肝硬化食管静脉曲张患者门静脉血栓形成的危险因素分析

左怀文; 沙启梅; 孙姣; 蔡智慧; 许洪伟; 刘慧

doi:10.3969/j.issn.1001-5256.2021.01.013

肝硬化食管静脉曲张患者门静脉血栓形成的危险因素分析

DOI: 10.3969/j.issn.1001-5256.2021.01.013

1.
山东大学附属省立医院消化内科，济南 250021
2.
山东省警官总医院特检科，济南 250002
3.
山东第一医科大学附属省立医院消化内科，济南 250021

基金项目:

山东省自然科学基金 (ZR2014HM106)

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：刘慧负责提出研究选题、终审论文；左怀文、沙启梅、孙姣负责设计研究方案、采集整理数据；左怀文负责调研整理文献、起草论文；蔡智慧负责统计分析；许洪伟提供指导性支持。

详细信息

作者简介:
左怀文(1994—)，男，主要从事肝病及其他消化疾病的诊治研究

通信作者:
刘慧，liuhuih3@126.com

中图分类号: R575.2
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出版历程
- 收稿日期: 2020-08-02
- 录用日期: 2020-08-31
- 出版日期: 2021-01-20

Risk factors of portal vein thrombosis in cirrhotic patients with esophageal varices

1.
Department of Gastroenterology, Shandong Provincial Hospital Affiliated to Shandong University, Jinan 250021, China
2.
Department of Special Clinical Laboratory, Shandong Police Hospital, Jinan 250002, China
3.
Department of Gastroenterology, Provincial Hospital Affiliated to Shandong First Medical University, Jinan 250021, China

摘要

摘要: 目的旨在识别肝硬化食管静脉曲张患者中门静脉血栓(PVT)形成的独立危险因素，并建立一个预测PVT发生风险的列线图。方法回顾性分析2013年12月—2018年12月于山东大学附属省立医院就诊的283例肝硬化食管静脉曲张患者资料，根据影像学检查将其分为PVT组(n=119)和非PVT组(n=164)。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。利用多因素logistic回归分析筛选独立危险因素，基于多因素回归结果建立并检验列线图，应用C指数(C-index)、校准曲线评价其性能。结果单因素分析显示，PVT组在Child-Pugh分级(χ²=9.388，P=0.009)、脾切除史(χ²=26.805，P＜0.001)、WBC(Z=-2.248，P=0.025)、PLT(Z=-3.323，P=0.001)、D-二聚体水平(Z=-6.236，P＜0.001)及脾脏厚度(Z=-2.432，P=0.015)方面高于非PVT组，而TG水平低于非PVT组(Z=-4.150，P＜0.001)。多因素分析显示，TG水平(OR=0.441, 95%CI：0.190~0.889)、D-二聚体水平升高(OR=1.151, 95%CI：1.041~1.272)、PT延长(OR=1.160, 95%CI：1.025~1.313)、有脾切除史(OR=2.933, 95%CI：l.164~7.389)是肝硬化食管静脉曲张患者PVT形成的独立风险因素。基于多因素回归结果，建立了列线图，其C指数值为0.745，校准曲线显示PVT发生的观测值和预测值之间有较好的一致性。结论 TG水平降低、有脾切除史、D-二聚体水平升高、PT延长是肝硬化食管静脉曲张患者PVT形成的独立危险因素，基于此所建立的列线图，为临床医生评估PVT形成风险提供了一个定量、直观的工具。
- 肝硬化 /
- 门静脉血栓 /
- 食管和胃静脉曲张 /
- 危险因素 /
- 列线图
Abstract: Objective To investigate the risk factors for portal vein thrombosis (PVT) in cirrhotic patients with esophageal varices, and to establish a nomogram for predicting the risk of PVT. Methods A retrospective analysis was performed for the clinical data of 283 cirrhotic patients with esophageal varices who attended Shandong Provincial Hospital Affiliated to Shandong University from December 2013 to December 2018, and according to imaging findings, the patients were divided into PVT group with 119 patients and non-PVT group with 164 patients. The t-test or the Mann-Whitney U test was used for comparison of continuous data between two groups, and the chi-square test was used for comparison of categorical data between two groups. A multivariate logistic regression analysis was used to screen out independent risk factors; a nomogram was established and validated based on the results of the multivariate logistic regression analysis, and C-index and calibration curve were used to evaluate its performance. Results The univariate analysis showed that compared with the non-PVT group, the PVT group had significantly higher Child-Pugh class (χ²=9.388, P=0.009), proportion of patients with a history of splenectomy (χ²=26.805, P < 0.001), white blood cell count (Z=-2.248, P=0.025), platelet count (Z=-3.323, P=0.001), D-dimer(Z=-6.236, P < 0.001), and spleen thickness (Z=-2.432, P=0.015) and a significantly lower level of triglyceride (TG) (Z=-4.150, P < 0.001). The multivariate logistic regression analysis showed that a reduction in TG (odds ratio [OR]=0.441, 95% confidence interval [CI]: 0.190-0.889), an increase in D-dimer (OR=1.151, 95%CI: 1.041-1.272), prolonged prothrombin time (PT) (OR=1.160, 95%CI: 1.025-1.313), and a history of splenectomy (OR=2.933, 95%CI: 1.164-7.389) were independent risk factors for PVT in cirrhotic patients with esophageal varices. In addition, a nomogram was established based on the results of the multivariate regression analysis, with a C-index of 0.745, and the calibration curve showed good consistency between the observed and predicted values for the development of PVT. Conclusion A reduction in TG, an increase in D-dimer, prolonged PT, and a history of splenectomy are independent risk factors for PVT in cirrhotic patients with esophageal varices, and the nomogram developed based on these results can provide a quantitative and intuitive tool for clinicians to assess the risk of PVT.
- Liver Cirrhosis /
- Portal Vein Thrombosis /
- Esophageal and Gastric Varices /
- Risk Factors /
- Nomogram

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图 1 预测肝硬化食管静脉曲张患者PVT形成的列线图

下载: 全尺寸图片幻灯片

图 2 模型校准图形

下载: 全尺寸图片幻灯片

表 1 两组患者一般资料比较

项目	PVT组(n=119)	非PVT组(n=164)	统计值	P值
性别(例)			χ²=0.260	0.650
男	75	99
女	44	65
年龄(岁)	55.87±10.80	54.04±10.9	t=-1.395	0.164
脾切除史(例)	53	27	χ²=26.805	＜0.001
脾栓塞史(例)	6	4	χ²=1.371	0.242
普萘洛尔应用史(例)	4	7	χ²=0.152	0.697
病因(例)			χ²=5.051	0.654
HBV	55	65
酒精性	23	27
HBV+酒精性	4	8
HCV	2	4
HBV+HCV	0	1
HCV+酒精性	0	1
自身免疫性	6	16
其他	29	42
Child-Pugh分级(例)			χ²=9.388	0.009
A级	54	90
B级	48	67
C级	17	7
吸烟史(例)	47	57	χ²=0.666	0.414
饮酒史(例)	40	56	χ²=0.009	0.926
高血压史(例)	14	23	χ²=0.310	0.578
糖尿病史(例)	20	23	χ²=0.414	0.520

下载: 导出CSV

表 2 两组患者临床资料比较

项目	PVT组(n=119)	非PVT组(n=164)	统计值	P值
WBC(×10⁹/L)	3.88(3.03~5.67)	3.35(2.41~5.13)	Z=-2.248	0.025
PLT(×10⁹/L)	124.00(64.00~260.00)	77.00(61.25~124.00)	Z=-3.323	0.001
Hb (g/L)	86.00(72.00~107.00)	91.00(74.00~108.00)	Z=-0.951	0.341
Alb (g/L)	33.60(28.78~37.63)	33.70(28.86~38.20)	Z=-0.359	0.720
AST (U/L)	34.50(24.75~45.25)	37.00(26.00~52.00)	Z=-1.319	0.190
ALT (U/L)	22.00(15.00~35.00)	26.00 (17.00~41.00)	Z=-1.728	0.110
TG (mmol/L)	0.75(0.59~1.03)	0.94(0.70~1.28)	Z=-4.150	＜0.001
TC (mmol/L)	3.89(2.97~4.65)	3.73(3.05~4.79)	Z=-0.085	0.920
LDL-C (mmol/L)	2.21(1.63~2.80)	2.21(1.68~2.77)	Z=-0.056	0.956
HDL-C (mmol/L)	1.03(0.72~1.38)	1.02(0.81~1.29)	Z=-0.223	0.824
TBil (μmol/L)	18.35(14.88~26.33)	20.10(14.6~28.3)	Z=-0.664	0.520
PT(s)	14.60 (13.60~16.90)	14.30(13.10~15.80)	Z=-1.917	0.055
APTT(s)	36.35(30.68~40.35)	34.35(29.75~39.20)	Z=-1.345	0.179
INR	1.22(1.15~1.35)	1.20(1.10~1.32)	Z=-1.789	0.074
D-二聚体(mg/L)	2.64(1.07~5.70)	0.89(0.40~2.10)	Z=-6.236	＜0.001
腹水[例(%)]			χ²=6.229	0.101
无	57 (47.90)	95 (57.93)
少量	40 (33.61)	48 (29.27)
中量	10 (8.40)	15 (9.15)
大量	12 (10.08)	6 (3.66)
门静脉主干内径(cm)	1.30(1.10~1.50)	1.30(1.20~1.40)	Z=-0.286	0.104
脾脏厚度(mm)	5.50(4.80~6.40)	5.00(4.50~6.00)	Z=-2.432	0.015
食管静脉曲张程度[例(%)]			χ²=2.283	0.319
轻	14 (11.76)	11 (6.71)
中	17 (14.29)	27 (16.46)
重	88 (73.95)	126 (76.83)
肝性脑病[例(%)]	12(10.08)	7(4.27)	χ²=5.555	0.135

下载: 导出CSV

表 3 多因素logistic回归分析

变量	B值	Wald	OR	95%CI	P值
TG	-0.889	5.101	0.411	0.190~0.889	0.024
D-二聚体	0.141	7.587	1.151	1.041~1.272	0.006
PT	0.149	5.550	1.160	1.025~1.313	0.018
脾切除史	1.076	5.209	2.933	1.164~7.389	0.022

下载: 导出CSV

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