南方医科大学学报

南方医科大学学报 ›› 2020, Vol. 40 ›› Issue (09): 1265-1272.doi: 10.12122/j.issn.1673-4254.2020.09.07

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乙型肝炎肝硬化患者行脾切除术后门静脉血栓形成的列线图预测模型的建立与验证

徐 伟，程 瑶，涂 兵   

  • 出版日期:2020-09-20 发布日期:2020-09-20

Construction and validation of a nomogram for predicting the risk of portal vein thrombosis after splenectomy in patients with hepatitis B cirrhosis

  • Online:2020-09-20 Published:2020-09-20

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摘要： 目的 建立并验证乙肝肝硬化患者行脾切除术后门静脉血栓形成的列线图预测模型，评价其临床应用价值。方法 回顾性收集重庆医科大学附属第二医院2014年1月~2020年1月期间收治的共180例乙肝肝硬化并行脾切除术患者的临床资料，本研究中患者行脾切除术后均常规予以低分子肝素或口服抗凝剂抗凝治疗，必要时加用双嘧达莫抗血小板治疗。通过随机数字表法按 7:3比例分为建模人群（120例）和验证人群（60例），并比较两人群的临床资料有无可比性。在建模人群中根据术后1月内有无门静脉血栓形成分为血栓组（49例）与无血栓组（71例），通过单因素及多因素Logistic回归分析筛选出乙肝肝硬化患者行脾切除术后门静脉血栓形成的独立危险因素，将这些因素纳入并建立列线图预测模型。分别在建模人群及验证人群中对预测模型进行内部及外部验证：采用AUROC（C指数）验证模型区分度；GiViTI校准带及Hosmer-Lemeshow检验验证模型校准度；DCA曲线验证模型临床有效性。结果 建模人群与验证人群间临床资料差异均无统计学意义（P>0.05），具有可比性。单因素及多因素Logistic回归分析显示：血栓组与无血栓组在消化道出血史、门静脉直径、脾静脉直径、脾脏体积、静脉曲张程度、术后D-二聚体、血小板变化值等方面差异有显著统计学意义（P<0.05），其中门静脉直径、脾静脉直径、术后血小板变化值是乙肝肝硬化脾切除术后门静脉血栓形成的独立危险因素（P<0.05），将上述独立危险因素纳入并成功建立个体化列线图预测模型。分别在建模人群及验证人群中对列线图预测模型进行内部及外部验证：AUROC（C指数）分别为.880（95%CI：0.818~0.942）和0.873（95%CI：0.785~0.960），预测模型区分度良好；GiViTI校准曲线带的80%及95%CI区域均未穿过45°角平分线，P值分别为0.965和0.632，Hosmer-Lemeshow检验中P值分别为0.624和0.911，预测模型的校准度较高；DCA曲线中阈概率值设定为30.5%，两人群临床净获益分别为30%和34%，表明预测模型具有临床有效性。结论 通过建立乙肝肝硬化脾切除术后门静脉血栓形成的列线图预测模型，有助于临床早期筛选并识别乙肝肝硬化脾切除术后门静脉血栓形成的高危患者。

关键词: 乙型肝炎后肝硬化, 门静脉血栓, 脾切除术, 列线图

Abstract: Objective To construct and validate an individualized nomogram to predict the probability of occurrence of portal vein thrombosis (PVT) after splenectomy in patients with hepatitis B cirrhosis. Methods We retrospectively collected the clinical data from 180 patients with hepatitis B cirrhosis undergoing splenectomy with postoperative anticoagulation therapy during the period from January, 2014 to January, 2020 in our hospital. The patients were randomized into modeling group (n= 120) and validation group (n=60), and the former group was further divided into PVT group (n=49) and non-PVT group (n=71) according to the occurrence of PVT occurred within 1 month after splenectomy. The independent risk factors of PVT after splenectomy were screened in the modeling group using univariate and multivariate binary logistic regression analyses and were used for construction of the nomogram prediction model. The area under the receiver-operating characteristic (AUROC) curve (C-index), GiViTI calibration belt and Hosmer-Lemeshow test, and the DCA curve were used to estimate the discrimination power, calibration and clinical efficiency of the prediction model in both the model construction group and validation group. Results Univariate and multivariate logistic regression analyses showed that a history of hemorrhage, portal vein diameter, spleen vein diameter, spleen volume, varicose, postoperative platelet change, and postoperative D-dimer differed significantly between PVT group and non-PVT group (P<0.05), and portal vein diameter, spleen vein diameter, and postoperative platelet change were independent risk factors of PVT after splenectomy (P<0.05). The prediction model had a good discrimination power with AUROC (C-index) of 0.880 (95% CI: 0.818-0.942) in the modeling group and 0.873 (95% CI: 0.785-0.960) in the validation group. The 80% and 95%CI region of GiViTI calibration belt did not cover the 45-degree diagonal bisector line (P=0.965 and 0.632, respectively), and the P-values of the Hosmer-Lemeshow test were 0.624 and 0.911, respectively, suggesting a high reliability of the predicted probability by the model. DCA curve analysis showed a threshold probability of 30.5% , with a net benefit of 30% in the modeling group and 34% in the validation group, indicating a good clinical efficiency of the model. Conclusions The model for predicting the risk of PVT after splenectomy in patients with hepatitis B cirrhosis can help in early identification of patients having high risks of PVT.

Key words: hepatitis B cirrhosis, portal vein thrombosis, splenectomy, nomograms