多因素联合预测先天性膈疝胎儿的生存

Combined multivariate prediction on survival of infants with congenital diaphragmatic hernia

目的探讨影响先天性膈疝(congenital diaphragmatic hernia,CDH)胎儿生存的因素,并建立CDH的预测模型。方法对2010年1月1日至2018年12月31日在上海交通大学医学院附属新华医院收治的252例产前超声诊断为CDH的新生儿进行回顾性分析。采用χ^(2)检验或t检验对16个产前因素和5个生后因素进行单因素分析,采用回归分析确定生存的独立预测因素,以及受试者工作特征(receiver operating characteristic,ROC)曲线评估相关因素对CDH生存的预测价值。以约登指数最大时预测值为界值,建立基于上述因素的预测模型,绘制预测CDH生存结局的ROC曲线,并计算曲线下面积(area under curve,AUC)、灵敏度和特异度。结果252例CDH患儿中,68.7%(173/252)出院时存活。单因素分析显示,肺头比(lung-to-head ratio,LHR)、右侧膈疝、肝疝、胸腔内胃、羊水过多、早产、低出生体重、5 min Apgar评分<7分及羊水指数(amniotic fluid index,AFI)等与CDH的生存显著相关;进一步行回归分析显示,羊水过多(OR=11.19,95%CI:2.83~45.33)、肝疝(OR=2.81,95%CI:1.32~11.92)、胸腔内胃(OR=5.02,95%CI:1.29~17.13)、低出生体重(OR=8.58,95%CI:1.59~45.01)和AFI(OR=3.68,95%CI:1.37~14.72)是CDH患儿出院时生存的独立危险因素,而LHR(OR=0.36,95%CI:0.01~0.69)则为保护因素。基于约登指数最大时的LHR、AFI、羊水过多、肝疝、胸腔内胃及低出生体重等6个指标单项预测界值(分别为1.6、232.5 mm、1.0、1.0、1.0、1.0)建立模型,预测CDH生存的AUC值为0.904,灵敏度为0.747,特异度为0.896。结论LHR、肝疝、胸内胃、羊水过多、低出生体重和AFI是CDH生存的独立危险因素。产前和生后指标联合预测CDH生存率的准确性较好。

Objective To investigate the influencing factors of the survival in infants with congenital diaphragmatic hernia(CDH)and to develop a prediction model for CDH.Methods Clinical data of 252 infants with a prenatal diagnosis of CDH in Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine from January 2010 to December 2018 were retrospectively analyzed.Adverse outcomes were defined as neonatal death on discharge.Chi-square and t test were used for univariate analysis of 16 perinatal and five postnatal risk factors.Regression analysis was used to determine the independent predictors of survival.The receiver operating characteristics(ROC)curves of the risk factors for predicting the survival of CDH were drawn.A prediction model based on the combination of risk factors for predicting adverse outcomes of CDH was established using the cut-off value.ROC curves of the model were drawn and the area under curve(AUC),sensitivity,and specificity were calculated.Results Out of the 252 patients,173(68.7%)survived on discharge.Univariate analysis showed that lung-to-head ratio(LHR),polyhydramnios,right diaphragmatic hernia,liver herniation,intrathoracic stomach,premature birth,low birth weight,5 min Apgar score<7,and amniotic fluid index(AFI)were significantly associated with the survival of CDH.Regression analysis showed that polyhydramnios(OR=11.19,95%CI:2.83-45.33),liver herniation(OR=2.81,95%CI:1.32-11.92),intrathoracic stomach(OR=5.02,95%CI:1.29-17.13),low birth weight(OR=8.58,95%CI:1.59-45.01)and AFI(OR=3.68,95%CI:1.37-14.72)were independent risk factors for survival at discharge in children with CDH,while LHR(OR=0.36,95%CI:0.01-0.69)were protective factors.The predictive cut-off values of LHR,polyhydramnios,liver herniation,intrathoracic stomach,low birth weight,and AFI were 1.6,1.0,1.0,1.0,1.0,and 232.5 mm,respectively.The model based on the combination of the above indicators for predicting CDH adverse outcomes was shown with an AUC value of 0.904,predictive sensitivity of 0.747,and specificity of 0.896.Conclusions In this study,LHR,liver herniation,intrathoracic stomach,polyhydramnios,low birth weight,and AFI are independent risk factors for CDH survival.The combination of prenatal and postnatal indicators is noted for a higher accuracy for predicting CDH survival.