基于全身免疫炎症指数和预后营养指数的列线图模型在肝移植术后急性肾损伤的预测价值探讨

Exploring the predictive value of a nomogram model based on the SII and PNI score for acute kidney injury after orthotopic liver transplantation

目的探讨原位肝移植(orthotopic liver transplantation,OLT)术后发生急性肾损伤(acute kidney injury,AKI)的独立危险因素,并构建列线图预测模型以个性化预测AKI事件的发生。方法回顾性分析2017年3月至2021年3月于中国人民解放军东部战区总医院行OLT手术的终末期肝病病人作为研究对象。入组病人根据OLT术后7 d内是否发生AKI事件分为两组。采用单因素、多因素logistic回归模型分析AKI的独立危险因素。多因素筛选出的独立危险因素进一步通过R软件绘制列线图预测模型并评估。结果本研究共纳入237例OLT手术病人,其中101例病人术后7 d内发生了AKI,发生率为42.6%。AKI组病人的术前伴随的肝昏迷比例[22.8%(23/101)比9.6%(13/136)]、APACHEⅡ评分、手术时间[(7.7±1.8)h比(7.0±1.6)h]、术中出血量[(3002±1606)mL]比(2525±1383)mL]、红细胞输注量、术前总胆红素、国际标准化比值(international normalized ratio,INR)(1.74±0.26比1.63±0.23)、肌酐及全身免疫炎症指数(systemic immune-inflammation index,SII)(725±458比553±355)水平均显著高于非AKI组(P<0.05),而预后营养指数(prognostic nutritional index,PNI)(41.4±5.3比45.0±6.1)则显著低于非AKI组病人(P<0.05)。多因素logistic回归分析提示PNI[OR 95%CI:2.63(1.67,3.87),P=0.005]、SII[OR 95%CI:2.65(1.18,4.41),P=0.011]、INR[OR 95%CI:1.73(1.02,3.01),P=0.017]、出血量[OR 95%CI:2.26(1.16,4.33),P=0.014]、肝昏迷[OR 95%CI:2.51(1.19,5.21),P=0.015]是术后7 d发生AKI事件的独立危险因素。根据这5个危险因素构建的列线图风险模型对于肝移植病人术后AKI发生预测价值较好,受试者操作特征(ROC)曲线下面积为0.73[95%CI:(0.65,0.81)]。结论基于SII、PNI等因素构建的风险模型可有效预测OLT病人术后AKI事件的发生。

Objective To investigate the independent risk factors for acute kidney injury(AKI)after orthotopic liver transplantation(OLT)and to construct a nomogram prediction model to predict AKI events.Methods Patients with end-stage liver disease who underwent OLT surgery from March 2017 to March 2021 in the Department of Anesthesiology,General Hospital of Eastern Theater Command of PLA were retrospectively analyzed as study subjects.The enrolled patients were divided into two groups according to whether AKI occurred within 7 days after OLT.Univariate and multivariate logistic regression models were used to analyze the independent risk factors for AKI.The screened independent risk factors screened by multiple factors were further predicted by the nomogram prediction model and evaluated by R software.Results A total of 237 OLT patients were enrolled in this study,of whom 101 patients developed AKI within 7 days after surgery,with an incidence of 42.6%.The proportion of preoperative hepatic encephalopathy[22.8%(23/101)vs.9.6%(13/136)],APACHEⅡscore,surgery duration[(7.7±1.8)vs.(7.0±1.6)h],intraoperative hemorrhage[(3002±1606)vs.(2525±1383)mL],erythrocyte transfusion,preoperative total bilirubin,international normalized ratio(INR)(1.74±0.26 vs.1.63±0.23),creatinine,and systemic immune-inflammation index(SII)(725±458 vs.553±355)levels were significantly higher in the AKI group than that in the non-AKI group(P<0.05),while the prognostic nutritional index(PNI)(41.4±5.3 vs.45.0±6.1)was significantly lower than that in the non-AKI group(P<0.05).The multivariate logistic regression analysis suggested that PNI[OR 95%CI:2.63(1.67,3.87),P=0.005],SII[OR 95%CI:2.65(1.18,4.41),P=0.011],INR[OR 95%CI:1.73(1.02,3.01),P=0.017],bleeding[OR 95%CI:2.26(1.16,4.33),P=0.014],and hepatic coma[OR 95%CI:2.51(1.19,5.21),P=0.015]were the independent risk factors for the occurrence of an AKI event at 7 d postoperatively.The nomogram risk model constructed based on these 5 risk factors had a good predictive value for the occurrence of postoperative AKI in OLT patients,with an area under the receiver operating characteristic(ROC)curve of 0.73[95%CI:(0.65,0.81)].Conclusion The nomogram risk model constructed based on the SII,PNI and other factors can effectively predict the occurrence of postoperative AKI events in OLT patients.