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GLIM标准下3种营养筛查工具对肝硬化患者的适用性分析

吴英珂 李满 陈辰 张亦超 苏洋 王卫星

引用本文:
Citation:

GLIM标准下3种营养筛查工具对肝硬化患者的适用性分析

DOI: 10.3969/j.issn.1001-5256.2022.02.019
基金项目: 

国家自然科学基金项目 (81870442)

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:吴英珂负责研究实施,资料分析,撰写论文;李满、张亦超对课题设计有关键贡献;苏洋参与资料收集及分析;王卫星、陈辰负责拟定写作思路,指导撰写文章并最后定稿。
详细信息
    通信作者:

    王卫星,sate.llite@163.com

Applicability of three nutritional screening tools in patients with liver cirrhosis under the Global Leadership Initiative on Malnutrition criteria

Research funding: 

National Natural Science Foundation of China (81870442)

More Information
  • 摘要:   目的  探讨皇家自由医院-营养优先排序工具(RFH-NPT)与营养风险筛查2002(NRS2002)哪项更适合肝硬化患者的营养风险筛查,探讨主观全面营养评定(SGA)在肝硬化患者营养评估中的适用性。  方法  选取2020年8月—2021年6月在武汉大学人民医院住院的113例肝硬化患者,应用RFH-NPT和NRS2002进行营养风险筛查,应用SGA进行营养评估,将结果与全球(营养)领导层倡议营养不良(GLIM)诊断标准进行比较,分别计算出3种工具的敏感度、特异度、阳性预测值(PPV)、阴性预测值(NPV)。分别绘制3种筛查工具的受试者工作特征曲线(ROC曲线),并计算曲线下面积(AUC)。分析患者营养状况与短期预后的关系。计量资料两组间比较采用独立样本t检验或Mann-Whitney U检验,计数资料两组间比较采用χ2检验。NRS2002、RFHNPT、SGA与GLIM标准的相关性采用Spearman秩相关进行分析。  结果  GLIM标准下有69.9%的患者被诊断为营养不良,RFH-NPT和NRS2002分别筛查出72.6%和51.3%的患者存在营养风险,SGA评估下有57.5%的患者为营养不良。与NRS2002相比,RFH-NPT与GLIM标准具有更高的相关性(r=0.764,P<0.001),更高的敏感度(94.9%)和NPV(87.1%),且具有更好的预测价值(AUC=0.872,95%CI:0.786~0.957)。GLIM标准下,SGA诊断肝硬化患者营养不良的特异度较高(88.2%),敏感度一般(77.2%),具有良好的相关性(r=0.607,P<0.001)和预测价值(AUC=0.827,95%CI:0.744~0.911)。GLIM标准、SGA、RFH-NPT评估下,营养风险或营养不良患者的住院时间更长(Z值分别为-3.301、-2.812、-3.813,P值均<0.05),再住院率更高(χ2值分别为3.957、6.922、6.766,P值均<0.05)。GLIM标准、NRS2002评估下有营养风险或营养不良的患者3个月内病死率明显增加(χ2值分别为4.511、0.776,P值均<0.05)。  结论  GLIM标准下,RFH-NPT比NRS2002更适合肝硬化患者的营养风险筛查,SGA在肝硬化患者的营养评估中具有较好的适用性。此外,GLIM标准、SGA、RFH-NPT分别与患者的临床结局相关。

     

  • 图  1  NRS2002、RPF-NPT、SGA预测GLIM标准下营养不良的ROC曲线

    表  1  GLIM标准下肝硬化患者的基线特征及各临床指标与营养状况的关系

    指标 总数(n=113) GLIM营养诊断 统计值 P
    营养良好(n=34) 营养不良(n=79)
    年龄(岁) 56.81±10.90 52.09±9.47 58.84±10.90 t=-3.791 <0.001
    男/女(例) 83/30 25/9 58/21 χ2=0.000 0.990
    BMI(kg/m2) 20.80±3.44 23.34±2.74 19.7±3.13 t=6.400 <0.001
    AMC(cm) 20.86(18.66~22.60) 22.73(21.99~23.25) 20.10(18.23~21.49) Z=-6.058 <0.001
    MELD评分 10(8~13) 8(7~10) 11(8~15) Z=-3.859 <0.001
    下肢水肿[例(%)] 22(19.5) 1(2.9) 21(26.6) χ2=8.473 <0.001
    腹水[例(%)] 65(57.5) 5(14.7) 60(75.9) χ2=31.647 <0.001
    肝性脑病[例(%)] 4(3.5) 1(2.9) 3(3.8) χ2=0.051 0.821
    消化道出血[例(%)] 39(34.5) 14(41.2) 25(31.6) χ2=0.955 0.328
    白蛋白(g/L) 33.67±6.62 38.51±5.10 31.58±6.10 t=5.581 <0.001
    前白蛋白(g/L) 103.41±41.20 129.78±36.60 92.05±37.90 t=4.435 <0.001
    总胆汁酸(μmol/L) 33.79(15.59~74.43) 24.71(9.97~41.33) 42.49(17.82~88.33) Z=-2.564 0.010
    总胆红素(μmol/L) 20.80(14.44~37.70) 17.58(12.90~25.47) 22.60(14.54~46.07) Z=-2.035 0.016
    胆碱酯酶(U/L) 3 598.0(2 678.5~5 293.5) 5 665.0(4 758.5~7 467.8) 3 038.0(2 361.0~4 038.0) Z=-5.083 <0.001
    PT(s) 13.60(12.70~15.00) 12.85(11.78~13.70) 14.20(13.10~15.30) Z=-3.775 <0.001
    INR 1.19(1.10~1.31) 1.12(1.02~1.19) 1.24(1.14~1.34) Z=-3.817 <0.001
    下载: 导出CSV

    表  2  不同营养评估方法下肝硬化患者营养风险及状况与肝功能分级关系

    评估方法 Child-Pugh A级(n=60) Child-Pugh B级(n=39) Child-Pugh C级(n=14) χ2 P
    NRS2002[例(%)] 23.766 <0.001
      低风险 42(70.0) 12(30.7) 1(7.1)
      中高风险 18(30.0) 27(69.3) 13(92.9)
    RFH-NPT[例(%)] 28.247 <0.001
      低风险 29(48.3) 2(5.1) 0
      中高风险 31(51.7) 37(94.9) 14(100)
    SGA[例(%)] 17.286 <0.001
      营养良好 36(60.0) 11(28.2) 1(7.1)
      中重度营养不良 24(40.0) 28(71.8) 13(92.9)
    GLIM[例(%)] 24.789 <0.001
      营养良好 30(50.0) 4(10.3) 0
      营养不良 30(50.0) 35(89.7) 14(100)
    下载: 导出CSV

    表  3  各营养筛查工具与GLIM标准下营养评定的相关性分析

    评估方法 GLIM营养诊断[例] 敏感度(%) 特异度(%) PPV(%) NPV(%) r P
    营养良好(n=34) 营养不良(n=79)
    NRS2002 69.6 91.2 94.8 56.4 0.558 <0.001
      低风险 31 24
      中高风险 3 55
    RFH-NPT 94.9 79.4 91.5 87.1 0.764 <0.001
      低风险 27 4
      中高风险 7 75
    SGA 77.2 88.2 93.8 62.5 0.607 <0.001
      营养良好 30 18
      营养不良 4 61
    下载: 导出CSV

    表  4  不同评估方法下患者营养风险与短期预后的关系

    预后指标 NRS2002 统计值 P RFH-NPT 统计值 P
    低风险(n=55) 中高风险(n=58) 低风险(n=31) 中高风险(n=82)
    住院时间(d) 10(7~12) 12(9~15) Z=-1.268 0.205 8(7~11) 12(9~16) Z=-3.813 <0.001
    3个月病死率[例(%)] 3(5.5) 12(20.7) χ2=0.776 0.017 1(3.2) 14(17.1) χ2=3.747 0.051
    3个月再入院率[例(%)] 13(23.6) 18(31.0) χ2=5.692 0.378 3(9.7) 28(34.1) χ2=6.766 0.009
    下载: 导出CSV

    表  5  不同评估方法下患者营养状况与短期预后的关系

    预后指标 SGA 统计值 P GLIM标准 统计值 P
    营养良好(n=48) 中重度营养不良(n=65) 营养良好(n=34) 营养不良(n=79)
    住院时间(d) 10(7~12) 11(9~16) Z=-2.812 0.005 8(7~11) 12(9~15) Z=-3.301 0.001
    3个月病死率[例(%)] 3(6.3) 12(16.9) χ2=3.576 0.059 1(2.9) 14(17.7) χ2=4.511 0.034
    3个月再入院率[例(%)] 7(14.6) 24(36.9) χ2=6.922 0.009 5(14.7) 26(32.9) χ2=3.957 0.047
    下载: 导出CSV
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