DPMAS与PE治疗肝衰竭的疗效及相关预后预测因子的筛选和预后列线图预测模型的构建

Effect of dual plasma molecular adsorption system and plasma exchange in the treatment of liver failure,screening of prognostic factors,and construction of prognostic nomogram prediction model

目的观察双重血浆分子吸附系统(DPMAS)与血浆置换(PE)治疗肝衰竭的效果,并筛选其相关预后预测因子,构建预后列线图预测模型。方法前瞻性选取2021年1月至2023年10月新乡市中心医院(新乡医学院第四临床学院)收治的159例行人工肝治疗的肝衰竭患者作为研究对象,其中66例接受PE治疗,43例接受DPMAS治疗,50例接受DPMAS联合PE治疗。统计预后情况,根据预后情况分为预后良好组110例和预后不良组49例,比较两组患者的临床资料,采用Lasso-Logistic回归筛选肝衰竭患者预后情况的独立预测因子,采用受试者工作特征曲线(ROC)评估独立预测因子预测预后的价值,并构建列线预测模型,采用校正曲线、ROC和决策曲线(DCA)曲线评估该模型的预测效能。结果经单因素分析结果显示,终末期肝病评估模式(MELD)评分、谷丙转氨酶(ALT)、治疗方案、白细胞计数(WBC)、感染、国际标准化比值(INR)、上消化道出血、总胆红素(TBIL)、肝性脑病、谷草转氨酶(AST)、肝肾综合征、C反应蛋白(CRP)、白细胞介素-6(IL-6)与DPMAS和PE治疗肝衰竭的预后有关(P<0.05);经Lasso回归分析筛选DPMAS和PE治疗肝衰竭预后的特征变量分别为MELD评分、治疗方案、感染、肝性脑病、ALT、AST、TBIL、INR、CRP、IL-6;经Logistic回归分析结果显示,MELD评分、感染、肝性脑病、ALT、AST、TBIL、INR、CRP、IL-6均是影响DPMAS和PE治疗肝衰竭预后的独立危险因素(P<0.05),DPMAS联合PE治疗是预后的独立保护因素(P<0.05);Lasso-Logistic回归筛选的10个独立预测因子具有良好预测价值,基于10个独立预测因子构建列线图模型,校正曲线结果显示C-index为0.912,校准度为0.895,ROC显示该预测模型的曲线下面积(AUC)为0.853(95%CI:0.778~0.927),DCA曲线显示该模型具有较高的临床正向净获益。结论肝衰竭患者接受DPMAS和与PE治疗后有明显好转,但有部分患者可出现预后不良,其中MELD评分、感染、肝性脑病、ALT、AST、TBIL、INR、CRP、IL-6及DPMAS联合PE治疗是影响肝衰竭患者预后的因素,基于以上因素构建的肝衰竭患者预后列线图预测模型具有良好的预测效能和临床适用性。

Objective To observe the effect of dual plasma molecular adsorption system(DPMAS)and plasma exchange(PE)in the treatment of liver failure,to screen the related prognostic predictors,and to construct a prognostic nomogram prediction model.Methods A prospective study was conducted to select 159 patients with liver failure who received artificial liver treatment at Xinxiang Central Hospital(the Fourth Clinical College of Xinxiang Medical College)from January 2021 to October 2023.Among them,66 patients received PE treatment,43 patients received DPMAS treatment,and 50 patients received DPMAS combined with PE treatment.The prognosis was statistically analyzed,and the patients were divided into a good prognosis group of 110 patients and a poor prognosis group of 49 patients based on the prognosis.The clinical data of the two groups of patients were compared,and the independent predictors of the prognosis of patients with liver failure were screened using Lasso-logistic regression.The value of the independent predictors in predicting the prognosis was evaluated using the Receiver Operating Characteristic(ROC)curve.A nomogram prediction model was constructed,and the predictive performance of the model was evaluated using calibration curves,ROC curves,and Decision Curves Analysis(DCA).Results The results of univariate analysis showed that the Model for End-Stage Liver Disease(MELD)score,alanine aminotransferase(ALT),treatment regimen,white blood cell count(WBC),infection,international normalized ratio(INR),upper gastrointestinal bleeding,total bilirubin(TBIL),hepatic encephalopathy,aspartate aminotransferase(AST),hepatorenal syndrome,C-reactive protein(CRP),interleukin-6(IL-6)were associated with the prognosis of liver failure treated by DPMAS and PE treatment(P<0.05).Lasso-regression analysis showed that the characteristic variables for the prognosis of DPMAS and PE treatment of liver failure were MELD score,treatment regimen,infection,hepatic encephalopathy,ALT,AST,TBIL,INR,CRP,IL-6.Lasso-logistic regression analysis showed that MELD score,infection,hepatic encephalopathy,ALT,AST,TBIL,INR,CRP,and IL-6 were all independent risk factors affecting the prognosis of DPMAS and PE treatment for liver failure(P<0.05),and DPMAS combined with PE treatment was an independent protective factor for prognosis(P<0.05).The 10 independent predictors screened by Lasso-logistic regression had good predictive value.Based on the 10 independent predictors,a nomogram model was constructed.The calibration curve showed that the C-index was 0.912 and the calibration degree was 0.895.The ROC showed that the area under the curve(AUC)of the prediction model was 0.853(95%CI:0.778-0.927).The DCA curve showed that the model had a high clinical positive net benefit.Conclusion Patients with liver failure showed significant improvement after receiving DPMAS and PE treatment,but some patients may have poor prognosis.Among them,MELD score,infection,hepatic encephalopathy,ALT,AST,TBIL,INR,CRP,IL-6,and DPMAS combined with PE treatment are factors that affect the prognosis of liver failure patients.The prognostic column chart prediction model for liver failure patients based on the above factors has good predictive power and clinical applicability.