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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

引用本文:
Citation:

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
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)

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

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:   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。

     

  • 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

    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

    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

    图  4  列线图预测模型的校准曲线

    Figure  4.  Calibration curve of the nomogram prediction model

    图  5  列线图预测模型的决策曲线

    Figure  5.  Decision curve of the nomogram prediction model

    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
    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 SE Wald值 OR 95%CI P
    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
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