = 1.7262-
0.0948X1+2.9846X2+0.6992X3+1.6019X4+ 2.0398X5);
Note: X1-PTA (numeric), X2-digestive tract hemorrhage
(0-none; 1-develops), X3-hepatic encephalopathy (0-none;
1-degree I; 2-degree II; 3-degree III; 4-degree IV), X4-
hepatorenal syndrome (0-none; 1-develops), X5-pulmonary
infection (0-none; 1-develops). When P>0.5, the patient
would get worse. Otherwise, the patient would improve.
The coincidence of its rightness was 83.55%, which
conformed to the reports abroad[7,8].
DISCUSSIONDISCUSSION
DISCUSSION DISCUSSION
DISCUSSION
The mortality rate of CLFHV is very high. The pathological
underlyings are mass apoptosis[9-11], necrosis or severe
degeneration of liver cells, which lead to liver failure.
There are abnormalities of many biochemical indices. The
prognoses are related to the extent of liver cell necrosis,
regeneration and whether complications will develop. Just
as the statistical results of 320 cases in our study, PT and
ALB, which represent synthetic functions of liver cells, Tbil
and Dbil, which represent transportation function of liver
cells[12], all have significant correlations with the prognoses
of FH. The increased Tbil and Dbil, prolonged PT[13] and
decreased ALB will suggest a poorer function of liver cells
and a poorer prognosis. The older a patient is, poorer the
ability of liver regeneration is, which is hard for recovery
of liver function and leads to a poor prognosis. The increase
of AFP in hepatitis is due to the acute reaction of liver
cells after infected by viruses and this is also the regeneration
label of liver cells after necrosis. A lower AFP suggests a
poorer regeneration ability of liver cells and a poorer
prognosis[14,15]. The prognosis of FH is greatly correlated
with the incidence, amount and severity of complications.
The increased and more serious complications will lead to
poorer prognoses. Especially when hepatic encephalopathy
IV, renal failure[16] or alimentary tract hemorrhage[17,18]
develops, a high mortality rate will occur.
The purpose of our multi-factors regression model is
to evaluate the influence of many factors on the prognoses
of FH more objectively and comprehensively. It is easy for
calculation receiving information and is good for observation
of the effects of treatments. We applied Forward method
to delete those not significant variables and got five variable
factors such as PTA, alimentary tract hemorrhage, hepatic
encephalopathy, hepatorenal syndrome and pulmonary
Table 1 Comparison of laboratory indices of the two groups (mean±SD)
Items Ineffective group Effective group Value of P
Glutamate-pyruvate transaminase (ALT)
Glutamic-oxalacetic transaminase (AST)
Alkaline phosphatase (ALP)
Total bilirubin (Tbil)
Direct bilirubin (Dbil)
Serum albumin (ALB)
Cholesterol (CHOL)
Cholinesterase (CHE)
Blood glucose (GLU)
Blood urea nitrogen (BUN)
Creatinine (Cr)
Alpha fetoprotein (AFP)
Blood ammonia (NH3)
Prothrombin time (PT)
Prothrombin activity (PTA)
196.70±291.74 U/ L
214.05±234.75 U/ L
137.42±74.60 U/ L
612.332±195.943 µmol/ L
356.837±119.196 µmol/ L
32.80±6.04 g/ L
1.601±3.146 mmol/ L
3 453.69±1 820.24 U/ L
4.609±3.932 mmol/ L
10.33±13.72 mmol/ L
159.26±170.88 mmol/ L
111.46±177.53 ng/ mL
101.80±54.03 µmol/ L
35.63±14.37 s
23.44±9.36%
215.54±349.53 U/ L
207.93±233.69 U/ L
150.61±44.94 U/ L
506.624±184.454 µmol/ L
306.827±112.52 µmol/ L
35.17±5.46 g/ L
1.721±0.884 mmol/ L
3 198.16±1 794.42 U/ L
4.650±2.303 mmol/ L
4.87±3.60 mmol/ L
85.37±37.71 mmol/ L
170.45±230.25 ng/ L
75.23±38.71 µmol/ L
27.14±11.04 s
32.56±9.51%
>0.05
>0.05
>0.05
<0.05
<0.05
<0.05
>0.05
>0.05
>0.05
<0.05
<0.05
<0.05
<0.05
<0.01
<0.01

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Li XM et al. Chronic liver failure caused by hepatitis 2843
infection, which had significant influence on the prognoses
of CLFHV, and further suggested that blood clotting
function and development of complications are the key
determinants of survival of CLFHV. It has been generally
accepted that PTA<40% is the affirmative threshold of
necrosis of liver cells[19]. The decreased PTA suggests a
poorer liver synthetic function of blood coagulation factors
and furthermore, the more severe necrosis of liver cells.
While the other four variable factors were all complications,
which further suggested the importance of the influence
of complications on the prognoses of CLFHV. We should
pay attention to the prevention and treatment of
complications in treating CLFHV.
Heretofore, the treatment of FH has not matured, with
a poor recovery rate. However, there are new treatments
such as liver transplantation[20-24], which has brought new
hope to patients with CLFHV[25-28]. During the course of
diagnosis and treatment, the combination of dynamic
observation of single indices and comprehensive judgment
on prognoses can not only direct our treatments according
to the change of condition, but also present objective criteria
for timely liver transplantation to shorten the course of
FH and relieve patients’ burden.
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