失代偿期肝硬化合并急性肾损伤患者入院后30天内死亡的危险因素及列线图预测模型构建

Risk factors for death within 30 days after admission in patients with decompensated liver cirrhosis and acute kidney injury and construction of a nomogram model

目的分析失代偿期肝硬化合并急性肾损伤(AKI)的患者入院后30天内死亡预测因素,同时建立并验证列线图预测模型。方法通过南昌大学第一附属医院联众病案管理系统,筛查2015年1月—2020年12月在消化内科和感染科住院的失代偿期肝硬化患者,纳入符合2015年国际腹水俱乐部AKI诊断标准的患者330例,其中训练组193例,验证组137例,通过Cox回归分析影响其死亡的预测因素,建立并验证入院后30天内的死亡风险列线图预测模型。符合正态分布的计量资料2组间比较采用成组t检验,多组间比较采用单因素方差分析,进一步两两比较采用LSD-t检验;不符合正态分布的计量资料2组间比较采用Mann-Whitney U检验,多组间比较采用Kruskal-Wallis H检验。计数资料组间比较采用χ2检验或Fisher精确检验。结果失代偿期肝硬化患者中AKI患病率为16.5%。纳入研究的330例患者平均年龄(53.6±12.4)岁,男性占79.1%,入院后30天病死率为50.0%,训练组和验证组病死率分别为46.6%和54.7%。入院时存在慢加急性肝衰竭(ACLF)是AKI 1期进展的独立危险因素(OR=2.571,95%CI:1.143~5.780,P=0.022)。基于入院时白细胞计数、国际标准化比值、是否有肝性脑病及AKI分期所建立的列线图能较好预测入院后30天死亡风险,训练组和验证组C指数分别为0.680和0.683,且不劣于CTP评分和MELD评分。结论ACLF是AKI 1期进展的独立危险因素,建立的列线图预测模型可有效预测患者入院后30天内死亡风险,对于早期识别和管理失代偿期肝硬化合并AKI患者有重要指导意义。

Objective To investigate the predictive factors for death within 30 days after admission in patients with decompensated liver cirrhosis and acute kidney injury(AKI),and to establish and validate a nomogram prediction model.Methods The Joint Medical Record Management System of The First Affiliated Hospital of Nanchang University was used to obtain the patients with decompensated liver cirrhosis who were hospitalized in Department of Gastroenterology and Department of Infectious Diseases from January 2015 to December 2020,among whom 330 patients who met the 2015 International Club of Ascites diagnostic criteria for AKI were enrolled and divided into training group with 193 patients and validation group with 137 patients.A Cox regression analysis was used to investigate the predictive factors for death,and then a nomogram prediction model for the risk of death within 30 days after admission was established and validated.The independent-samples t-test was used for comparison of normally distributed continuous data between two groups,and a one-way analysis of variance was used for comparison between multiple groups,while the least significant difference t-test was used for further comparison between two groups;The Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups,while the Kruskal-Wallis H test was used for comparison between multiple groups.The chi-square test or the Fisher’s exact test was used for comparison of categorical data between groups.Results The prevalence rate of AKI was 16.5%in patients with decompensated liver cirrhosis.The 330 patients included in the study had a mean age of 53.6±12.4 years,and male patients accounted for 79.1%.The mortality rate was 50.0%within 30 days after admission,with a mortality rate of 46.6%in the training group and 54.7%in the validation group.The presence of acute-on-chronic liver failure(ACLF)on admission was an independent risk factor for the progression of AKI into stage 1(odds ratio=2.571,95%confidence interval:1.143-5.780,P=0.022).The nomogram based on white blood cell count,international normalized ratio,presence or absence of hepatic encephalopathy,and AKI stage on admission could well predict the risk of death with 30 days after admission,with a C-index of 0.680 in the training group and 0.683 in the validation group,and it was not inferior to CTP score and MELD score.Conclusion ACLF is an independent risk factor for the progression of AKI into stage 1.The nomogram prediction model established in this study can effectively predict the risk of death within 30 days after admission and thus has important guiding significance for the early identification and management of patients with decompensated liver cirrhosis and AKI.