經頸靜脈肝內門體分流術治療肝硬化伴食管胃靜脈曲張破裂出血患者術后生存預測模型的建立和驗證

Abstract：ObjectiveToinvestigate theriskfactors forsurvival aftertransjugular intrahepaticportosystemicshunt（TPS）in patientswithlivercirrosisandesophagogastricvaricealbleeding（EGVB），andtoestablishapredictivemodelforsurvivalafter TIPS.MethodsClinicaldatawerecollctedfrom352patientswithlivercirhosisandEGVBwhounderwentTIPSinDepartment ofGastroenterologyAfiliatedDumTowerHospitalofNanjing UniversityMedicalSchool，fromJanuaryO15toDecember2018， and the patients were randomly divided into training group （ n=248 ）andvalidation group （ n=104 ）at a ratio of 7：3 . The Cox regresionanalysiswasusedtoidentifytheindependentriskfactorsforsurvivalafterTIPS，andanomogrampredictivemodelwas established.Theindexofconcordance（C-index）andthereceiveroperatingcharacteristic（ROC）curve wereusedtossesste discriminatoryabilityofthemodelandthecalibratiocurveasusedtossstepredictivevalueoftemodel.Teindepedent samples t testwasusedforcomparisonofnormallydistributedcontinuousdatabetween two groups，andtheWilcoxonrank-sumtestwas usedforcomparisonofnon-noalldisriutedcontiuousdatabetweetwgroups；thechisquaretestwasusedforcomparisonof categoricaldatabetweentwogroups.TeKaplan-Meieranalysiswasusedtocalculatecumulativesurvivalrate.ResultsFortepatints in the training group，the 1-，3-，and 5-year cumulative survival rates were 91.1 % 79.5% ，and 77.0% ，respectively. The multivariate Cox regression analysis showed that age （hazard ratio [HR]=1.047 ，95 % confidence interval ?CI?：1.032-1.092，Plt;0.001） ，MELD score （HR=1.127，95%CI： 1.003—1.268， P =0.045），and serum sodium（Na）（ HR =0.928， 95%CI： 0.878—0.981， P =0.008）were independentinfluencingfactorsforsurvival，andapredictivemodelandanomogramwereestablishedbasedonthesefactors.The predictivemodelhadaC-idexofO.76OinthetraininggroupandO.757inthevalidationgroup.Inthetraining groupthenomogamhad an area under the ROC curve of O.8O7，O.788，and O.787，respectively，in predicting 1-，3- ，and 5-year cumulative survival rates. The calibrationcureshowedrelativelyhighconsistencybetweetheresultspredictedbythenomogramandtheactualresultsConclusionA nomogrammodelisestablishedbasedonage，MELDscore，andNaforpredictingsurvivalafterTSinpatientswithliverciosisnd EGVB，and this model has good discriminatory ability and accuracy.

KeyWords：Liver Cirrosis；Esophagealand Gastric Varices；PortasystemicShunt，Transjugular Intraepatic；Prognosis; Nomograms

Research funding：National Natural ScienceFoundation ofChina（82370628）

門靜脈高壓癥是肝硬化的主要并發癥之一，包括腹水、肝性腦?。℉E）和出血。食管胃靜脈曲張破裂出血（esophagogastricvaricealbleeding，EGVB）是肝硬化常見的主要并發癥，6周病死率為 10%～20%^[1] 。經頸靜脈肝內門體分流術（TIPS）可以快速有效地降低門靜脈壓力，成為門靜脈高壓相關并發癥（尤其是靜脈曲張出血和頑固性腹水）的重要治療方法。2017年美國肝病學會（AASLD）實踐指南2推薦對內科治療失敗或再出血風險高的患者進行早期TIPS。既往研究表明，TIPS可以改善肝硬化患者的反復靜脈曲張出血率和生存率[3-5]

近年來，多項研究報道了肝硬化門靜脈高壓癥合并EGVB患者的預后影響因素。Riggio等6指出，質子泵抑制劑與肝硬化患者的輕微型HE有關，增加患者病死率。肌少癥是影響肝硬化患者預后的另一個因素。骨骼肌質量下降不僅反映了患者的營養不良狀態，還與TIPS術后HE和患者生活質量惡化相關[7]。腸道菌群紊亂可能與疾病進展和不良預后有關[8]。既往已有研究評估了幾種肝病評分系統對TIPS治療后早期病死率的預測價值。MELD和MELD-Na評分可有效預測TIPS術后的早期生存情況[9]。一項單中心回顧性研究顯示，年齡、腎功能、血清鈉和血清白蛋白水平是TIPS術后肝硬化患者長期生存的獨立預測因素[10]，對于低鈉血癥患者，TIPS支架置入應謹慎。

現有的單一評分系統（如MELD評分）預測效能有限，整合多因素模型可提高準確性[11]。列線圖作為多變量可視化預測工具，在腫瘤領域已展現出優勢[12-13]。本研究擬通過分析TIPS術后EGVB患者的多種預后影響因素，構建整合多因素的生存預測模型，為個體化治療提供依據。……