以肠道症状首发的系统性红斑狼疮的预测因素分析

Analysis of predictors of systemic lupus erythematosus with intestinal symptoms as the first manifestation

目的分析以肠道症状为首发表现的系统性红斑狼疮(SLE)的预测因素,为该疾病的诊断与鉴别诊断提供依据。方法回顾性分析2013年1月至2020年6月郑州大学第一附属医院诊治的165例SLE患者的临床资料,根据肠道症状是否为首发表现分为肠道症状首发组(50例)和肠道症状非首发组(115例)。比较分析两组患者的基线资料、影像学表现、各脏器受累情况和实验室检查指标等。统计学方法采用独立样本t检验、非参数检验和卡方检验。采用logistic回归分析建立以肠道症状首发的SLE的预测模型,使用受试者操作特征曲线(ROC)、Hosmer-Lemeshow拟合优度检验评价模型的预测价值。收集2020年7月至2021年5月于郑州大学第一附属医院诊治的72例SLE患者资料,肠道症状首发组22例,肠道症状非首发组50例,验证模型的预测能力。结果与肠道症状非首发组相比,肠道症状首发组发热、肌肉受累、关节受累的患者占比均较低,多浆膜腔积液、腹水、肠管水肿扩张或增厚、肾盂输尿管积水或扩张、肾脏受累、血液系统受累的患者占比均较高,患者的补体C3水平、补体C4水平、淋巴细胞绝对值、白蛋白水平均较低[67.8%(78/115)比32.0%(16/50)、24.3%(28/115)比4.0%(2/50)、68.7%(79/115)比14.0%(7/50)、27.8%(32/115)比86.0%(43/50)、16.5%(19/115)比78.0%(39/50)、13.9%(16/115)比86.0%(43/50)、4.3%(5/115)比62.0%(31/50)、29.6%(34/115)比48.0%(24/50)、30.4%(35/115)比52.0%(26/50)、0.76 g/L(0.43 g/L,0.97 g/L)比0.48 g/L(0.40 g/L,0.57 g/L)、0.14 g/L(0.08 g/L,0.23 g/L)比0.09 g/L(0.06 g/L,0.15 g/L)、0.90×109/L(0.51×109/L,1.28×109/L)比0.64×109/L(0.44×109/L,1.08×109/L)、(34.07±7.30)g/L比(28.77±5.43)g/L],差异均有统计学意义(χ^(2)=18.246、9.699、41.776、47.567、57.781、78.833、67.903、5.195、6.955,Z=-4.053、-3.295、-2.204,t=-4.606;P均<0.05)。多因素logistic回归分析显示,低补体C3、低白蛋白是以肠道症状首发的SLE的危险因素[比值比(95%可信区间)分别为0.136(0.031~0.590)、0.923(0.871~0.977),P=0.008、0.006]。建立的以肠道症状首发的SLE的预测模型为p=1/(1+e-Y),其中Y=2.906-1.994×补体C3(g/L)-0.08×白蛋白(g/L),ROC的曲线下面积为0.761(95%可信区间0.687~0.834,P<0.01),Hosmer-Lemeshow拟合优度检验结果说明模型具有较好的校准能力(χ^(2)=13.024,P=0.111)。验证结果显示,p≥0.255时预测为以肠道症状首发的SLE,模型预测的灵敏度为72.7%(16/22),特异度为76.0%(38/50),准确度为75.0%(54/72)。结论以肠道症状首发的SLE症状隐匿,易被误诊。临床上对以肠道症状为首发表现就诊的患者,若影像学检查示肠管水肿扩张或增厚、肾盂输尿管积水或扩张,或实验室检查示低补体C3、低白蛋白时,要警惕SLE可能,早期诊断和干预可很大程度改善患者预后。

Objective To analyze the predictors of systemic lupus erythematosus(SLE)with intestinal symptoms as the first manifestation,and to provide evidence for the diagnosis and differential diagnosis of the disease.Methods From January 2013 to June 2020,the clinical data of 165 patients diagnosed with SLE and treated at the First Affiliated Hospital of Zhengzhou University were retrospectively analyzed.According to whether the intestinal symptoms were the first manifestations,they were divided into intestinal symptoms as the first manifestations group(n=50)and intestinal symptoms not as the first manifestations group(n=115).The baseline data,imaging findings,orgen involvement and laboratory indicators of the two groups were compared and analyzed.Independent sample t test,non-parametric test and chi-square test were used for statistical analysis.Logistic regression analysis was used to establish a prediction model of SLE with intestinal symptoms as the first manifestation.Receiver operating characteristic curve(ROC)and Hosmer-Lemeshow test were used to evaluate the predictive value of the model.From July 2020 to May 2021,the data of 72 SLE patients treated at the First Affiliated Hospital of Zhengzhou University were collected(22 patients with intestinal symptoms as the first manifestation and 50 patients with intestinal symptoms not the first manifestation),and the predictive power of the model was validated.Results Compared with intestinal symptoms not as the first manifestation group,the proportions of patients with fever,muscle involvement and joint involvement in intestinal symptoms as the first manifestation group were lower,while the proportions of patients with polyserositis,ascites,edema and dilatation or thickening of intestines,hydronephrosis or dilatation of the ureter,kidney involvement,blood system involvement were higher,and the level of complement C3,level of complement C4,absolute lymphocyte value and albumin level were lower(67.8%,78/115 vs.32.0%,16/50;24.3%,28/115 vs.4.0%,2/50;68.7%,79/115 vs.14.0%,7/50;27.8%,32/115 vs.86.0%,43/50;16.5%,19/115 vs.78.0%,39/50;13.9%,16/115 vs.86.0%,43/50;4.3%,5/115 vs.62.0%,31/50;29.6%,34/115 vs.48.0%,24/50;30.4%,35/115 vs.52.0%,26/50;0.76 g/L,0.43 to 0.97 g/L vs.0.48 g/L,0.40 to 0.57 g/L;0.14 g/L,0.08 to 0.23 g/L vs.0.09 g/L,0.06 to 0.15 g/L;0.90×109/L,0.51×109 to 1.28×109/L vs.0.64×109/L,0.44×109 to 1.08×109/L;(34.07±7.30)g/L vs.(28.77±5.43)g/L),and the differences were statistically significant(χ^(2)=18.246,9.699,41.776,47.567,57.781,78.833,67.903,5.195 and 6.955,Z=-4.053,-3.295 and-2.204,t=-4.606;all P<0.05).The results of multivariate logistic regression analysis showed that low level of complement C3 and low albumin level were risk factors of SLE with intestinal symptoms as the first manifestation(odds ratio 0.136,95%confidence interval 0.031 to 0.590;odds ratio 0.923,95%confidence interval 0.871 to 0.977;P=0.008 and 0.006).The established prediction model for SLE with intestinal symptoms as the first manifestation was p=1/(1+e-Y),in which Y=2.906-1.994×complement C3(g/L)-0.08×albumin(g/L).The area under the ROC was 0.761(95%confidence interval 0.687 to 0.834,P<0.01).The result of Hosmer-Lemeshow test showed the model had good calibration ability(χ^(2)=13.024,P=0.111).The result of validation analysis showed that when p≥0.255 to predict SLE with intestinal symptoms as the first symptoms,the sensitivity of the model was 72.7%(16/22),the specificity was 76.0%(38/50),and the accuracy was 75.0%(54/72).Conclusions The symptoms of SLE with intestinal symptoms as the first manifestations are obscure and easily misdiagnosed.When the imaging examination of patients with intestinal symptoms as the first manifestations shows edema and dilatation or thickening of intestines,hydronephrosis or dilatation of the ureter,or laboratory examination indicates low level of complement C3 and low albumin level,be wary of the possibility of SLE.Early diagnosis and intervention can greatly improve the prognosis of patients.