肝硬化食管胃底静脉曲张破裂出血患者经颈静脉肝内门体分流术后非计划再入院的危险因素分析及列线图模型构建

殷芹; 吴兆荣; 张峰; 金春燕; 曹燕平; 肖江强; 诸葛宇征; 王倩

doi:10.12449/JCH240913

肝硬化食管胃底静脉曲张破裂出血患者经颈静脉肝内门体分流术后非计划再入院的危险因素分析及列线图模型构建

DOI: 10.12449/JCH240913

南京大学医学院附属鼓楼医院消化内科，南京 210008

基金项目:

国家自然科学基金 (82100652);

南京大学医学院附属鼓楼医院护理科研项目 (ZSA796-1)

伦理学声明：本研究方案于2021年1月6日经南京大学医学院附属鼓楼医院伦理委员会审批，批号：2021-004-01。

利益冲突声明：本研究不存在任何利益冲突。

作者贡献声明：殷芹、肖江强负责课题设计，资料分析，撰写论文；吴兆荣、金春燕、曹燕平负责数据收集、统计学分析；张峰、诸葛宇征、王倩负责拟定写作思路，论文修改，指导撰写文章并最后定稿。

详细信息

通信作者:
王倩， 523199780@qq.com （ORCID： 0009-0003-8598-1169）

计量
- 文章访问数: 168
- HTML全文浏览量: 1010
- PDF下载量: 32
- 被引次数: 0
出版历程
- 收稿日期: 2024-01-15
- 录用日期: 2024-04-11
- 出版日期: 2024-09-25

Risk factors for unplanned readmission after transjugular intrahepatic portosystemic shunt in cirrhotic patients with esophagogastric variceal bleeding and construction of a nomogram model

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

Research funding:

National Natural Science Found of China (82100652);

Affiliated Drum Tower Hospital of Nanjing University Medical School Nursing Research Project (ZSA796-1)

More Information

Corresponding author: WANG Qian， 523199780@qq.com （ORCID： 0009-0003-8598-1169）

摘要

摘要: 目的探讨经颈静脉肝内门体分流术（TIPS）的肝硬化食管胃底静脉曲张破裂出血患者出院30 d内发生非计划再入院危险因素，并构建风险预测列线图模型。方法选取2020年1月—2023年6月在南京大学医学院附属鼓楼医院因肝硬化食管胃底静脉曲张破裂出血行TIPS的241例患者作为研究对象。分析患者30 d内非计划再入院情况，并依据是否发生非计划再入院分为再入院组（n=36）和未再入院组（n=198）。收集患者临床资料，符合正态分布的计量资料2组间比较采用成组t检验，偏态分布的计量资料2组间比较采Mann-Whitney U检验；计数资料2组间比较采用χ²检验。Logistic回归分析筛选出与非计划再入院相关的独立危险因素。建立列线图预测模型，绘制受试者工作特征曲线（ROC曲线）评估列线图模型预测非计划再入院发生的区分度；绘制校准曲线评估列线图模型预测非计划再入院发生的一致性，采用R语言ResourceSelection包进行Hosmer-Lemeshow评估模型的拟合度，决策曲线分析评估模型的实用性。结果年龄（OR=2.664，95%CI：1.139～6.233）、CTP评分（OR=1.655，95%CI：1.098～2.495）、血氨（OR=1.032，95%CI：1.016～1.048）是行TIPS患者出院30 d内非计划再入院的独立危险因素（P值均<0.05）。依据多因素分析结果，构建风险预测列线图模型，通过Bootstrap法重复抽样1 000次展开内部验证，ROC曲线下面积为0.773，高于年龄（0.582）、CTP评分（0.675）、血氨（0.641），校准曲线显示列线图模型预测非计划再入院的概率与实际概率具有较好一致性，Hosmer-Lemeshow显示拟合优度良好（χ²=5.647 3，P=0.686 7）。结论年龄、CTP评分和血氨是TIPS术后30 d非计划再入院的独立危险因素，以此建立的列线图预测模型有助于预测行TIPS患者非计划再入院发生风险，为早期预防提供较为准确的决策依据。
- 肝硬化 /
- 门体分流术，经颈静脉肝内 /
- 危险因素
Abstract: Objective To investigate the risk factors for unplanned readmission within 30 days after discharge in cirrhotic patients with esophagogastric variceal bleeding undergoing transjugular intrahepatic portosystemic shunt （TIPS）， and to construct a nomogram predictive model. Methods A total of 241 cirrhotic patients who underwent TIPS due to esophagogastric variceal bleeding in Affiliated Drum Tower Hospital of Nanjing University Medical School from January 2020 to June 2023 were enrolled as subjects， and unplanned readmission within 30 days was analyzed. According to the presence or absence of unplanned readmission， they were divided into readmission group with 36 patients and non-readmission group with 198 patients， and related clinical data were collected from all patients. The independent-samples t test was used for comparison of normally distributed continuous data between two groups， and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups； the chi-square test was used for comparison of categorical data between two groups. A logistic regression analysis was used to identify independent risk factors for unplanned readmission. A nomogram prediction model was constructed， and the receiver operating characteristic （ROC） curve was plotted to assess its discriminatory ability for unplanned readmission； the calibration curve was plotted to evaluate the consistency of the nomogram model in predicting unplanned readmission； the ResourceSelection package of R language was used for the Hosmer-Lemeshow goodness-of-fit test to evaluate the degree of fitting of the mode； the decision curve analysis was used to investigate the practicality of the model. Results Age （odds ratio ［OR］=2.664， 95% confidence interval ［CI］： 1.139‍ ‍—‍ ‍6.233， P<0.05）， CTP score （OR=1.655， 95%CI： 1.098‍ ‍—‍ ‍2.495， P<0.05）， and blood ammonia （OR=1.032， 95%CI： 1.016‍ ‍—‍ ‍1.048， P<0.05） were independent risk factors for unplanned readmission within 30 days after discharge in the patients undergoing TIPS. The multivariate analysis showed that for the nomogram predictive model constructed in this study， repeated sampling for 1 000 times using the Bootstrap method was performed for internal validation， and the area under the ROC curve was 0.773， which was significantly higher than that of age （0.582）， CTP score （0.675）， and blood ammonia （0.641）. The calibration curve showed good consistency between the probability of unplanned readmission predicted by the nomogram model and the actual probability， and the Hosmer-Lemeshow goodness-of-fit test showed good degree of fitting （c² =5.647 3， P=0.686 7）. Conclusion Age， CTP score， and blood ammonia are independent risk factors for unplanned readmission within 30 days after TIPS， and the nomogram prediction model constructed based on these factors can help to predict the risk of unplanned readmission in TIPS patients and provide an accurate decision-making basis for early prevention.
- Liver Cirrhosis /
- Portasystemic Shunt， Transjugular Intrahepatic /
- Risk Factors

HTML全文

图 1 TIPS患者出院30 d内非计划再入院风险预测列线图

Figure 1. Nomogram predicted risk of unplanned readmission within 30 days of discharge for TIPS patients

下载: 全尺寸图片幻灯片

图 2 TIPS患者出院30 d内非计划再入院ROC曲线分析

Figure 2. ROC curve analysis of unplanned readmission within 30 days of discharge for TIPS patients

下载: 全尺寸图片幻灯片

图 3 列线图预测模型及单个预测因素ROC曲线

Figure 3. Nomogram and individual predictor ROC curves

下载: 全尺寸图片幻灯片

图 4 列线图预测模型的校准曲线

Figure 4. Calibration curve of the nomogram prediction model

下载: 全尺寸图片幻灯片

图 5 列线图预测模型的决策曲线

Figure 5. Decision curve of the nomogram prediction model

下载: 全尺寸图片幻灯片

表 1 TIPS患者出院30 d内非计划再入院单因素分析

Table 1. Univariate analysis of unplanned readmission within 30 days of discharge for TIPS patients

项目	再入院组（n=36）	非再入院组（n=198）	统计值	P值
男/女（例）	21/15	114/84	χ²=0.007	0.933
年龄（<65岁/≥65岁，例）^1）	21/15	148/50	χ²=4.091	0.043
入院途径（急诊/门诊，例）	17/19	89/109	χ²=0.063	0.801
住院时间（d）	11.0（9.0～14.5）	12.0（9.0～14.0）	Z=-0.844	0.399
术后住院时间（d）	7.00（5.00～8.75）	7.00（5.75～9.00）	Z=-0.961	0.337
支付类型（医保/非医保，例）	28/8	53/145	χ²=0.327	0.568
高血压（有/无，例）	8/28	47/151	χ²=0.039	0.844
糖尿病（有/无，例）	7/29	47/151	χ²=0.316	0.574
合并门静脉血栓（有/否，例）	15/21	64/134	χ²=1.189	0.276
既往出血次数（1次/≥2次，例）	15/21	70/128	χ²=0.525	0.469
腹水（无-轻度/中重度，例）	9/27	97/101	χ²=7.075	0.008
CTP评分（分）	8（7～9）	7（6～8）	Z=-3.427	0.001
MELD评分（分）	11.36±2.94	10.94±2.83	t=1.108	0.274
静脉曲张分型（EV+GOV1/GOV2+IGV1，例）	19/17	97/101	χ²=0.175	0.676
TIPS术中联合侧支血管栓塞（未栓塞/栓塞，例）	8/28	27/171	χ²=1.765	0.184
术前实验室检查项目
WBC（×10⁹/L）	3.85（2.23～5.85）	2.80（1.80～5.03）	Z=-1.554	0.120
Hb（g/L）	73.00（61.25～85.75）	75.00（65.75～87.00）	Z=-0.622	0.534
PLT（×10⁹/L）	59.50（40.00～136.75）	60.50（39.75～85.25）	Z=-0.470	0.639
ALT（U/L）	72.00（54.75～85.25）	19.45（14.55～29.73）	Z=-0.626	0.531
AST（U/L）	27.30（21.00～40.85）	27.00（20.50～36.65）	Z=-0.319	0.750
TBil（μmol/L）	22.30（12.68～36.68）	19.90（13.85～31.03）	Z=-0.637	0.524
Alb（g/L）	32.25（30.30～34.73）	33.60（31.20～36.70）	Z=-2.100	0.036
肌酐（μmol/L）	56.60（49.25～78.00）	62.00（51.75～73.00）	Z=-0.493	0.622
PT（s）	14.75（13.73～16.35）	14.50（13.28～15.60）	Z=-1.266	0.205
INR	1.30（1.21～1.45）	1.28（1.17～1.38）	Z=-1.157	0.247
术后实验室检查项目
WBC（×10⁹/L）	4.75（3.15～6.58）	4.60（3.00～6.60）	Z=-0.794	0.427
Hb（g/L）	81.00（71.00～86.75）	80.00（72.00～93.00）	Z=-0.928	0.354
PLT（×10⁹/L）	60.00（39.00～108.50）	61.50（42.00～92.25）	Z=-0.256	0.798
ALT（U/L）	30.20（19.73～50.53）	36.15（22.80～69.60）	Z=-1.413	0.158
AST（U/L）	45.10（25.83～69.73）	45.55（33.70～70.25）	Z=-0.395	0.693
TBil（μmol/L）	34.90（21.53～47.85）	33.25（21.55～47.68）	Z=-0.096	0.923
Alb（g/L）	32.15（28.85～35.55）	33.40（30.98～36.35）	Z=-1.775	0.076
肌酐（μmol/L）	51.50（43.00～66.50）	54.35（46.95～68.00）	Z=-1.108	0.268
血氨（μmol/L）	41.50（22.18～68.75）	26.00（14.75～46.00）	Z=-2.685	0.007
注：1）按照世界卫生组织定义，一个国家的老龄化是以65岁以上人口占全国人口比率划分。

下载: 导出CSV

表 2 TIPS患者出院30 d内非计划再入院的多因素回归分析

Table 2. Multivariate regression analysis of unplanned readmission within 30 days of discharge for TIPS patients

项目	β值	SE	Wald值	OR	95%CI	P值
常数	-6.346	2.978	4.542	0.020		0.033
年龄	0.980	0.434	5.104	2.664	1.139～6.233	0.024
CTP评分	0.504	0.209	5.788	1.655	1.098～2.495	0.016
腹水	0.494	0.546	0.817	1.638	0.561～4.781	0.366
术前Alb	0.033	0.068	0.234	1.034	0.904～1.182	0.628
术后Alb	-0.068	0.063	1.151	0.934	0.825～1.058	0.283
术后血氨	0.031	0.008	15.341	1.032	1.016～1.048	<0.001

下载: 导出CSV

参考文献(23)

[1]	BOIKE JR, THORNBURG BG, ASRANI SK, et al. North American practice-based recommendations for transjugular intrahepatic portosystemic shunts in portal hypertension[J]. Clin Gastroenterol Hepatol, 2022, 20( 8): 1636- 1662. e 36. DOI: 10.1016/j.cgh.2021.07.018.
[2]	de FRANCHIS R, BAVENO VI FACULTY. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension[J]. J Hepatol, 2015, 63( 3): 743- 752. DOI: 10.1016/j.jhep.2015.05.022.
[3]	LYU Y, FAN DM, HAN GH. Application status and future prospect of transjugular intrahepatic portosystemic shunt in gastroesophageal variceal bleeding in liver cirrhosis[J]. J Clin Hepatol, 2022, 38( 6): 1229- 1233. DOI: 10.3969/j.issn.1001-5256.2022.06.004. 吕勇, 樊代明, 韩国宏. 经颈静脉肝内门体分流术在肝硬化食管胃底静脉曲张破裂出血中的应用现状与未来展望[J]. 临床肝胆病杂志, 2022, 38( 6): 1229- 1233. DOI: 10.3969/j.issn.1001-5256.2022.06.004.
[4]	ZHANG K, LIU JL, LIU YL, et al. To observe the clinical effect of transjugular intrahepatic portosystemic shunt guided by 3D model constructed by CT thin-layer scanning data computer in the treatment of cirrhotic portal hypertension complicated with gastrointestinal bleeding[J]. Clin J Med Offic, 2023, 51( 6): 655- 656, 660. DOI: 10.16680/j.1671-3826.2023.06.28. 张凯, 刘晶磊, 刘燚隆, 等. 应用CT薄层扫描数据电脑构建3D模型指导经颈静脉肝内门体分流术治疗肝硬化门脉高压合并消化道出血临床效果观察[J]. 临床军医杂志, 2023, 51( 6): 655- 656, 660. DOI: 10.16680/j.1671-3826.2023.06.28.
[5]	CHEN GH, WANG GC, ZHANG CQ. Current status of research on hepatic encephalopathy after transjugular intrahepatic portosystemic shunt[J]. J Clin Hepatol, 2021, 37( 5): 1201- 1204. DOI: 10.3969/j.issn.1001-5256.2021.05.047. 陈功海, 王广川, 张春清. 经颈静脉肝内门体分流术后肝性脑病的研究现状[J]. 临床肝胆病杂志, 2021, 37( 5): 1201- 1204. DOI: 10.3969/j.issn.1001-5256.2021.05.047.
[6]	FENG LJ, WANG Y, JIA JD. Clinical management of common complications of liver cirrhosis[J]. Chin Hepatol, 2023, 28( 1): 13- 16. DOI: 10.14000/j.cnki.issn.1008-1704.2023.01.033. 冯丽娟, 王宇, 贾继东. 肝硬化常见并发症的临床管理[J]. 肝脏, 2023, 28( 1): 13- 16. DOI: 10.14000/j.cnki.issn.1008-1704.2023.01.033.
[7]	The Chinese College of Interventionalists. CCI clinical practice guidelines: Management of TIPS for portal hypertension(2019 edition)[J]. J Clin Hepatol, 2019, 35( 12): 2694- 2699. DOI: 10.3969/j.issn.1001-5256.2019.12.010. 中国医师协会介入医师分会. 中国门静脉高压经颈静脉肝内门体分流术临床实践指南(2019年版)[J]. 临床肝胆病杂志, 2019, 35( 12): 2694- 2699. DOI: 10.3969/j.issn.1001-5256.2019.12.010.
[8]	ZHOU NS, ZHANG J, MA XM, et al. The study of unplanned readmission within 31 days after being discharged in one general third-level grade A hospital in Beijing[J]. Chin Hosp Manag, 2010, 30( 4): 18- 20. DOI: 10.3969/j.issn.1001-5329.2010.04.008. 周念松, 张俊, 马谢民, 等. 北京市某三甲医院31天内非计划性再入院研究[J]. 中国医院管理, 2010, 30( 4): 18- 20. DOI: 10.3969/j.issn.1001-5329.2010.04.008.
[9]	General Office of the Ministry of Health. Notice on printing and distributing the indicators of medical quality management and control in tertiary general hospitals(2011 edition)[EB/OL].( 2011-01-27)[ 2023-11-10]. http://www.gov.cn/gzdt/2011-01/27/content_1793358.htm. http://www.gov.cn/gzdt/2011-01/27/content_1793358.htm 卫生部办公厅. 关于印发《三级综合医院医疗质量管理与控制指标(2011年版)》的通知[EB/OL].( 2011-01-27)[ 2023-11-10]. http://www.gov.cn/gzdt/2011-01/27/content_1793358.htm. http://www.gov.cn/gzdt/2011-01/27/content_1793358.htm
[10]	HAN Q. Analysis of types of diseases, days of interval and influencing factors of unplanned re-admission patients within 31 days after discharge[J]. Chin Nurs Res, 2020, 34( 16): 2862- 2867. DOI: 10.12102/j.issn.1009-6493.2020.16.010. 韩祺. 出院31 d内非计划再入院病人疾病种类、间隔天数与影响因素分析[J]. 护理研究, 2020, 34( 16): 2862- 2867. DOI: 10.12102/j.issn.1009-6493.2020.16.010.
[11]	SARWAR A, WEINSTEIN JL, NOVACK V, et al. Causes and rates of 30-day readmissions after transjugular intrahepatic portosystemic shunts[J]. AJR Am J Roentgenol, 2020, 215( 1): 235- 241. DOI: 10.2214/AJR.19.21732.
[12]	SHENG S, HUANG Y. Establishment and validation of the interactive nomogram model for all-cause readmission within 90-days in patients with heart failure[J]. Chin J Integr Med Cardio Cerebrovasc Dis, 2023, 21( 16): 2909- 2915. DOI: 10.12102/j.issn.1672-1349.2023.16.002. 盛松, 黄烨. 心力衰竭病人90 d内再入院的交互式列线图模型建立与验证[J]. 中西医结合心脑血管病杂志, 2023, 21( 16): 2909- 2915. DOI: 10.12102/j.issn.1672-1349.2023.16.002.
[13]	CHEN XY, LI K, WANG X, et al. Establishment of prediction model of unplanned readmission within 30 days after discharge in elderly patients receiving total knee arthroplasty[J]. Pract Geriatr, 2023, 37( 8): 772- 776. DOI: 10.3969/j.issn.1003-9198.2023.08.005. 陈翔宇, 李凯, 王旭, 等. 老年病人行全膝关节置换术出院后30天内非计划再入院预测模型的建立[J]. 实用老年医学, 2023, 37( 8): 772- 776. DOI: 10.3969/j.issn.1003-9198.2023.08.005.
[14]	MA L, WANG ZX, LUO B. Predictive value of HALP index for unplanned readmission within 30 days after discharge in elderly patients with acute exacerbation of chronic obstructive pulmonary disease[J]. Pract J Card Cereb Pneumal Vasc Dis, 2024, 32( 2): 20- 23. DOI: 10.12114/j.issn.1008-5971.2024.00.028. 马玲, 王志贤, 罗兵. HALP指数对老年慢性阻塞性肺疾病急性加重期患者出院后30 d内非计划再入院的预测价值[J]. 实用心脑肺血管病杂志, 2024, 32( 2): 20- 23. DOI: 10.12114/j.issn.1008-5971.2024.00.028.
[15]	ZHANG JQ, WANG ZC, YANG JY, et al. Construction and validation of the risk prediction model for secondary hepatic encephalopathy in patients with chronic hepatitis B and cirrhosis[J]. Chin Hepatol, 2023, 28( 8): 916- 920, 931. DOI: 10.14000/j.cnki.issn.1008-1704.2023.08.011. 张家齐, 王再超, 杨家耀, 等. 慢性乙型肝炎肝硬化患者继发肝性脑病风险预测模型的构建与验证[J]. 肝脏, 2023, 28( 8): 916- 920, 931. DOI: 10.14000/j.cnki.issn.1008-1704.2023.08.011.
[16]	PUGH RN, MURRAY-LYON IM, DAWSON JL, et al. Transection of the oesophagus for bleeding oesophageal varices[J]. Br J Surg, 1973, 60( 8): 646- 649. DOI: 10.1002/bjs.1800600817.
[17]	LI H, XIA ZB, XIAO NJ, et al. Current research status of prognostic models for transjugular intrahepatic portosystemic shunt[J]. J Clin Hepatol, 2023, 39( 5): 1191- 1196. DOI: 10.3969/j.issn.1001-5256.2023.05.030. 李慧, 夏志波, 肖年军, 等. 经颈静脉肝内门体分流术预后模型的研究现状[J]. 临床肝胆病杂志, 2023, 39( 5): 1191- 1196. DOI: 10.3969/j.issn.1001-5256.2023.05.030.
[18]	LIU ZL, FAN ZP, LIU YL, et al. Value of Model for End-Stage Liver Disease and Child-Turcotte-Pugh score in predicting the prognosis of patients with hepatic sinus obstruction syndrome associated with Gynura segetum(Lour.) Merr[J]. J Clin Hepatol, 2020, 36( 11): 2462- 2466. DOI: 10.3969/j.issn.1001-5256.2020.11.013. 刘贞利, 范作鹏, 柳雅立, 等. 终末期肝病模型及CTP评分系统对土三七相关肝窦阻塞综合征患者预后的预测价值[J]. 临床肝胆病杂志, 2020, 36( 11): 2462- 2466. DOI: 10.3969/j.issn.1001-5256.2020.11.013.
[19]	ZHANG F, LIU B, SHI YQ, et al. Analysis of risk factors for hepatic encephalopathy in patients with liver cirrhosis with upper gastrointestinal bleeding[J]. Chin J Integr Tradit West Med Dig, 2018, 26( 11): 934- 937. DOI: 10.3969/j.issn.1671-038X.2018.11.10. 张飞, 刘斌, 施彦卿, 等. 肝硬化上消化道出血患者并发肝性脑病的危险因素分析[J]. 中国中西医结合消化杂志, 2018, 26( 11): 934- 937. DOI: 10.3969/j.issn.1671-038X.2018.11.10.
[20]	LOCKWOOD AH. Blood ammonia levels and hepatic encephalopathy[J]. Metab Brain Dis, 2004, 19( 3-4): 345- 349. DOI: 10.1023/b: mebr.0000043980.74574.eb.
[21]	VILSTRUP H, AMODIO P, BAJAJ J, et al. Hepatic encephalopathy in chronic liver disease: 2014 Practice Guideline by the American Association for the Study of Liver Diseases and the European Association for the Study of the Liver[J]. Hepatology, 2014, 60( 2): 715- 735. DOI: 10.1002/hep.27210.
[22]	BROWN JR, ALONSO A, MAZIMBA S, et al. Improved 30 day heart failure rehospitalization prediction through the addition of device-measured parameters[J]. ESC Heart Failure, 2020, 7( 6): 3762- 3771. DOI: 10.1002/ehf2.12956.
[23]	GLANCE LG, KELLERMANN AL, OSLER TM, et al. Hospital readmission after noncardiac surgery: the role of major complications[J]. JAMA Surg, 2014, 149( 5): 439- 445. DOI: 10.1001/jamasurg.2014.4.