老年血液透析患者体外循环管路凝血发生的列线图预测模型构建与评估

Establishment and evaluation of a nomogram prediction model for coagulation in the extracorporeal circuit in elderly hemodialysis patients

目的建立影响老年血液透析(HD)患者体外循环管路凝血的预测模型。方法回顾性病例对照研究,纳入2019年3月1日至2022年1月30日在我院血液净化中心首次进行4 h血液透析的老年慢性肾衰竭患者196例,入组患者均采用肝素类药物进行抗凝(包括普通肝素和低分子量肝素),凝血分级≥1为凝血组14例(7.1%),非凝血组182例(92.9%)。收集人口学资料,透析前静息状态下坐位生命体征及实验室检查。得出预测模型后,在2022年2月1日至2023年2月1日在我院首次完成4 h血液透析的年龄≥60岁老年慢性肾衰竭患者中进行验证。结果凝血组和非凝血组患者心率[(82.6±12.3)次/min比(74.4±11.1)次/min]和总胆固醇[(4.3±1.2)mmol/L比(3.2±1.2)mmol/L]比较,差异有统计学意义(t值分别为2.231、2.012,均P<0.05)。多因素Logistic分析结果显示心率(OR=0.930,95%CI:0.871~0.993,P<0.05)和胆固醇(OR=0.623,95%CI:0.391~0.992,P<0.05)对体外循环管路凝血有影响。心率预测体外循环管路凝血的受试者工作特征曲线下面积(AUC)为0.639(最佳截断点值为71次/min),总胆固醇预测凝血的AUC为0.708(最佳截断点值:4.275 mmol/L),将心率和总胆固醇联合预测时效能更高(AUC值为0.735)。对模型在98例患者中进行验证,效果较好(AUC值为0.895)。结论根据列线图可初步判断初始血液透析的老年患者体外循环管路的凝血风险。

Objective To establish a predictive model for coagulation in the extracorporeal circuit in elderly hemodialysis(HD)patients.Methods The retrospective case-control study included 196 elderly patients with chronic renal failure receiving 4-h hemodialysis for the first time at the blood purification center of our hospital between March 1,2019 and January 30,2022.All enrolled patients were treated with heparin or related drugs for anticoagulation(including unfractionated heparin and low molecular weight heparin),with 14 cases(7.1%)in the coagulation group with a coagulation grade≥1.There were 182 cases(92.9%)in the non-coagulation group.Demographic data,vital signs in a sitting position and the resting state before dialysis and laboratory tests before dialysis were collected.After the prediction model was developed,it was validated in elderly patients with chronic renal failure aged≥60 years receiving 4-hour hemodialysis for the first time at our hospital between February 1,2022 and February 1,2023.Results There were significant differences in heart rate[(82.6±12.3)times/min vs.(74.4±11.1)times/min]and total cholesterol[(4.3±1.2)mmol/L vs.(3.2±1.2)mmol/L]between the coagulation group and the non-coagulation group(t=2.231,2.012,P<0.05).Multivariate logistic analysis showed that the heart rate(OR=0.930,95%CI:0.871-0.993,P<0.05)and cholesterol(OR=0.623,95%CI:0.391-0.992,P<0.05)had an effect on blood coagulation in cardiopulmonary bypass.The area under the curve(AUC)for predicting cardiopulmonary bypass clotting by heart rate was 0.639(the optimal cutoff value was 71 beats/min),the AUC for predicting clotting by total cholesterol was 0.708(the optimal cutoff value:4.275 mmol/L),and the prediction using the combination of heart rate and total cholesterol was more effective(AUC=0.735).The model was verified in 98 patients with good results(AUC=0.895).Conclusions The initial coagulation risk of the extracorporeal circuit in elderly patients undergoing initial HD can be preliminarily estimated based on the nomogram.