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肝癌肝切除术后感染风险预测模型的建立与评价

朱明强 杨大帅 熊祥云 裴俊鹏 彭阳 丁佑铭

引用本文:
Citation:

肝癌肝切除术后感染风险预测模型的建立与评价

DOI: 10.3969/j.issn.1001-5256.2023.01.017
基金项目: 

国家重点研发计划 2022YFC2407304

利益冲突声明:本研究不存在研究者、伦理委员会成员、受试者监护人以及与公开研究成果有关的利益冲突。
作者贡献声明:朱明强负责课题设计,资料分析,撰写论文;杨大帅参与数据分析;熊祥云、裴俊鹏参与收集数据;彭阳参与修改论文;丁佑铭负责拟定写作思路,指导撰写文章并最后定稿。
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    通信作者:

    丁佑铭,dingym62@163.com(ORCID: 0000-0001-6695-3275)

Establishment and validation of a nomogram risk prediction model for infection complications in patients after hepatectomy for liver cancer

Research funding: 

National Key R & D Plan 2022YFC2407304

More Information
    Corresponding author: DING Youming, dingym62@163.com (ORCID: 0000-0001-6695-3275)
  • 摘要:   目的  探讨肝癌肝切除术后发生感染的危险因素,建立并验证风险预测模型。  方法  收集2020年1月—2022年4月于武汉大学人民医院行肝切除术的167例原发性肝癌患者的临床资料。根据术后早期是否发生感染,将所有患者分为术后感染组(n=28) 和非感染组(n=139)。计量资料两组间比较采用t检验或Mann- Whitney U检验,计数资料两组间比较采用χ2检验。采用单因素分析与Logistic回归分析筛选肝癌肝切除术后感染的影响因素,并建立术后发生感染的列线图风险预测模型,将所有患者按7∶ 3随机分为训练集(n=119)和验证集(n=48),采用Bootstrap法对模型进行内部验证,应用模型校准曲线和受试者工作特征曲线(ROC曲线)来评价列线图模型的校准度和区分度。  结果  167例患者中28例(16.8%)发生术后感染。Logistc多因素分析结果显示,糖尿病、CONUT评分≥4分、术前NLR、手术时间、术中失血量、引流管放置时间>7 d是肝癌肝切除术后发生感染的独立危险因素(P值均<0.05)。基于上述6个危险因素构建的列线图,训练集和验证集的ROC曲线下面积分别为0.848、0.853。列线图模型校准曲线显示预测值与实际观测值基本一致,表明列线图模型预测的准确度较好。  结论  基于糖尿病、CONUT评分≥4分、术前NLR、手术时间、术中失血量、引流管放置时间>7 d建立的个体化列线图风险预测模型预测效能良好,对高风险患者具有较高的预测价值。

     

  • 图  1  肝癌肝切除术后感染发生风险的列线图模型

    Figure  1.  Nomogram to predict postoperative infection after hepatectomy for HCC

    图  2  训练集校准曲线

    Figure  2.  The calibration plot for the training cohort

    图  3  验证集校准曲线

    Figure  3.  The calibration plot for the validation cohort

    图  4  训练集ROC曲线

    Figure  4.  The ROC curve for the training cohort

    图  5  验证集ROC曲线

    Figure  5.  The ROC curve for the validation cohort

    表  1  肝切除术后感染影响因素的单因素分析

    Table  1.   Univariate analysis of the influencing factors of infection after hepatectomy

    变量 感染组(n=28) 非感染组(n=139) 统计值 P
    年龄(岁) 63.3±8.2 59.3±11.1 t=1.783 0.076
    男/女(例) 22/6 117/22 χ2=0.524 0.469
    高血压(是/否,例) 11/15 47/90 χ2=0.610 0.435
    糖尿病(是/否,例) 9/19 16/123 χ2=7.794 0.005
    乙型肝炎(是/否,例) 18/10 99/40 χ2=0.535 0.465
    肝硬化(是/否,例) 11/17 72/67 χ2=1.60 0.227
    肿瘤数目[例(%)] χ2=3.571 0.059
      单发 17(60.7) 108(77.7)
      多发 11(39.3) 31(22.3)
    肿瘤大小[例(%)] χ2=2.056 0.152
      <5 cm 8(28.6) 60(43.2)
      ≥5 cm 20(71.4) 79(65.8)
    Edmonson分级[例(%)] χ2=0.004 0.952
      Ⅰ~Ⅱ级 7(25.0) 34(24.5)
      Ⅲ~Ⅳ级 21(75.0) 105(75.5)
    手术部位[例(%)] χ2=0.307 0.858
      左半肝 8(28.6) 44(31.6)
      右半肝 18(64.3) 82(59.0)
      双侧半肝 2(7.1) 13(9.4)
    肝段切除[例(%)] χ2=0.874 0.350
      <3段 19(67.9) 106(76.3)
      ≥3段 9(32.1) 33(23.7)
    手术方式[例(%)] χ2=8.224 0.004
      开腹 24(85.7) 79(56.8)
      腹腔镜 4(14.3) 60(43.2)
    AFP[例(%)] χ2=0.204 0.652
      ≥20 ng/mL 10(35.7) 56(40.3)
      <20 ng/mL 18(64.3) 83(59.7)
    ALT(U/L) 28.5(18.3~53.3) 27.0(17.0~40.0) Z=-0.791 0.429
    AST(U/L) 29.5(24.3~42.3) 29.0(22.0~47.0) Z=-0.079 0.937
    TBil(μmol/L) 18.9(12.8~34.5) 16.0(11.7~21.4) Z=-1.545 0.122
    Alb (g/L) 40.0(37.0~42.9) 40.1(37.3~43.0) Z=-0.261 0.794
    PT (s) 11.5(10.8~12.2) 11.5(10.9~12.2) Z=-0.718 0.473
    PLT(×109/L) 164.0(122.0~221.0) 171.5(119.0~213.3) Z=-0.287 0.774
    血肌酐(μmol/L) 60.0(52.3~80.8) 65.5(56.8~74.0) Z=-0.600 0.548
    总胆固醇(mmol/L) 4.0(3.1~4.5) 3.9(3.4~4.5) Z=-0.006 0.995
    乳酸脱氢酶(U/L) 199.5(181.5~249.2) 212.0(182.0~257.0) Z=-0.651 0.515
    碱性磷酸酶(U/L) 97.3(73.5~139.9) 84.0(69.0~114.7) Z=-1.294 0.196
    术前NLR 3.4(2.2~4.6) 2.4(1.9~3.2) Z=-2.609 0.009
    ALBI评分 -2.6(-2.8~-2.2) -2.6(-2.9~-2.4) Z=-0.782 0.434
    CONUT评分[例(%)] χ2=6.487 0.011
      ≥4分 15(53.6) 40(28.8)
      <4分 13(46.4) 99(71.2)
    引流管放置时间[例(%)] χ2=10.102 0.001
      >7 d 18(64.3) 45(32.4)
      ≤7 d 10(35.7) 94(67.6)
    ASA分级[例(%)] χ2=0.157 0.692
      1~2级 16(57.1) 85(61.2)
      3~4级 12(42.9) 54(38.8)
    手术时间(min) 365(228~380) 240(190~300) Z=-3.451 0.001
    术中出血量(mL) 800(600~1300) 500(300~700) Z=-4.992 0.001
    术中补液量(mL) 2500(2100~2800) 2150(1800~2700) Z=-2.542 0.011
    肝门阻断时间(min) 40(30~49) 30(19~40) Z=-2.134 0.033
    血浆输注(有/无,例) 17/11 52/87 χ2=5.220 0.022
    红细胞输注(有/无,例) 18/10 55/84 χ2=5.787 0.016
    术后胆漏(有/无,例) 7/21 10/129 χ2=8.081 0.004
    下载: 导出CSV

    表  2  肝切除术后感染影响因素的多因素分析

    Table  2.   Multivariate analysis of the influencing factors of infection after hepatectomy

    变量 β SE Wald OR 95%CI P
    糖尿病 -1.934 0.618 9.780 0.145 0.043~0.486 0.002
    CONUT≥4分 1.254 0.525 5.695 3.504 1.251~9.814 0.017
    术前NLR -0.247 0.114 4.736 0.781 0.625~0.976 0.030
    手术时间 -0.006 0.003 4.533 0.994 0.988~0.999 0.033
    术中失血量 -0.001 0.001 5.870 0.999 0.998~1.000 0.015
    引流管放置时间>7 d 1.019 0.516 3.891 2.770 1.006~7.621 0.049
    下载: 导出CSV
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