风险评估模型预测人工肝治疗肝衰竭患者发生静脉血栓栓塞症的价值分析

陆素芳; 黄睿; 赵红利; 王丹丹; 丁玉珍; 周红

doi:10.3969/j.issn.1001-5256.2023.03.019

风险评估模型预测人工肝治疗肝衰竭患者发生静脉血栓栓塞症的价值分析

DOI: 10.3969/j.issn.1001-5256.2023.03.019

南京大学医学院附属鼓楼医院感染性疾病科, 南京 210008

基金项目:

国家自然科学基金青年基金项目 (81702011);

南京大学现代医院管理与发展研究所课题项目&南京鼓楼医院医学发展医疗救助基金 (NDYG2021016)

伦理学声明：本研究方案于2018年2月10日经由南京大学医学院附属鼓楼医院伦理委员会审批，批号：2018022。

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：陆素芳、黄睿负责课题设计，资料分析，撰写论文；赵红利、王丹丹参与收集数据，修改论文；丁玉珍、周红负责拟定写作思路，指导撰写文章并最后定稿。

详细信息

通信作者:
陆素芳，sufanglu0708@126.com (ORCID: 0000-0001-5471-2511)

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出版历程
- 收稿日期: 2022-08-01
- 录用日期: 2022-10-11
- 出版日期: 2023-03-20

Value of a risk assessment model in predicting venous thromboembolism in patients with liver failure after artificial liver support therapy

Department of Infectious Diseases, Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China

Research funding:

Research funding: National Natural Science Foundation of China (81702011);

Research Project of Modern Hospital Management and Development Institute of Nanjing University and Medical Development and Medical Assistance Fund of Nanjing Drum Tower Hospital (NDYG2021016)

More Information

Corresponding author: LU Sufang, sufanglu0708@126.com (ORCID: 0000-0001-5471-2511)

摘要

摘要: 目的探讨风险评估模型对人工肝治疗肝衰竭患者静脉血栓栓塞症(VTE)发生风险的预测价值。方法回顾性选取2018年3月—2021年12月于南京大学医学院附属鼓楼医院行人工肝治疗的肝衰竭患者184例，其中并发VTE组患者41例，未并发VTE患者(对照组)143例。比较两组患者临床资料，并采用Caprini风险评估模型对两组患者进行评分及风险分级。计量资料两组间比较采用t检验；计数资料两组间比较采用χ²检验；等级资料两组间比较采用Mann-Whitney U秩和检验。采用Logistic回归分析人工肝治疗肝衰竭患者发生VTE的独立危险因素。采用受试者工作特征曲线(ROC曲线)分析Caprini量表评分、多因素预测模型及二者联合对VTE的预测价值。结果并发VTE组患者Caprini量表评分为(4.39±1.10)分，明显高于对照组(3.12±1.04)分(t=6.805, P＜0.001)。两组患者Caprini量表危险度分级存在明显差异(Z=-4.872, P＜0.001)，并发VTE的患者中，高危、极高危组占比更高。单因素分析结果显示，并发VTE组与对照组患者在年龄(t=6.400，P＜0.001)、置管方式(χ²=14.413，P＜0.001)、人工肝治疗次数(Z=-4.720，P＜0.001)、活动情况(Z=-6.282，P＜0.001)、合并感染(χ²=33.071，P＜0.001)、D-二聚体(t=8.746，P＜0.001)、28 d死亡率(χ²=5.524，P=0.022)比较差异均有统计学意义。多因素分析结果显示，人工肝治疗次数(X₁)(OR=0.251, 95%CI: 0.111~0.566, P=0.001)、活动情况(X₂)(OR=0.122, 95%CI: 0.056~0.264, P＜0.001)、D-二聚体(X₃)(OR=2.921, 95%CI: 1.114~7.662, P=0.029)为影响肝衰竭人工肝治疗患者VTE发生的独立危险因素。个体预测概率方程为P=1/[1+e^{-(7.425-1.384X₁-2.103X₂+1.072X₃})]。ROC曲线分析结果显示，Caprini评分曲线下面积为0.802(95%CI: 0.721~0.882, P＜0.001)，多因素模型曲线下面积为0.768(95%CI: 0.685~0.851, P＜0.001)，二者联合运用曲线下面积为0.957(95%CI: 0.930~0.984, P＜0.001)。结论 Caprini风险评估模型对人工肝治疗肝衰竭患者VTE发生风险具有较高的预测效能，联合多因素预测模型后可更为显著地提高对VTE的预测价值。
- 肝功能衰竭 /
- 静脉血栓栓塞 /
- 肝, 人工 /
- 危险因素 /
- 模型, 统计学
Abstract: Objective To investigate the value of a risk assessment model in predicting venous thromboembolism (VTE) in patients with liver failure after artificial liver support therapy. Methods A retrospective analysis was performed for the clinical data of 124 patients with liver failure who received artificial liver support therapy in Affiliated Drum Tower Hospital of Nanjing University Medical School from March 2019 to December 2021, among whom there were 41 patients with VTE (observation group) and 143 patients without VTE (control group). Related clinical data were compared between the two groups, and the Caprini risk assessment model was used for scoring and risk classification of the patients in both groups. The t-test was used for comparison of continuous data between two groups; the chi-square test was used for comparison of categorical data between two groups; the Mann-Whitney U rank sum test was used for comparison of ranked data between two groups. The logistic regression analysis was used to investigate the independent risk factors for VTE in patients with liver failure after artificial liver support therapy. The receiver operating characteristic (ROC) curve was used to investigate the value of Caprini score and the multivariate predictive model used alone or in combination in predicting VTE. Results The observation group had a significantly higher Caprini score than the control group (4.39±1.10 vs 3.12±1.04, t=6.805, P < 0.001). There was a significant difference between the two groups in risk classification based on Caprini scale (P < 0.05), and the patients with high risk or extremely high risk accounted for a higher proportion among the patients with VTE. The univariate analysis showed that there were significant differences between the two groups in age (t=6.400, P < 0.001), catheterization method (χ²=14.413, P < 0.001), number of times of artificial liver support therapy (Z=-4.720, P < 0.001), activity (Z=-6.282, P < 0.001), infection (χ²=33.071, P < 0.001), D-dimer (t=8.746, P < 0.001), 28-day mortality rate (χ²=5.524, P=0.022). The multivariate analysis showed that number of times of artificial liver support therapy (X₁) (odds ratio [OR]=0.251, 95% confidence interval [CI]: 0.111-0.566, P=0.001), activity (X₂) (OR=0.122, 95%CI: 0.056-0.264, P < 0.001), D-dimer (X₃) (OR=2.921, 95%CI: 1.114-7.662, P=0.029) were independent risk factors for VTE in patients with liver failure after artificial liver support therapy. The equation for individual predicted probability was P=1/[1+e^{-(7.425-1.384X₁-2.103X₂+1.072X₃)}]. The ROC curve analysis showed that Caprini score had an area under the ROC curve of 0.802 (95%CI: 0.721-0.882, P < 0.001), and the multivariate model had an area under the ROC curve of 0.768 (95%CI: 0.685-0.851, P < 0.001), while the combination of Caprini score and the multivariate model had an area under the ROC curve of 0.957 (95%CI: 0.930-0.984, P < 0.001). Conclusion The Caprini risk assessment model has a high predictive efficiency for the risk of VTE in patients with liver failure after artificial liver support therapy, and its combination with the multivariate predictive model can significantly improve the prediction of VTE.
- Liver Failure /
- Venous Thromboembolism /
- Liver, Artificial /
- Risk Factors /
- Models, Statistical

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图 1 Caprini评分、多因素模型及二者联合预测人工肝治疗肝衰竭患者发生VTE的ROC曲线

Figure 1. ROC curve analysis of the predictive value of Caprini score, multifactor model and their combination on the occurrence of VTE in patients with liver failure undergoing artificial liver therapy

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表 1 两组患者Caprini量表评分及危险分级比较

Table 1. Comparison of Caprini scale score and risk classification between two groups

组别	例数	Caprini评分 (分)	危险度分级[例(%)]
组别	例数	Caprini评分 (分)	低危组	中危组	高危组	极高危组
并发VTE组	41	4.39±1.10	1(2.44)	9(21.95)	19(46.34)	12(29.27)
对照组	143	3.12±1.04	37(25.87)	53(37.06)	41(28.67)	12(8.39)
统计值		t=6.805	Z=-4.872
P值		＜0.001	＜0.001

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表 2 人工肝治疗肝衰竭患者发生VTE的单因素分析

Table 2. Univariate analysis of VTE in patients with liver failure undergoing artificial liver therapy

项目	并发VTE组(n=41)	对照组(n=143)	统计值	P值
性别[例(%)]			χ²=0.037	0.848
男	31(75.61)	106(74.13)
女	10(24.39)	37(25.87)
年龄(岁)	63.84±8.32	54.75±7.93	t=6.400	＜0.001
文化程度[例(%)]			Z=0.129	0.720
初中及以下	15(36.59)	48(33.57)
高中及以上	26(63.41)	95(66.43)
BMI(kg/m²)	22.37±2.38	22.02±2.15	t=0.897	0.371
空腹血糖(mmol/L)	5.33±1.20	5.49±1.41	t=0.661	0.510
吸烟[例(%)]			χ²=0.066	0.797
是	16(39.02)	59(41.26)
否	25(60.98)	84(58.74)
置管方式[例(%)]			χ²=14.413	＜0.001
颈静脉置管	5(12.20)	64(44.76)
股静脉置管	36(87.80)	79(55.24)
置管有无使用肝[例(%)]			χ²=0.329	0.566
有	8(19.51)	34(23.78)
无	33(80.49)	109(76.22)
促凝治疗[例(%)]			χ²=0.218	0.641
有	31(75.61)	113(79.02)
无	10(24.39)	30(20.98)
人工肝治疗次数[例(%)]			Z=-4.720	＜0.001
＜3次	12(29.27)	97(67.83)
3~5次	20(48.78)	39(27.27)
≥6次	9(21.95)	7(4.90)
肝衰竭病因[例(%)]			Z=-0.552	0.581
病毒性肝炎	33(80.48)	111(77.62)
自身免疫性肝病	5(12.20)	13(9.09)
药物性肝炎	3(7.32)	14(9.79)
其他	0(0.00)	5(3.50)
合并感染[例(%)]			χ²=33.071	＜0.001
是	11(26.83)	108(75.52)
否	30(73.17)	35(24.47)
活动情况[例(%)]			Z=-6.282	＜0.001
自由活动	0(0.00)	65(45.45)
每天下床＜4 h	8(19.51)	39(27.27)
每天下床＜1 h	18(43.90)	21(14.69)
绝对卧床	15(36.59)	18(12.59)
肝性脑病[例(%)]			Z=-0.499	0.618
无	23(56.10)	85(59.44)
Ⅰ~Ⅱ级	16(39.02)	55(38.46)
Ⅲ~Ⅳ级	2(4.88)	3(2.10)
TBil(μmol/L)	228.94±58.32	235.46±60.35	t=0.614	0.540
ALT(U/L)	265.94±60.39	287.39±71.54	t=1.749	0.082
D-二聚体(μg/L)	985.62±215.63	649.06±226.49	t=8.746	＜0.001
纤维蛋白原(g/L)	1.46±0.49	1.54±0.52	t=0.879	0.380
28 d生存情况[例(%)]			χ²=5.524	0.022
死亡	10(24.39)	15(10.49)
存活	31(75.61)	128(89.51)
人工肝模式[例(%)]			Z=-0.301	0.763
血浆置换	22(53.66)	81(56.64)
持续血液滤过	13(31.71)	36(25.17)
血浆置换+持续血液滤过	6(14.63)	23(16.08)

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表 3 人工肝治疗肝衰竭患者发生VTE的多因素分析

Table 3. Multivariate analysis of VTE in patients with liver failure undergoing artificial liver therapy

变量	B值	SE	Wald	P值	OR	95%CI
人工肝治疗次数	-1.384	0.416	11.068	0.001	0.251	0.111~0.566
活动情况	-2.103	0.394	28.490	＜0.001	0.122	0.056~0.264
D-二聚体	1.072	0.492	4.747	0.029	2.921	1.114~7.662

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