成人肝移植围手术期严重心血管事件危险因素分析及预测模型研究

The establishment of predictive model and influencing factors of major adverse cardiovascular events during perioperative period of adult liver transplantation

目的探讨成人肝移植围手术期发生严重心血管事件(MACE)的影响因素,并创建列线图风险预测模型。方法回顾性分析2016年1月至2020年12月在青岛大学附属医院器官移植中心接受肝移植的545例成人肝移植受者临床资料,根据围手术期是否发生MACE分为MACE组(57例)和未发生MACE组(488例),比较两组受者围手术期相关资料。采用Kaplan-Meier法绘制生存曲线,应用log-rank检验比较。根据logistics回归分析显示的独立危险因素,构建列线图,采用受试者工作特征(ROC)曲线判断列线图的预测价值。结果与未发生MACE组受者相比,MACE组受者年龄较大,术前终末期肝病模型(MELD)评分较高,既往有高血压、心脏病和肝性脑病史的受者比例更高,术中出血量及输注红细胞量更多,且术中无肝期时间、术后ICU住院时间及机械通气时间更长,差异均有统计学意义(t=-2.544和-2.924,χ^(2)=9.815、6.506和7.808,Z=-2.140,-2.464,-2.506,-4.847和-4.243,P均<0.05)。在门静脉和下腔静脉全部阻断后5 min内、全部开放后5 min内以及手术结束出手术室前,MACE组受者乳酸水平均较未发生MACE组升高,差异均有统计学意义(t=-2.291、-3.322和-2.392,P均<0.05)。logistic回归分析结果显示,年龄(OR=1.041,95%CI:1.008~1.350,P<0.05)、术前MELD评分(OR=1.057,95%CI:1.022~1.453,P<0.05)和高血压病史(OR=2.149,95%CI:1.061~4.804,P<0.05)以及门静脉和下腔静脉全部开放后5 min内乳酸水平(OR=1.334,95%CI 1.088~1.636,P<0.05)是肝移植围手术期发生MACE的独立危险因素。根据多因素回归分析结果构建的列线图预测成人肝移植受者围手术期发生MACE的ROC曲线下面积为0.736,一致性指数为0.8,内部验证显示预测发生率与实际发生率拟合度较好。MACE组受者术后1年总体生存率低于未发生MACE组(84.2%和96.1%,P<0.05)。结论年龄、术前MELD评分、高血压病史、门静脉和下腔静脉全部开放后5 min内乳酸水平是成人肝移植围手术期发生MACE的独立危险因素,据此构建的列线图风险模型在预测成人肝移植围手术期MACE发生方面具有较好的临床价值。

Objective To investigate the influencing factors and prognosis analysis of major adverse cardiovascular events(MACE)during perioperative period of adult liver transplantation,and to create a nomogram predict risk model.Methods The clinical data of 545 adult recipients who underwent liver transplantation in the Affiliated Hospital of Qingdao University from January 2016 to December 2020 were retrospectively analyzed.According to the occurrence of MACE during the perioperative period,the patients were divided into MACE group(57 cases)and non-MACE group(488 cases).The perioperative data of the two groups were compared.Survival curves were plotted using the Kaplan-Meier method and compared using the log-rank test.According to the independent risk factors shown by logistics regression analysis,nomograms were constructed,and receiver operating characteristic(ROC)curves were used to determine the predictive value of nomograms.Results Compared with the non-MACE group,recipients in MACE group were older,had higher preoperative model for end-stage liver disease(MELD)scores,had a higher proportion of recipients with previous history of hypertension,heart disease and hepatic encephalopathy,more intraoperative blood loss and red blood cell transfusion,and had longer intraoperative anhepatic phase time,postoperative ICU length of stay and mechanical ventilation time,and the differences were statistically significant(t=-2.544 and-2.924,χ^(2)=9.815,6.506 and 7.808,Z=-2.140,-2.464,-2.506,-4.847 and-4.243,P<0.05).Within 5 min after total occlusion of the portal vein and inferior vena cava,within 5 min after total opening,and before exit from the operating room at the end of surgery,lactate levels of the MACE group were increased compared with the non-MACE group,and the differences were statistically significant(t=-2.291,-3.322 and-2.392,all P<0.05).Logistic regression analysis showed that age(OR=1.041,95%CI 1.008-1.350,P<0.05),preoperative MELD score(OR=1.057,95%CI 1.022-1.453,P<0.05)and history of hypertension(OR=2.149,95%CI 1.061-4.804,P<0.05)as well as lactate level within 5 min after total opening of the portal vein and inferior vena cava(OR=1.334,95%CI 1.088-1.636,P<0.05)were independent risk factors for MACE during perioperative period of adult liver transplantation.The nomogram constructed according to the results of multivariate regression analysis predicted the perioperative occurrence of MACE in adult liver transplant recipients with an area under curve of 0.736 and a concordance index of 0.8,and internal validation showed a good fit between the predicted incidence and the actual incidence.The overall survival rate at 1 year after surgery was lower in the MACE group than in the non-MACE group(84.2%and 96.1%,P<0.05).Conclusions Age,preoperative MELD score,history of hypertension and lactate level within 5 min after total opening of the portal vein and inferior vena cava were independent risk factors for perioperative MACE in adult liver transplantation.The risk prediction model has a good clinical value in predicting the occurrence of perioperative MACE in adult liver transplantation.