百草枯中毒患者急性肾损伤风险预测

Risk prediction of acute kidney injury in paraquat poisoning patients

目的构建百草枯(paraquat,PQ)中毒引起急性肾损伤(acute kidney injury,AKI)的风险预测模型。方法回顾性分析2010-09-20至2022-01-16期间因急性PQ中毒就诊于四川大学华西医院急诊科的患者,收集患者基本特征及实验室检查结果,根据住院期间是否发生AKI分为AKI组和非AKI组。按照7∶3的比例,将患者随机分为训练集和验证集。采用多因素Logistic回归筛选变量,列线图建立预测模型。采用受试者工作特征曲线(ROC)、校准曲线评价预测模型的区分度和校准度,决策曲线分析(DCA)评估预测模型的临床有效性。结果纳入符合标准的PQ患者718例,323例(45.0%)患者院内发生AKI,378例(52.6%)院内死亡,AKI组患者病死率高于非AKI组(72.8%vs.36.2,P<0.05)。多因素Logistic回归分析显示中毒至就诊时间(OR=1.018,95%CI:1.006~1.030)、入院时白细胞计数(OR=1.128,95%CI:1.084~1.173)、天门冬氨酸氨基转移酶(OR=1.017,95%CI:1.006~1.027)、胱抑素C(OR=516.753,95%CI:99.337~2688.172)、血浆PQ质量浓度(OR=1.064,95%CI:1.044~1.085)是PQ中毒患者发生AKI的独立危险因素(P<0.01)。预测模型训练集受试者工作曲线下面积(AUC)为0.943(95%CI:0.923~0.962),敏感度和特异度分别为82.4%和93.6%。校准曲线显示模型与理想曲线接近,决策曲线显示有临床应用前景。结论中毒至就诊时间、入院时白细胞计数、天门冬氨酸氨基转移酶、胱抑素C、血浆PQ质量浓度是PQ中毒患者发生AKI的独立危险因素。基于上述指标构建的预测模型评估PQ中毒后AKI具有较高的敏感度和特异度。本预测模型是否可推广应用至其他PQ中毒患者有待进一步扩大样本量验证。

Objective To establish a risk prediction model of acute kidney injury in paraquat(PQ)poisoning patients.Methods A retrospective observational cohort of adult patients with acute PQ poisoning between September 10,2010 and January 16,2020 from the Emergency Department of West China Hospital,Sichuan University were conducted.Data on demographics,clinical records,and laboratory results were collected from electronic medical record.The patients were divided into the AKI group and the non-AKI group according to whether AKI occurred during hospitalization.The patients were randomly divided into the training and validation groups(7:3).Multivariate logistic regression analysis was used to screen the independent risk factors of AKI and the nomogram was used to establish a prediction model.Receiver operating characteristic(ROC)curve and calibration curve were used to evaluate the differentiation and calibration of the prediction model.Decision curve analysis(DCA)was used to evaluate the clinical validity of the prediction model.Results A total of 718 patients were included in this study.AKI occurred in 323(45%)patients in hospital and 378(52.6%)patients died.The mortality rate of the AKI group was higher than that of the non-AKI group(72.8%vs.36.2%,P<0.05).Multivariate logistic regression analysis showed that the time from poisoning to treatment(OR=1.018,95%CI:1.006-1.030),white blood cell count(OR=1.128,95%CI:1.084-1.173),aspartate aminotransferase(OR=1.017,95%CI:1.006-1.027),cystatin C(OR=516.753,95%CI:99.337-2688.172),and PQ concentration(OR=1.064,95%CI:1.044-1.085)in blood on admission were independent risk factors of AKI in patients with PQ poisoning(P<0.01).The area under the ROC curve was 0.943(95%CI:0.923-0.962)in the training cohort,and the sensitivity and specificity were 82.4%and 93.6%,respectively.The calibration curve showed optimal agreement between prediction by nomogram and actual observation.Decision curve and clinical impact curve analysis indicated that the nomogram conferred high clinical net benefit.Conclusions The time from poisoning to treatment,white blood cell count,aspartate aminotransferase,cystatin C,and PQ concentration in blood on admission were independent risk factors of AKI.The predictive model based on the above indicators has high sensitivity and specificity in evaluating AKI after PQ poisoning.Whether this prediction model can be applied to other PQ poisoning patients needs to be further expanded for verification.