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肝硬化食管胃静脉曲张破裂出血治疗后1年内再出血的危险因素分析及列线图模型构建
DOI: 10.12449/JCH260917
伦理学声明：本研究方案于2025年12月29日经甘肃省人民医院伦理委员会审批，批号：2025-750。
利益冲突声明：本文不存在任何利益冲突。
作者贡献声明：季盼盼负责课题设计，资料分析，撰写论文；李苗苗、陈金玥、文婷婷参与收集数据；陈万红、王婧负责修改论文；李娟负责指导撰写文章并最后定稿。
Risk factors analysis and construction of a nomogram model for rebleeding within one year after treatment of esophagogastric variceal bleeding in patients with cirrhosis
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摘要:
目的 探讨白蛋白-胆红素（ALBI）评分联合血小板计数/脾脏厚度（PC/ST）比值对肝硬化食管胃静脉曲张破裂出血（EVB）患者经内镜下套扎治疗后1年内再出血风险的预测价值，评估该联合模型的风险预测能力，进而为临床预防再出血提供参考依据。 方法 回顾性收集2020年1月1日—2024年12月31日于甘肃省人民医院住院的肝硬化EVB患者的临床资料。所有患者均经内镜下套扎治疗成功止血，根据术后1年内是否发生再出血分为再出血组与未再出血组。计量资料两组间比较采用成组t检验或Mann-Whitney U检验。计数资料两组间比较采用χ2检验或Fisher确切概率法。采用单因素及多因素Cox回归分析筛选再出血的独立影响因素，基于筛选出的因素构建预测模型，并绘制列线图实现模型可视化。应用受试者操作特征曲线评估模型的区分度，计算曲线下面积；校准曲线评估模型的校准度；决策曲线分析（DCA）评估模型的临床净获益。 结果 共纳入258例患者，其中1年内发生再出血70例，再出血率为27.1%。多因素Cox回归分析显示，ALBI评分（风险比=4.679，95%置信区间：2.952～7.417，P<0.001）和PC/ST比值（风险比=0.461，95%置信区间：0.318～0.668，P<0.001）是肝硬化EVB患者再出血的独立影响因素。基于这两项指标构建的模型预测6周、6个月及1年内再出血风险的曲线下面积分别为0.766（95%置信区间：0.667～0.866）、0.775（95%置信区间：0.699～0.851）和0.809（95%置信区间：0.752～0.866）。校准曲线显示，该模型对6周及6个月内再出血概率的预测存在系统性低估，而对1年内再出血概率的预测结果与理想曲线贴合度良好。DCA结果显示，模型对1年内再出血的预测具有明确的临床净获益。 结论 ALBI评分联合PC/ST比值构建的模型对肝硬化EVB患者内镜下套扎术后1年内再出血风险具有良好的预测效能。 Abstract:Objective To investigate the value of albumin-bilirubin （ALBI） score combined with platelet count-to-spleen thickness ratio （PC/ST） in predicting rebleeding within one year after endoscopic variceal ligation in liver cirrhosis patients with esophagogastric variceal bleeding （EVB）， to evaluate the risk assessment ability of this model， and to provide a reference for clinical prevention of rebleeding. Methods A retrospective analysis was performed on the clinical data of liver cirrhosis patients with EVB who were hospitalized in Gansu Provincial Hospital from January 1， 2020 to December 31， 2024. All patients achieved successful hemostasis after endoscopic variceal ligation， and according to whether rebleeding occurred within one year after surgery， they were divided into rebleeding group and non-rebleeding group. The independent-samples t test or the Mann-Whitney U test was used for comparison of continuous data between two groups， and the chi-square test or the Fisher’s exact test was used for comparison of categorical data between two groups. The univariate and multivariate Cox regression analyses were used to identify independent influencing factors for rebleeding. A prediction model was constructed based on the factors identified， and a nomogram was plotted for model visualization. The receiver operating characteristic （ROC） curve was used to assess the discriminatory ability of the model， and the area under the ROC curve （AUC） was calculated； calibration curve was used to assess calibration； decision curve analysis was used to assess the net clinical benefit of the model. Results A total of 258 patients were enrolled， among whom 70 patients experienced rebleeding within one year， resulting in a rebleeding rate of 27.1%. The multivariate Cox regression analysis showed that ALBI score （hazard ratio ［HR］=4.679， 95% confidence interval ［CI］： 2.952 — 7.417， P<0.001） and PC/ST （HR=0.461， 95%CI： 0.318 — 0.668， P<0.001） were independent influencing factors for rebleeding in liver cirrhosis patients with EVB. The model constructed based on these two factors yielded an AUC of 0.766 （95%CI： 0.667 — 0.866）， 0.775 （95%CI： 0.699 — 0.851）， and 0.809 （95%CI： 0.752 — 0.866）， respectively， for predicting the risk of rebleeding at 6 weeks， 6 months， and 1 year. The calibration curve showed that the model systematically underestimated the probability of rebleeding at 6 weeks and 6 months， but its prediction for the probability of rebleeding at 1 year aligned well with the ideal curve. The decision curve analysis showed that the model provided a clear net clinical benefit for predicting rebleeding within 1 year. Conclusion The model constructed based on ALBI score and PC/ST had good performance in predicting the risk of rebleeding within 1 year after endoscopic variceal ligation in liver cirrhosis patients with EVB. -
注： a， 6周内再出血概率校准曲线；b，6个月内再出血概率校准曲线；c，1年内再出血概率校准曲线。
图 4 校准曲线
Figure 4. Calibration curve
表 1 再出血组与未再出血组基线资料的比较
Table 1. Baseline characteristics of patients with and without rebleeding
指标 再出血组（n=70） 未再出血组（n=188） 统计值 P值 年龄（岁） 52.47±14.19 55.17±12.21 t=1.509 0.133 性别［例（%）］ χ2=0.563 0.453 男 42（60.0） 103（54.8） 女 28（40.0） 85（45.2） 高血压［例（%）］ χ2=0.003 0.953 有 8（11.4） 21（11.2） 无 62（88.6） 167（88.8） 糖尿病［例（%）］ χ2=0.192 0.661 有 10（14.3） 23（12.2） 无 60（85.7） 165（87.8） 肝硬化病因［例（%）］ χ2=2.633 0.612 乙型肝炎 55（78.6） 151（80.3） 丙型肝炎 5（7.1） 15（8.0） 酒精性肝病 1（1.4） 1（0.5） 原发性胆汁性胆管炎 3（4.3） 12（6.4） 自身免疫性肝炎 6（8.6） 9（4.8） 
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表 2 再出血组与未再出血组临床特征的比较
Table 2. Comparison of clinical characteristics between the rebleeding group and the non-rebleeding group
指标 再出血组（n=70） 未再出血组（n=188） 统计值 P值 红色征［例（%）］ χ2=0.371 0.542 有 65（92.9） 170（90.4） 无 5（7.1） 18（9.6） 胃底静脉曲张［例（%）］ χ2=0.889 0.346 有 34（48.6） 79（42.0） 无 36（51.4） 109（58.0） 门静脉高压性胃病［例（%）］ χ2=0.813 0.367 有 19（27.1） 41（21.8） 无 51（72.9） 147（78.2） 腹水［例（%）］ χ2=1.227 0.220 无 30（42.9） 87（46.3） 轻度 13（18.6） 52（27.7） 中重度 27（38.6） 49（26.1） 肝性脑病［例（%）］ χ2=0.181 0.670 有 3（4.3） 6（3.2） 无 67（95.7） 182（96.8） 门静脉血栓［例（%）］ χ2=0.024 0.877 有 6（8.6） 15（8.0） 无 64（91.4） 173（92.0） 脾脏厚度（mm） 58.00（50.00～64.75） 47.00（42.00～54.00） Z=-6.169 <0.001 门静脉内径（mm） 13.80（13.00～15.00） 13.00（12.00～14.00） Z=-2.561 0.010 序贯治疗［例（%）］ χ2=5.411 0.020 有 16（22.9） 72（38.3） 无 54（77.1） 116（61.7） 服用NSBB［例（%）］ χ2=0.417 0.518 有 12（17.1） 39（20.7） 无 58（82.9） 149（79.3） 注：NSBB，非选择性β受体阻滞剂。
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表 3 再出血组与未再出血组实验室指标的比较
Table 3. Comparison of laboratory parameters between the rebleeding group and the non-rebleeding group
指标 再出血组（n=70） 未再出血组（n=188） 统计值 P值 WBC（×109/L） 4.00（2.30～5.73） 3.90（2.80～6.28） Z=-0.542 0.588 PLT（×109/L） 64.50（41.00～82.00） 75.00（51.00～101.75） Z=-3.253 0.001 HGB（g/L） 83.93±29.32 86.62±26.23 t=0.710 0.478 Alb（g/L） 29.50±5.48 33.56±4.39 t=6.145 <0.001 TBil（μmol/L） 31.81（25.93～42.35） 24.24（17.93～34.68） Z=-4.402 <0.001 ALT（U/L）） 26.00（19.40～37.00） 30.04（20.00～49.42） Z=-1.497 0.134 AST（U/L） 30.00（22.00～43.25） 37.00（23.00～60.00） Z=-1.903 0.057 ALP（U/L） 89.00（62.75～123.25） 86.00（67.00～114.66） Z=-0.296 0.767 GGT（U/L） 37.85（22.23～71.50） 32.22（21.01～73.76） Z=-0.408 0.683 Na+（mmol/L） 138.20（136.83～140.68） 138.90（137.00～140.10） Z=-0.656 0.512 PT（s） 17.00（15.50～18.50） 16.55（15.20～18.10） Z=-0.658 0.511 Cr（μmol/L） 61.56（51.86～77.37） 58.40（48.20～68.15） Z=-1.490 0.136 PC/ST比值 1.15（0.66～1.61） 1.63（1.00～2.36） Z=-4.841 <0.001 ALBI评分（分） -1.58（-1.86～-1.27） -1.89（-2.16～-1.66） Z=-5.913 <0.001 注：WBC，白细胞；PLT，血小板；HGB，血红蛋白；Alb，白蛋白；TBil，总胆红素；ALT，丙氨酸氨基转移酶；AST，天冬氨酸氨基转移酶；ALP，碱性磷酸酶；GGT，γ-谷氨酰转移酶；Na+，钠离子；PT，凝血酶原时间；Cr，肌酐；PC/ST，血小板计数/脾脏厚度；ALBI，白蛋白-胆红素。
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表 4 单因素Cox回归分析
Table 4. Univariate Cox regression analysis
变量 HR（95%CI） P值 脾脏厚度 1.082（1.059～1.106） <0.001 门静脉内径 1.100（0.993～1.219） 0.067 是否序贯（否=0，是=1） 0.638（0.365～1.115） 0.115 血小板 0.987（0.980～0.995） 0.001 总胆红素 1.029（1.019～1.039） <0.001 白蛋白 0.882（0.846～0.920） <0.001 PC/ST比值 0.409（0.279～0.598） <0.001 ALBI评分 5.439（3.441～8.597） <0.001 注：HR，风险比；CI：置信区间；PC/ST，血小板计数/脾脏厚度；ALBI，白蛋白-胆红素。
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