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失代偿期肝硬化合并急性肾损伤患者入院后30天内死亡的危险因素及列线图预测模型构建

郭雪云 钟璇 章婷婷 陈思海 张望 李弼民 朱萱 汪安江

引用本文:
Citation:

失代偿期肝硬化合并急性肾损伤患者入院后30天内死亡的危险因素及列线图预测模型构建

DOI: 10.12449/JCH241115
基金项目: 

国家自然科学基金 (82160115);

江西省科技厅重点研发项目 (20202BBGL73093)

伦理学声明:本研究方案经由南昌大学第一附属医院医学伦理委员会审批,批号:IIT[2021]临伦审第032号。
利益冲突声明:本文不存在任何利益冲突。
作者贡献声明:郭雪云、钟璇负责实验设计,收集数据,论文撰写;郭雪云、钟璇、章婷婷负责随访患者,数据收集和整理;陈思海、张望负责数据统计分析和作图;李弼民、朱萱、汪安江负责实验设计,随访患者,论文撰写和修改。
详细信息
    通信作者:

    汪安江, waj1103@163.com (ORCID: 0000-0001-6670-6645)

Risk factors for death within 30 days after admission in patients with decompensated liver cirrhosis and acute kidney injury and construction of a nomogram model

Research funding: 

National Natural Science Foundation of China (82160115);

Project of Science and Technology Department of Jiangxi Province (20202BBGL73093)

More Information
    Corresponding author: WANG Anjiang, waj1103@163.com (ORCID: 0000-0001-6670-6645)
  • 摘要:   目的  分析失代偿期肝硬化合并急性肾损伤(AKI)的患者入院后30天内死亡预测因素,同时建立并验证列线图预测模型。  方法  通过南昌大学第一附属医院联众病案管理系统,筛查2015年1月—2020年12月在消化内科和感染科住院的失代偿期肝硬化患者,纳入符合2015年国际腹水俱乐部AKI诊断标准的患者330例,其中训练组193例,验证组137例,通过Cox回归分析影响其死亡的预测因素,建立并验证入院后30天内的死亡风险列线图预测模型。符合正态分布的计量资料2组间比较采用成组t检验,多组间比较采用单因素方差分析,进一步两两比较采用LSD-t检验;不符合正态分布的计量资料2组间比较采用Mann-Whitney U检验,多组间比较采用Kruskal-Wallis H检验。计数资料组间比较采用χ2检验或Fisher精确检验。  结果  失代偿期肝硬化患者中AKI患病率为16.5%。纳入研究的330例患者平均年龄(53.6±12.4)岁,男性占79.1%,入院后30天病死率为50.0%,训练组和验证组病死率分别为46.6%和54.7%。入院时存在慢加急性肝衰竭(ACLF)是AKI 1期进展的独立危险因素(OR=2.571,95%CI: 1.143~5.780, P=0.022)。基于入院时白细胞计数、国际标准化比值、是否有肝性脑病及AKI分期所建立的列线图能较好预测入院后30天死亡风险,训练组和验证组C指数分别为0.680和0.683,且不劣于CTP评分和MELD评分。  结论  ACLF是AKI 1期进展的独立危险因素,建立的列线图预测模型可有效预测患者入院后30天内死亡风险,对于早期识别和管理失代偿期肝硬化合并AKI患者有重要指导意义。

     

  • 图  1  纳入研究患者筛选过程

    Figure  1.  Screening process included in the study patients

    图  2  失代偿期肝硬化并发AKI患者入院后30天死亡预测列线图模型

    Figure  2.  A 30-day mortality prediction model for patients with decompensated cirrhosis complicated with AKI after admission

    表  1  失代偿期肝硬化合并AKI不同分期患者入院后的基线特征

    Table  1.   Baseline characteristics of patients with decompensated cirrhosis and AKI at different stages after admission

    项目 总计(n=330) AKI 1期(n=198) AKI 2期(n=64) AKI 3期(n=68) 统计值 P
    年龄(岁) 53.6±12.4 54.2±12.3 52.7±11.6 52.6±13.6 F=0.625 0.536
    男性[例(%)] 261(79.1) 158(79.8) 51(79.7) 52(76.5) χ 2=0.358 0.837
    糖尿病[例(%)] 46(13.9) 30(15.2) 9(14.1) 7(10.3) χ 2=0.997 0.608
    肝硬化病因[例(%)]
    乙型肝炎 262(79.4) 159(80.3) 51(79.7) 52(76.5) χ 2=0.459 0.795
    酒精性 48(14.5) 27(13.6) 9(14.1) 12(17.6) χ 2=0.670 0.715
    自身免疫性 6(1.8) 2(1.0) 2(3.1) 2(2.9) χ 2=1.817 0.403
    血吸虫性 13(3.9) 8(4.0) 3(4.7) 2(2.9) χ 2=0.279 0.870
    其他 29(8.8) 19(9.6) 4(6.3) 6(8.8) χ 2=0.676 0.713
    MAP(mmHg) 87.5±14.3 86.8±14.7 88.3±13.0 88.7±14.2 F=0.583 0.559
    心率(次/min) 88.5±15.8 87.3±16.0 91±15.6 89.8±15.0 F=1.630 0.198
    WBC(×109/L) 6.6(4.7~9.8) 6.7(4.8~9.6) 6.7(4.9~9.7) 6.3(4.3~9.9) χ 2=0.357 0.837
    Hb(g/L) 106.2±26.7 106.0±28.0 108.2±23.8 104.4±25.6 F=0.338 0.713
    PLT(×109/L) 79(50~123) 79(50~120) 76(50~116) 85(50~148) χ 2=1.645 0.439
    Alb(g/L) 29.1±5.1 29.3±5.1 29.6±5.4 28.0±4.7 F=2.014 0.135
    ALT(U/L) 89.0(32.0~271.0) 89.0(31.0~238.8) 93.4(43.3~342.8) 78.9(27.3~310.5) χ 2=1.130 0.568
    AST(U/L) 130.5(64.8~291.3) 131.5(58.8~263.0) 126.0(89.5~361.8) 132.5(65.5~339.3) χ 2=1.236 0.539
    TBil(μmol/L) 248.7±188.1 242.4±188.4 293.0±187.0 225.6±184.2 F=2.418 0.091
    Na+(mmol/L) 134.4(130.0~138.0) 134.5(130.0~137.9) 134.2(129.6~138.0) 134.0(130.0~138.4) χ 2=0.166 0.920
    INR 1.9(1.4~2.4) 1.9(1.4~2.5) 1.9(1.5~2.3) 1.7(1.3~2.2) χ 2=2.606 0.272
    SCr(mg/dL) 1.3±0.9 1.2±0.6 0.9±0.5 1.8±1.5 F=19.718 <0.001
    MELD评分(分) 22.6±8.9 22.6±8.5 21.8±7.3 23.5±11.2 F=0.616 0.541
    Child-Pugh评分(分) 11.1±2.0 10.8±2.1 11.4±2.01) 11.6±1.81) F=5.469 0.005
    并发症[例(%)]
    腹水 311(94.2) 186(93.9) 58(90.6) 67(98.5) χ 2=3.880 0.144
    EGVB 35(10.6) 24(12.1) 5(7.8) 6(8.8) χ 2=1.234 0.540
    SBP 119(36.1) 72(36.4) 24(37.5) 23(33.8) χ 2=0.213 0.899
    显性肝性脑病 96(29.1) 42(21.2) 27(42.2)1) 27(39.7)2) χ 2=14.994 0.001
    ACLF 205(62.1) 118(59.6) 49(76.6)1) 38(55.9)2) χ 2=7.334 0.026

    注:MAP,平均动脉压;EGVB,食管胃静脉曲张破裂出血;SBP,自发性细菌性腹膜炎。与AKI 1期比较,1) P<0.05;与AKI 2期比较,2) P<0.05。

    下载: 导出CSV

    表  2  失代偿期肝硬化合并AKI 1期患者住院期间好转或进展基线资料

    Table  2.   Baseline data on improvement or progression during hospitalization in patients with decompensated cirrhosis and AKI stage 1

    项目 好转情况 进展情况
    好转(n=75) 未好转(n=123) P 进展(n=38) 未进展(n=160) P
    年龄(岁) 53.2±12.0 54.9±12.5 0.356 53.4±11.4 54.4±12.6 0.661
    男性[例(%)] 57(76.0) 101(82.1) 0.299 32(84.2) 126(78.8) 0.451
    糖尿病[例(%)] 7(9.3) 23(18.7) 0.075 8(21.1) 22(13.8) 0.259
    肝硬化病因[例(%)]
    乙型肝炎 61(81.3) 98(79.7) 0.776 33(86.8) 126(78.8) 0.260
    酒精性 10(13.3) 17(13.8) 0.923 4(10.5) 23(14.4) 0.534
    MAP(mmHg) 86.2±15.3 87.1±14.3 0.685 87.7±13.3 86.5±15.1 0.655
    心率(次/min) 87.9±17.0 86.9±15.5 0.459 90.2±16.0 86.6±16.0 0.333
    WBC(×109/L) 7.5±4.1 7.9±4.6 0.576 7.9±3.4 7.7±4.6 0.216
    Hb(g/L) 104.4±29.5 107.4±27.2 0.468 109.4±20.4 105.5±29.6 0.338
    PLT(×109/L) 84.2±44.0 91.0±62.6 0.361 98.6±53.7 86.8±56.9 0.317
    Alb(g/L) 28.6±6.1 29.7±4.3 0.145 30.2±3.8 29.1±5.3 0.154
    ALT(U/L) 68(31~237) 110(33~245) 0.285 148(69~393) 74(30~218) 0.053
    AST(U/L) 119(62~232) 146(53~266) 0.583 211(92~304) 119(57~262) 0.032
    TBil(μmol/L) 230.6±181.6 249.6±192.8 0.495 315.2±166.9 225.1±115.6 0.008
    Na+(mmol/L) 133.7±6.2 134.1±5.3 0.491 134.2±4.7 133.9±5.9 0.690
    INR 1.9(1.4~2.4) 1.8(1.4~2.5) 0.860 2.1(1.6~2.8) 1.8(1.4~2.4) 0.040
    基线SCr>1.5 mg/L[例(%)] 17(22.7) 32(26) 0.596 5(13.2) 44(27.5) 0.066
    Child-Pugh C级[例(%)] 58(77.3) 90(73.2) 0.513 31(81.6) 117(73.1) 0.281
    Child-Pugh评分(分) 10.9±2.0 10.7±2.1 0.420 11.0±1.9 10.7±2.1 0.497
    MELD评分(分) 22.7±7.7 22.5±9.0 0.870 23.9±8.5 22.2±8.5 0.204
    并发症[例(%)]
    腹水 72(96.0) 114(92.7) 0.343 35(92.1) 151(94.4) 0.598
    EGVB 9(12.0) 15(12.2) 0.967 4(10.5) 20(12.5) 0.738
    SBP 25(33.3) 47(38.2) 0.489 16(42.1) 56(35.0) 0.413
    显性肝性脑病 17(22.7) 25(20.3) 0.696 8(21.1) 34(21.3) 0.979
    ACLF 44(58.7) 74(60.2) 0.835 29(76.3) 89(55.6) 0.019
    下载: 导出CSV

    表  3  训练组和验证组基线资料特征

    Table  3.   Baseline data characteristics of training group and validation group

    项目 训练组(n=193) 验证组(n=137)
    死亡组(n=90) 生存组(n=103) P 死亡组(n=75) 生存组(n=62) P
    年龄(岁) 53.9±13.1 52.7±12.9 0.541 53.8±10.0 54.4±13.4 0.761
    男性[例(%)] 73(81.1) 75(72.8) 0.174 63(84.0) 59(80.6) 0.607
    糖尿病[例(%)] 9(10.0) 10(9.7) 0.946 14(18.7) 13(21.0) 0.736
    MAP(mmHg) 85.2±13.0 88.9±14.8 0.067 89.4±13.8 85.9±15.4 0.150
    心率(次/min) 89.7±14.3 86.8±14.5 0.011 92.0±16.7 85.4±17.9 0.025
    WBC(×109/L) 7.9(5.3~11.2) 6.1(3.8~8.3) 0.003 7.5(5.2~10.0) 6.6(4.5~9.0) 0.219
    Hb(g/L) 104.2±27.3 106.4±25.9 0.568 112.1±26.0 101.9±27.5 0.027
    PLT(×109/L) 66(47~122) 79(48~119) 0.522 91(62~136) 76(51~117) 0.199
    Alb(g/L) 28.0±4.7 29.4±5.6 0.143 29.4±4.3 29.7±5.4 0.657
    ALT(U/L) 105(52~287) 89(28~265) 0.121 187(54~473) 34(20~127) <0.001
    AST(U/L) 160(90~368) 122(62~260) 0.046 166(99~471) 66(37~159) <0.001
    TBil(μmol/L) 262.3±182.2 245.5±191.0 0.536 334.0(151.2~417.9) 87.6(19.5~298.2) <0.001
    Na+(mmol/L) 131.7±5.8 133.7±5.9 0.039 134.2±5.4 136.4±4.9 0.014
    INR 1.9(1.5~2.8) 1.7(1.4~2.2) <0.001 2.1(1.7~2.6) 1.5(1.3~2.0) <0.001
    基线SCr>1.5 mg/L[例(%)] 29(32.2) 27(26.2) 0.359 12(16.0) 11(17.7) 0.786
    Child-Pugh评分(分) 12.1±1.7 11.2±1.8 <0.001 10.9±1.7 9.5±2.2 <0.001
    MELD评分(分) 24.9±9.5 21.9±7.7 0.015 24.6±8.7 18.0±8.5 <0.001
    并发症[例(%)]
    腹水 86(95.6) 97(94.2) 0.666 70(93.3) 58(93.5) 0.960
    EGVB 6(6.7) 5(4.9) 0.588 12(16.0) 12(19.4) 0.607
    SBP 25(27.8) 23(22.3) 0.382 48(64.0) 23(37.1) 0.002
    显性肝性脑病 46(51.1) 32(31.1) 0.005 15(20.0) 3(4.8) 0.009
    ACLF 61(67.8) 62(60.2) 0.274 59(78.7) 23(37.1) <0.001
    AKI分期[例(%)]
    1期 39(43.3) 60(58.3) 0.039 47(62.7) 52(83.9) 0.006
    2期 19(21.1) 19(18.4) 0.642 19(25.3) 7(11.3) 0.037
    3期 32(35.6) 24(23.3) 0.061 9(12.0) 3(4.8) 0.140
    下载: 导出CSV

    表  4  训练组和验证组不同预测模型的预测准确性比较

    Table  4.   Comparison of prediction accuracy of different prediction models between the training group and the verification group

    项目 Cut-off 敏感度(%) 特异度(%) 约登指数 AUC 95%CI
    训练组
    列线图 0.358 75.56 60.19 0.358 0.702 0.632~0.765
    Child-Pugh评分 0.243 46.67 77.67 0.243 0.650 0.578~0.717
    MELD评分 0.252 55.33 71.84 0.252 0.6161) 0.543~0.685
    验证组
    列线图 0.439 90.67 53.23 0.439 0.767 0.687~0.835
    Child-Pugh评分 0.294 82.67 46.77 0.294 0.6741) 0.589~0.752
    MELD评分 0.377 58.67 79.03 0.377 0.704 0.620~0.779

    注:与列线图比较,P<0.05

    下载: 导出CSV
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  • 收稿日期:  2024-02-25
  • 录用日期:  2024-03-29
  • 出版日期:  2024-11-25
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