重症急性胰腺炎并发急性非结石性胆囊炎的影响因素分析及预测模型构建

doi:10.11958/20252583

摘要/Abstract

摘要：

目的探究重症急性胰腺炎（SAP）患者并发急性非结石性胆囊炎（AAC）的影响因素，并构建预测模型。方法回顾性选取220例SAP患者的临床资料，根据住院期间是否并发AAC将患者分为AAC组（64例）和非AAC组（156例）。比较2组一般临床资料[年龄、性别、吸烟、饮酒、体质量指数（BMI）、SAP病因、禁食水时间、基础疾病、合并脓毒症]、实验室指标[全身炎症反应指数（SIRI）、C反应蛋白与白蛋白比值（CAR）、白细胞计数与血小板平均体积比值（WMR）]，采用多因素Logistic回归法分析SAP患者住院期间发生AAC的影响因素，基于影响因素构建列线图预测模型，受试者工作特征（ROC）曲线、校准曲线、临床决策曲线分析（DCA）评估预测模型的预测效能。结果与非AAC组比较，AAC组禁食水时间长、合并脓毒症比例高，入院时总胆红素（TBil）、SIRI、CAR、WMR水平高（P<0.05）。多因素Logistic回归分析显示，禁食水时间长和SIRI、CAR、WMR、TBil水平高是SAP患者并发AAC的独立危险因素（P<0.05）。依据上述5个变量构建回归方程：Logit（P）=-11.364＋0.444×禁食水时间＋0.217×SIRI＋0.278×CAR＋1.869×WMR+0.053×TBil，依此构建列线图预测模型。ROC曲线示，列线图风险预测模型预测AAC的曲线下面积（AUC）及95%CI、敏感度、特异度分别为0.872（95%CI：0.824~0.921）、76.56%、87.18%。Bootstrap法验证结果示，校准曲线与实际曲线一致性良好；Homser-Lemeshow检验显示，拟合优度良好；DCA示，在阈值为0.04~0.99时，该列线图预测模型可使患者临床获益。结论基于以上危险因素构建的列线图预测模型具有良好的预测效能，可为临床早期识别AAC高风险患者提供参考。

关键词: 胰腺炎, 无结石性胆囊炎, 危险因素, 列线图, 重症急性胰腺炎, 预测模型

Abstract:

Objective To explore the factors influencing the occurrence of acute acalculous cholecystitis (AAC) in patients with severe acute pancreatitis (SAP), and construct a prediction model. Methods The clinical data of 220 patients with SAP were retrospectively collected. Patients were divided into the AAC group (64 cases) and the non-AAC group (156 cases) according to whether AAC occurred during hospitalization. The general clinical data including age, gender, smoking, drinking, body mass index (BMI), cause of SAP, fasting time, underlying diseases and concurrent sepsis were compared between the two groups. Laboratory indexes [systemic inflammatory response index (SIRI), C-reactive protein to albumin ratio (CAR), white blood cell count to mean platelet volume ratio (WMR)]were also compared between the two groups. Multivariate Logistic regression was used to analyze the factors influencing the occurrence of AAC in patients with SAP during hospitalization. Based on the influencing factors, a nomogram prediction model was constructed. The performance of the prediction model was evaluated using the receiver operating characteristic (ROC) curve, the calibration curve and clinical decision analysis (DCA). Results Compared with the non-AAC group, the AAC group showed a longer fasting time, a higher proportion of combined sepsis and higher levels of TBil, SIRI, CAR and WMR at admission (P<0.05). Multivariate Logistic regression analysis showed that long fasting time, high levels of SIRI, CAR, WMR and TBil were independent risk factors for AAC in patients with SAP (P<0.05). Based on the five variables, a regression equation was developed as follows: Logit (P)=-11.364+0.444×fasting time+0.217×SIRI+0.278×CAR+1.869×WMR+0.053×TBil, and a nomogram prediction model was constructed. ROC curves showed that the area under the curve (AUC) and 95%CI, sensitivity and specificity of the nomogram risk prediction model for predicting AAC were 0.872 (95%CI: 0.824-0.921), 76.56% and 87.18%, respectively. Bootstrap validation results showed good consistency between the calibration curve and the actual curve, and Homser-Lemeshow test showed good goodness of fit. DCA showed that the nomogram prediction model could bring clinical benefits to patients when the threshold was between 0.04 and 0.99. Conclusion The nomogram prediction model constructed based on these risk factors demonstrates good predictive performance and can provide reference for early identification of patients at high risk of AAC in clinical practice.

Key words: pancreatitis, acalculous cholecystitis, risk factors, nomograms, severe acute pancreatitis, prediction model

中图分类号:

R576.1

图/表 7

参考文献 25

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组别	n	年龄/岁		男性		吸烟		饮酒		BMI/（kg/m²）		禁食水时间/d
非AAC组	156	52.35±7.38		108（69.23）		53（33.97）		70（44.87）		23.18±1.94		7.63±2.08
AAC组	64	54.17±8.83		41（64.06）		24（37.50）		21（32.81）		22.69±2.07		10.25±2.87
χ²或t		1.459		0.555		0.248		2.721		1.644		6.621^＊＊
组别	SAP病因								基础疾病				脓毒症
组别	高脂血症性		酒精性		特发性		其他		高血压		糖尿病		脓毒症
非AAC组	56（35.90）		60（38.46）		23（14.74）		17（10.90）		58（37.18）		24（15.38）		23（14.74）
AAC组	26（40.63）		15（23.44）		10（15.63）		13（20.31）		30（46.88）		16（25.00）		18（28.13）
χ²	6.250								1.778		2.821		5.359^＊

组别	n	年龄/岁		男性		吸烟		饮酒		BMI/（kg/m²）		禁食水时间/d
非AAC组	156	52.35±7.38		108（69.23）		53（33.97）		70（44.87）		23.18±1.94		7.63±2.08
AAC组	64	54.17±8.83		41（64.06）		24（37.50）		21（32.81）		22.69±2.07		10.25±2.87
χ²或t		1.459		0.555		0.248		2.721		1.644		6.621^＊＊
组别	SAP病因								基础疾病				脓毒症
组别	高脂血症性		酒精性		特发性		其他		高血压		糖尿病		脓毒症
非AAC组	56（35.90）		60（38.46）		23（14.74）		17（10.90）		58（37.18）		24（15.38）		23（14.74）
AAC组	26（40.63）		15（23.44）		10（15.63）		13（20.31）		30（46.88）		16（25.00）		18（28.13）
χ²	6.250								1.778		2.821		5.359^＊

组别		PLT/（×10⁹/L）		PCT/（μg/L）		ALT/（U/L）		AST/（U/L）		TBil/（μmol/L）
非AAC组		197.40±39.00		0.66±0.19		50.81±9.97		46.49±10.87		26.39±8.87
AAC组		208.86±47.29		0.70±0.20		52.75±10.48		48.76±11.64		32.65±10.48
t		1.714		1.721		1.292		1.384		4.512^＊＊
组别	n		AMY/（U/L）		LIP/（U/L）		SIRI		CAR		WMR
非AAC组	156		535.75±101.39		413.86±87.29		5.06（3.98，6.62）		3.68（2.67，4.81）		1.19±0.23
AAC组	64		517.81±123.66		433.87±90.43		7.44（4.73，10.38）		4.33（3.69，5.41）		1.28±0.30
t或Z			1.027		1.529		4.028^＊＊		2.997^＊＊		2.269^＊

组别		PLT/（×10⁹/L）		PCT/（μg/L）		ALT/（U/L）		AST/（U/L）		TBil/（μmol/L）
非AAC组		197.40±39.00		0.66±0.19		50.81±9.97		46.49±10.87		26.39±8.87
AAC组		208.86±47.29		0.70±0.20		52.75±10.48		48.76±11.64		32.65±10.48
t		1.714		1.721		1.292		1.384		4.512^＊＊
组别	n		AMY/（U/L）		LIP/（U/L）		SIRI		CAR		WMR
非AAC组	156		535.75±101.39		413.86±87.29		5.06（3.98，6.62）		3.68（2.67，4.81）		1.19±0.23
AAC组	64		517.81±123.66		433.87±90.43		7.44（4.73，10.38）		4.33（3.69，5.41）		1.28±0.30
t或Z			1.027		1.529		4.028^＊＊		2.997^＊＊		2.269^＊

变量	β	SE	Wald χ²	P	OR	OR 95%CI
禁食水时间	0.444	0.089	25.005	<0.001	1.559	1.310~1.855
脓毒症	0.559	0.467	1.430	0.232	1.748	0.700~4.366
SIRI	0.217	0.060	12.998	<0.001	1.242	1.104~1.398
CAR	0.278	0.124	5.038	0.025	1.321	1.036~1.684
WMR	1.869	0.807	5.364	0.021	6.480	1.333~31.508
TBil	0.053	0.021	6.430	0.011	1.054	1.012~1.098
常数项	-11.364	1.751	42.100	<0.001	0.000