NRS-2002联合炎症反应标志物预测恶性梗阻性黄疸患者预后的Nomogram模型构建

Construction of the Nomogram model of NRS-2002 combined with inflammatory markers to predict the prognosis of patients with MOJ

目的基于营养风险评估表(NRS-2002)联合炎症反应标志物构建预测恶性梗阻性黄疸(MOJ)患者预后的Nomogram模型。方法选取129例MOJ患者,均接受胆道支架植入术联合经皮肝穿刺胆管引流术治疗。收集患者NRS-2002、中性粒细胞与淋巴细胞比值(NLR)、血小板与淋巴细胞比值(PLR)等资料。观察患者生存情况,采用受试者工作特征(ROC)曲线获取各连续性临床资料[年龄、体质量指数(BMI)、总胆红素(TBIL)、直接胆红素(DBIL)、总胆固醇(TC)、白蛋白(ALB)、血红蛋白(Hb)、NLR、PLR]诊断MOJ患者死亡的最佳截断值,采用单因素和多因素COX比例风险模型分析MOJ患者死亡的独立危险因素。根据独立危险因素构建Nomogram模型,并采用外部数据进行效能验证。结果129例MOJ患者均获得随访,生存时间32~351(184.71±26.74)d,20例MOJ患者存活、109例MOJ患者死亡,病死率84.5%。根据患者是否死亡,将年龄、BMI、TBIL、DBIL、TC、ALB、Hb、NLR、PLR进行ROC曲线分析,其曲线下面积(AUC)分别为0.652、0.637、0.549、0.531、0.596、0.727、0.586、0.744、0.735,最佳截断值分别为65岁、19.4 kg/m^(2)、172.7μmol/L、138.2μmol/L、4.13 mmol/L、38.6 g/L、85 g/L、2.52、0.52。129例MOJ患者中,营养正常14例,营养不良风险86例,营养不良29例。死亡患者的ALB(≤38.6 g/L)、NLR(>2.52)、PLR(>0.52)及营养不良比例均高于存活患者(P均<0.05);而营养正常比例低于存活患者(P<0.05)。多因素Cox风险比例模型分析结果显示:NLR(HR:1.718,95%CI:1.119~2.637)、PLR(HR:1.699,95%CI:1.042~2.711)、NRS-2002[营养不良风险(HR:3.204,95%CI:1.339~6.368),营养不良(HR:7.416,95%CI:1.231~9.525)]是MOJ患者死亡的独立危险因素(P均<0.05)。Nomogram模型的外部验证结果显示:90、180、270天生存率C-index分别为0.756(95%CI:0.695~0.862)、0.701(95%CI:0.647~0.781)、0.698(95%CI:0.611~0.778)。结论成功构建基于NRS-2002联合炎症反应标志物预测MOJ患者预后的Nomogram模型。

Objective Based on nutritional risk assessment-2002(NRS-2002)and inflammatory markers,the Nomogram model was established to predict the prognosis of patients with malignant obstructive jaundice(MOJ).Methods Totally 129 patients with MOJ were treated with biliary stent implantation combined with percutaneous transhepatic biliary drainage.NRS-2002,neutrophil-lymphocyte ratio(NLR),platelet-lymphocyte ratio(PLR)and other data of patients were collected.The situations of patients were observed,and the best cut-off value of continuous clinical data[age,body mass index(BMI),total bilirubin(TBIL),direct bilirubin(DBIL),total cholesterol(TC),albumin(ALB),hemoglobin(HB),NLR,and PLR]was obtained by receiver operating characteristic(ROC)curve to diagnose the death of patients with MOJ.Univariate and multivariate Cox proportional risk models were used to analyze the independent risk factors for death in MOJ patients.According to the independent risk factors,Nomogram model was constructed,and external data were used for the effectiveness verification.Results Totally 129 patients with MOJ were followed up,and the survival time was 32-351(184.71±26.74)d.Twenty patients with MOJ survived,109 patients with MOJ died,and the mortality was 84.5%.The age,BMI,TBIL,DBIL,TC,ALB,Hb,NLR and PLR were analysed by Roc.The area under the curve(AUC)of age,BMI,TBIL,DBIL,TC,ALB,Hb,NLR and PLR were 0.652,0.637,0.549,0.531,0.596,0.727,0.586,0.744 and 0.735 respectively.The best cut-off values were 65 years old,19.4kg/m^(2),172.7 umol/L,138.2 umol/L,4.13 mmol/L,38.6 g/L,85 g/L,2.52 and 0.52,respectively.Among 129 patients with MOJ,there were 14 patients with normal nutrition,86 patients with malnutrition risk and 29 patients with malnutrition.The proportion of ALB(≤38.6 g/L),NLR(>2.52),PLR(>0.52)and malnutrition in the dead patients were higher than those in the survival patients(all P<0.05),while the proportion of normal nutrition was lower than that in the survival patients(P<0.05).Multivariate Cox proportional hazard model analysis showed that NLR(HR:1.718,95%CI:1.119-2.637),PLR(HR:1.699,95%CI:1.042-2.711),NRS-2002[malnutrition risk(HR:3.204,95%CI:1.339-6.368),malnutrition(HR:7.416,95%CI:1.231-9.525)]were independent risk factors for death in MOJ patients(all P<0.05).The external validation results of nomogram model showed that the survival C-index of 90,180 and 270 d was 0.756(95%CI:0.695-0.862),0.701(95%CI:0.647-0.781)and 0.698(95%CI:0.611-0.778),respectively.Conclusion Based on NRS-2002 combined with inflammatory markers,Nomogram model is successfully constructed to predict the prognosis of patients with MOJ.