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基于APRI和PALBI构建的列线图对肝硬化并发食管胃底静脉曲张破裂出血的预测价值
DOI: 10.12449/JCH240314
伦理学声明：本研究于2023年6月19日通过苏州大学附属第一医院伦理委员会批准，批号：2023伦研批第237号。所有患者均知情同意。
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：陈丽负责课题设计，拟定写作思路及指导撰写文章；李欣忆负责资料分析及撰写论文；李娇娇、李莹莹、魏虹合、熊雨凡、张新弛负责收集分析数据；孙蔚负责修改论文并最后定稿。
Establishment of a nomogram model for predicting liver cirrhosis with esophagogastric variceal bleeding based on aspartate aminotransferase-to-platelet ratio index and platelet-albumin-bilirubin score
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摘要:
目的 评估天冬氨酸转氨酶与血小板比值指数（APRI）和血小板-白蛋白-胆红素评分（PALBI）对肝硬化并发食管胃底静脉曲张破裂出血风险的预测价值。 方法 选取苏州大学附属第一医院于2021年5月—2022年6月收治的肝硬化患者119例，收集患者的临床资料、血常规、血清生化及血凝等检查结果。根据是否合并食管胃底静脉曲张破裂出血，将患者分为未出血组（n=59）和出血组（n=60），比较组间差异。正态分布的计量资料两组间比较采用独立样本t检验，非正态分布的计量资料两组间比较采用Mann-Whitney U检验。计数资料组间比较采用χ2检验或Fisher精确概率法。使用多因素Logistic回归分析，筛选肝硬化并发食管胃底静脉曲张破裂出血的独立危险因素，并构建列线图预测模型。 结果 出血组男性患者占75.00%，未出血组男性患者占40.68%，两组在性别构成方面，差异具有统计学意义（χ2=14.384，P<0.001）。出血组和未出血组患者病因均以慢性乙型肝炎为主（53.33% vs 38.98%），两者构成比差异无统计学意义（χ2=2.464，P=0.116）。出血组患者抗凝血酶原Ⅲ活性（AT-IIIA）水平高于未出血组（t=3.329，P=0.001），PLT、TBil、Ca、TC、TT水平则低于未出血组（P值均<0.05）。APRI和PALBI在出血组和未出血组之间比较，差异均有统计学意义（χ2值分别为6.175、19.532，P值均<0.05）。进一步二元Logistic回归分析发现，APRI（OR=0.309，95%CI：0.109～0.881，P=0.028）、PALBI（OR=7.667，95%CI：2.005～29.327，P=0.003）、Ca（OR=0.001，95%CI：0.000～0.141，P=0.007）、TC（OR=0.469，95%CI：0.226～0.973，P=0.042）和TT（OR=0.599，95%CI：0.433～0.830，P=0.002）是影响肝硬化并发食管胃底静脉曲张破裂出血的独立影响因素。基于以上因素建立列线图模型，一致性指数（C-index）为0.899，校准曲线拟合良好。 结论 APRI及PALBI对肝硬化并发食管胃底静脉曲张破裂出血具有良好的预测价值，基于本研究构建的列线图模型可以个体化预测肝硬化患者食管胃底静脉曲张破裂出血发生率。 Abstract:Objective To investigate the value of aspartate aminotransferase-to-platelet ratio index （APRI） and platelet-albumin-bilirubin （PALBI） score in predicting the risk of esophagogastric variceal bleeding in patients with liver cirrhosis. Methods A total of 119 patients with liver cirrhosis who were admitted to The First Affiliated Hospital of Soochow University from May 2021 and June 2022 were enrolled， and clinical data， routine blood test results， serum biochemistry， and coagulation test results were collected from all patients. According to the presence or absence of esophagogastric variceal bleeding， the patients were divided into non-bleeding group with 59 patients and bleeding group with 60 patients， and a comparative analysis was performed for the two groups. 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-squared test or the Fisher’s exact test was used for comparison of categorical data between groups. The multivariate Logistic regression analysis was used to identify the independent risk factors for esophagogastric variceal bleeding in patients with liver cirrhosis and establish a nomogram predictive model. Results The male patients accounted for 75.00% in the bleeding group and 40.68% in the non-bleeding group， and there was a significant difference in sex composition between the two groups （χ2=14.384， P<0.001）. Chronic hepatitis B was the main etiology in both the bleeding group and the non-bleeding group （53.33% vs 38.98%）， and there was no significant difference in composition ratio between the two groups （χ2=2.464， P=0.116）. Compared with the non-bleeding group， the bleeding group had a significantly higher activity of AT-IIIA （t=3.329， P=0.001） and significantly lower levels of PLT， TBil， Ca， TC， and TT （all P<0.05）. There were significant differences in APRI and PALBI between the two groups （χ2=6.175 and 19.532， both P<0.05）. The binary logistic regression analysis showed that APRI （odds ratio ［OR］=0.309， 95% confidence interval ［CI］： 0.109 — 0.881， P=0.028）， PALBI （OR=7.667， 95%CI： 2.005 — 29.327， P=0.003）， Ca （OR=0.001， 95%CI： 0.000 — 0.141， P=0.007）， TC （OR=0.469， 95%CI： 0.226 — 0.973， P=0.042）， and TT （OR=0.599， 95%CI： 0.433 — 0.830， P=0.002） were independent influencing factors for esophagogastric variceal bleeding in liver cirrhosis. A nomogram model was established based on the above factors and had an index of concordance of 0.899 and a well-fitted calibration curve. Conclusion APRI and PALBI have a good value in predicting esophagogastric variceal bleeding in patients with liver cirrhosis， and the nomogram model established based on this study can predict the incidence rate of esophagogastric variceal bleeding in patients with liver cirrhosis. -
Key words:
- Liver Cirrhosis /
- Esophageal and Gastric Varices /
- Gastrointestinal Hemorrhage /
- APRI /
- PALBI /
- Nomograms
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图 1 APRI及PALBI的ROC曲线
Figure 1. The receiver operating characteristic （ROC） curves of APRI and PALBI
图 2 基于Logistics回归模型绘制的列线图
Figure 2. A nomogram column chart based on a Logistic regression model
图 3 列线图模型的ROC曲线
Figure 3. The receiver operating characteristic （ROC） curve of the model
表 1 肝硬化并发消化道出血患者临床特征
Table 1. Clinical characteristics of patients with liver cirrhosis complicated by gastrointestinal bleeding
项目 出血组（n=60） 未出血组（n=59） 统计值 P值 性别［例（%）］ χ2=14.384 <0.001 男 45（75.00） 24（40.68） 女 15（25.00） 35（59.32） 年龄（岁） 58.00±14.48 62.29±14.29 t=-1.626 0.107 肝硬化病因［例（%）］ 乙型肝炎 32（53.33） 23（38.98） χ2=2.464 0.116 酒精性 7（11.67） 1（1.69） χ2=3.261 0.071 血吸虫性 7（11.67） 13（22.04） χ2=2.287 0.130 自身免疫性 1（1.66） 4（6.78） χ2=0.871 0.351 其他 13（21.67） 18（30.51） χ2=0.464 0.496 WBC（×109/L） 3.30（2.45～4.59） 3.03（2.36～4.20） Z=-0.460 0.646 PLT（×109/L） 56.00（43.00～69.25） 65.00（50.00～84.00） Z=-2.318 0.020 TBil（μmol/L） 19.15（12.35～25.93） 31.50（21.90～47.60） Z=-5.084 <0.001 AST（U/L） 31.90（23.28～43.95） 36.80（28.00～47.90） Z=-1.629 0.103 Alb（g/L） 31.18±3.63 30.92±6.23 t=-0.273 0.785 APRI［例（%）］ χ2=6.175 0.013 ≤0.597 25（41.67） 38（64.41） >0.597 35（58.33） 21（35.59） PALBI［例（%）］ χ2=19.532 <0.001 ≤-1.932 49（81.67） 25（42.37） >-1.932 11（18.33） 34（57.63） Ca（mmol/L） 2.02±0.13 2.09±0.15 t=2.677 0.008 TC（mmol/L） 2.92（2.47～3.51） 3.53（3.01～4.12） Z=-3.864 <0.001 TG（mmol/L） 0.95（0.70～1.24） 0.81（0.68～1.05） Z=-1.414 0.157 LDL（mmol/L） 1.63（1.20～2.03） 1.68（1.30～2.02） Z=-0.736 0.462 PT（s） 15.65（14.43～17.08） 15.10（13.50～16.50） Z=-1.789 0.074 APTT（s） 35.50±6.46 36.63±7.34 t=-0.894 0.373 TT（s） 18.15（16.73～19.85） 19.80（18.70～21.20） Z=-4.490 <0.001 AT-ⅢA（%） 62.55±14.99 52.42±18.03 t=3.329 0.001 
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表 2 影响肝硬化并食管胃底静脉曲张破裂出血的二元Logistic回归分析
Table 2. Binary Logistic regression analysis of factors affecting gastrointestinal bleeding in liver cirrhosis
变量 B值 SE Wald P值 OR 95%CI APRI -1.173 0.534 4.830 0.028 0.309 0.109～0.881 PALBI 2.037 0.684 8.857 0.003 7.667 2.005～29.327 Ca -7.100 2.622 7.335 0.007 0.001 0.000～0.141 TC -0.758 0.373 4.130 0.042 0.469 0.226～0.973 TT -0.512 0.166 9.516 0.002 0.599 0.433～0.830 AT-ⅢA 0.025 0.023 1.106 0.293 1.025 0.979～1.073 注：APRI≤0.597赋值为0，APRI>0.597赋值为1；PALBI>-1.932赋值为0，PALBI≤-1.932赋值为1。
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