中国血液净化

中国血液净化 ›› 2019, Vol. 18 ›› Issue (02): 110-114.doi: 10.3969/j.issn.1671-4091.2019.02.008

• 血管通路 • 上一篇    下一篇

预测自体动静脉内瘘成熟的列线图模型的建立

梁玉枫1,陈勇平1,涂淑珍2,邱莉1,廖伟增3,黄彬三1,丘美兰1,卢彩成3   

  1. 1. 福建省龙岩市第二医院肾内科
    2. 龙岩学院数学与应用数学系
    3. 福建省龙岩市第二医院彩超室
  • 收稿日期:2018-07-03 修回日期:2018-11-12 出版日期:2019-02-12 发布日期:2019-01-25
  • 通讯作者: 陈勇平 chenyongpin@medmail.com.cn E-mail:chenyongpin@medmeil.com.cn
  • 基金资助:

    龙岩市科技计划项目(2016LY65);福建省卫生计生委青年项目(2017-01-97); 福建省中青年教师科研项目(ja15487)

A nomogram to predict the maturity of arteriovenous fistulas for hemodialysis

  • Received:2018-07-03 Revised:2018-11-12 Online:2019-02-12 Published:2019-01-25

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摘要： 【摘要】目的通过对行自体动静脉内瘘(arteriovenous fistulas,AVF)的尿毒症患者术前临床资料、彩超检查等指标构建列线图模型，探讨预测AVF 成熟度的方法。方法选取2016 年1 月～2018 年1月收治的238 例确诊终末期肾病并且需要行AVF 手术的患者组成建模组，收集2018 年1 月1 日～2018 年8月1 日拟行AVF 的尿毒症患者80 例，作为验证组。收集患者相关指标，经单因素筛选临床变量后，应用Logistic 回归模型进行多因素分析，确立进入最终模型变量。采用R 3.4.3 统计软件建立列线图，引入最终进入多因素模型的所有变量，进一步评估模型的效能。结果238 例尿毒症患者，动静脉内瘘成熟发生率为74.8%，收缩压(OR=0.987，95% CI：0.975～0.999，P=0.032),血磷(OR=0.012，95% CI：0.312～0.866，P=0.012),总胆固醇(OR=0.694，95% CI：0.577～0.835，P=＜0.001)，合并糖尿病(OR=0.226，95%CI：0.107～0.477，P=＜0.001),合并高血压(OR=0.121，95% CI：0.059～0.249，P=＜0.001)为影响AVF 成熟的危险因素，而头静脉内径(OR=7.301，95% CI：3.369～15.821，P=＜0.001)、桡动脉内径(OR=3.225，95%CI=1.441～7.218，P=0.004)、桡动脉流速(OR=1.086，95% CI：1.058～1.115，P＜0.001)、加压后静脉内径(OR=2.955，95% CI：1.747～4.998，＜0.001)为影响AVF 成功率的保护性因素。根据多因素分析结果，由头静脉内径(β=1.700，P＜0.001)、桡动脉流速(β=0.054，P＜0.001)、总胆固醇(β=-0.326，P=0.034)、合并高血压(β=-1.549，P=0.002)、合并糖尿病(β=-1.183，P=0.017)建立的列线图模型进行内部预测，通过bootstrap 法进行内部验证，模型的校正情况良好，AVF 成熟的发生率c-index 为0.897。校准曲线显示列线图预测与实际观察的AVF 成熟发生率有良好的一致性。受试者工作曲线(ROC 曲线)分析显示验证组80 例运用列线图预测AVF 成熟的效能AUC 为0.848(95% CI: 0.745～0.952，P＜0.001)，其诊断价值高于传统徒手检查(AUC 0.649，95% CI: 0.540～0.758，P=0.028)、术前彩超筛查(AUC 0.786，95% CI: 0.694～0.879，P＜0.001)。结论本研究构建的列线图模型较单独应用彩超或者简单依靠医生徒手检查具有更高的诊断价值。该模型更加直接、简洁的为患者提供个性化AVF 成熟的预测。

关键词: 尿毒症, 动静脉内瘘, 成熟, 列线图

Abstract: 【Abstract】 Objective   To develop a nomogram for predicting arteriovenous fistula (AVF) maturity in hemodialysis patients. Methods   A total of 238 hemodialysis patients treated in the period from January 1, 2016 to January 1, 2018 were enrolled in this study as the model group, and a total of 80 uremic patients treated in the period from January 1, 2018 to July 8, 2018 were recruited as the validation group. Baseline characteristics and ultrasound parameters were collected for analyses. We performed logistic regression analysis to identify the independent risk factors for AVF maturity, and then constructed a nomogram according to a regression equation to predict the results. Concordance index (C-index) and calibration curve were used to verify the predictive and discriminative abilities of the nomogram. Results A total of 176 patients (74.8%) achieved AVF maturation during the 8- week study period. Multivariate logistic regression showed that the risk factors for AVF maturity included systolic pressure (OR=0.987, 95% CI: 0.975～0.999, P=0.032), serum phosphate (OR = 0.012, 95% CI: 0.312～0.866, P=0.012), serum cholesterol (OR=0.694, 95% CI: 0.577～0.835,P＜0.001), diabetes (OR=0.226, 95% CI: 0.107～0.477, P＜0.001) and hypertension (OR=0.121, 95% CI: 0.059～0.249, P＜0.001); and that the protective factors significantly associated with the maturity included cephalic vein diameter (OR=7.301, 95% CI: 3.369～15.821, P＜0.001), radial artery diameter (OR=3.225, 95% CI=1.441～7.218, P=0.004), radial artery blood flow (OR=1.086, 95% CI: 1.058～1.115, P＜0.001) and cephalic vein diameter after pressure (OR=2.955, 95% CI: 1.747～4.998, P＜0.001). A nomogram, which included the variances of cephalic vein diameter (β =1.700, P＜0.001), radial artery blood flow (β =0.054, P＜ 0.001), serum cholesterol (β=-0.326, P=0.034), diabetes (β=-1.183, P=0.017) and hypertension (β=-1.624, P= 0.002), was constructed. This nomogram has better discrimination and calibration abilities to predict AVF maturation. Receiver operator curves (ROC) indicated that the area under the curve (AUC) of the nomogram model was higher than that of physical and routine color Doppler ultrasound examinations for predicting AVF maturity among 80 patients. Conclusion The nomogram established in this study is better than preoperative routine vascular ultrasound and physical examinations for predicting AVF maturity. This nomogram provides a simple and direct method for personalized prediction of AVF maturity.

Key words: uremia, arteriovenous fistulas, maturity, nomogram