日间经皮肾镜碎石取石术患者延迟出院的危险因素分析和列线图构建

doi:10.3877/cma.j.issn.1674-3253.2022.03.003

目的

探讨日间经皮肾镜碎石取石术（PCNL）患者延迟出院的危险因素，并构建风险预测列线图。

方法

回顾性审查370例日间PCNL患者的电子病历，根据患者是否在24 h内出入院，将其分为延迟出院组（61例）和正常出院组（309例）。采用单因素分析比较两组的一般资料、术后1 h生命体征和血液学指标。通过Logistic回归分析确定延迟出院的危险因素，绘制列线图以预测延迟出院的风险，应用校准曲线评估列线图的内部校准性能。

结果

370例患者中有61例（16.5%）出现延迟出院，18例（4.9%）住院时间超过48 h。Logistic回归分析显示年龄>65岁（OR：3.992，95%CI：1.792~8.892，P=0.001）、通道数量（OR：3.139，95%CI：1.548~6.367，P=0.002）、术中严重出血（OR：12.207，95%CI：2.761~53.973，P=0.001）、术后1 h体温>38℃（OR：4.623，95%CI：1.445~14.789，P=0.010）、中性粒细胞比率>75%（OR：1.951，95%CI：1.008~3.777，P=0.047）和钾<3.5 mmol/L（OR：5.469，95%CI：1.641~18.226，P=0.006）是日间PCNL患者延迟出院的独立危险因素。延迟出院预测模型的ROC曲线下面积为0.784，通过危险因素构建的列线图具有良好的区分度和准确性。

结论

基于年龄、通道数量、术中严重出血、术后感染和低钾血症构建的延迟出院风险预测列线图预测性能良好，可帮助医护人员快速识别术后延迟出院高风险患者，以便尽早实施医疗干预。

关键词: 日间手术, 经皮肾镜取石术, 延迟出院, 危险因素, 列线图

Objective

To explore the risk factors of delayed discharge following day-surgery percutaneous nephrolithotomy (PCNL) and construct a risk prediction nomogram.

Methods

370 patients underwent day-surgery PCNL were retrospectively reviewed. According to whether the patients were admitted and discharged within 24 h, they were divided into delayed discharge group (n=61) and normal discharge group (n=309). Univariate analysis was used to compare the general data, vital signs and hematological indexes of the two groups. Furtherly, risk factors of delayed discharge was evaluated in multivariate logistic regression analysis. Nomogram was plotted, and calibration curve was applied to assess the internal calibration of the nomogram.

Results

61 of 370 patients (16.5%) suffered delayed discharge, 18 patients (4.9%) were hospitalized for more than 48 h. Age over 65 years (OR: 3.992, 95%CI: 1.792-8.892, P=0.001), number of tracts (OR: 3.139, 95%CI: 1.548-6.367, P=0.002), intraoperaive severe bleeding (OR: 12.207, 95%CI: 2.761-53.973, P=0.001), body temperature over 38℃(OR: 4.623, 95%CI: 1.445-14.789, P=0.010), neutrophil ratio greater than 75% (OR: 1.951, 95%CI: 1.008-3.777, P=0.047) and potassium less than 3.5 mmol/L (OR: 5.469, 95%CI: 1.641-18.226, P=0.006) were identified as independent predictors of delayed discharge following day-surgery PCNL. The area under the ROC curve of delayed discharge prediction model is 0.784, and the nomogram constructed by risk factors has good discrimination and accuracy.

Conclusion

The nomogram constructed based on age, number of channels, intraoperative severe bleeding, postoperative body temperature, neutrophil ratio, and hypokalemia has good performance in predicting the risk of delayed discharge. It can help medical staff quickly identify high-risk patients with delayed discharge, so that medical intervention can be implemented as soon as possible.

Key words: Day-surgery, Percutaneous nephrolithotomy, Delayed discharge, Risk factor, Nomogram

表1 两组PCNL患者的一般资料比较

项目	例数	性别(例)		年龄>65岁(例)	BMI值[kg/m²，(±s)]	主要取石部位(例)		结石大小[mm，(±s)]	结石类型(例)			主要结石成分(例)
项目	例数	男	女	年龄>65岁(例)	BMI值[kg/m²，(±s)]	左	右	结石大小[mm，(±s)]	单个	多发	鹿角形	草酸钙	碳酸磷灰石	尿酸或其他
DD组	061	039	022	16	24.0±4.1	036	025	21.2±8.8	024	032	05	047	06	08
ND组	309	193	116	24	23.8±3.6	170	139	20.5±8.6	128	160	21	229	35	45
统计值		χ²=0.047		χ²=13.370	t=0.397	χ²=0.330		t=0.555	χ²=0.200			χ²=2.726
P值		0.828		<0.001	0.693	0.565		0.581	0.905			0.256
项目	穿刺部位(例)				通道数量(例)		肾造瘘管数量(例)			手术时间>120 min(例)	术中严重出血^b(例)	基础疾病(例)
项目	上盏	中盏	下盏	多个肾盏穿刺^a	单通道	多通道	无管	1条	2条或以上	手术时间>120 min(例)	术中严重出血^b(例)	高血压	糖尿病	心功能不全	肾功能不全
DD组	6	039	08	08	037	24	023	028	10	06	8	14	05	04	07
ND组	53	173	58	25	270	39	139	140	30	10	4	40	18	10	11
统计值	χ²=4.627				χ²=25.750		χ²=2.726			χ²=3.887	χ²=19.072	χ²=4.092	χ²=0.491	χ²=1.543	χ²=5.292
P值	0.201				<0.001		0.256			0.049	<0.001	0.043	0.483	0.214	0.021

表1 两组PCNL患者的一般资料比较

项目	例数	性别(例)		年龄>65岁(例)	BMI值[kg/m²，(±s)]	主要取石部位(例)		结石大小[mm，(±s)]	结石类型(例)			主要结石成分(例)
项目	例数	男	女	年龄>65岁(例)	BMI值[kg/m²，(±s)]	左	右	结石大小[mm，(±s)]	单个	多发	鹿角形	草酸钙	碳酸磷灰石	尿酸或其他
DD组	061	039	022	16	24.0±4.1	036	025	21.2±8.8	024	032	05	047	06	08
ND组	309	193	116	24	23.8±3.6	170	139	20.5±8.6	128	160	21	229	35	45
统计值		χ²=0.047		χ²=13.370	t=0.397	χ²=0.330		t=0.555	χ²=0.200			χ²=2.726
P值		0.828		<0.001	0.693	0.565		0.581	0.905			0.256
项目	穿刺部位(例)				通道数量(例)		肾造瘘管数量(例)			手术时间>120 min(例)	术中严重出血^b(例)	基础疾病(例)
项目	上盏	中盏	下盏	多个肾盏穿刺^a	单通道	多通道	无管	1条	2条或以上	手术时间>120 min(例)	术中严重出血^b(例)	高血压	糖尿病	心功能不全	肾功能不全
DD组	6	039	08	08	037	24	023	028	10	06	8	14	05	04	07
ND组	53	173	58	25	270	39	139	140	30	10	4	40	18	10	11
统计值	χ²=4.627				χ²=25.750		χ²=2.726			χ²=3.887	χ²=19.072	χ²=4.092	χ²=0.491	χ²=1.543	χ²=5.292
P值	0.201				<0.001		0.256			0.049	<0.001	0.043	0.483	0.214	0.021

表2 两组PCNL患者术后1 h生命体征和血液学指标比较（例）

项目	DD组	ND组	χ²值	P值
例数	61	309
T>38℃	9	7	16.3050	<0.0010
P<50 or >110 min^-1	4	9	1.805	0.179
B<12 or >24 min^-1	5	10	2.074	0.150
SBP<80 or >160 mmHg	6	9	4.624	0.032
DBP<50 or >100 mmHg	6	13	2.259	0.133
WBC<4 or >12×10⁹/L	18	73	0.951	0.329
NEUT%>75%	29	76	13.1960	<0.0010
RBC<4×10¹²/L	13	53	0.601	0.438
Hb<90 g/L	7	12	4.570	0.033
PLT<100 or >300×10⁹/L	2	23	0.819	0.365
GLU<3.9 or >6.1 mmol/L	10	27	3.317	0.069
BUN>7.2 mmol/L	10	32	1.845	0.174
SCr>133 umol/L	14	44	2.925	0.087
K<3.5 mmol/L	8	7	12.7530	<0.0010
Na<134 or >145 mmol/L	2	18	0.244	0.621
Cl<96 or>111 mmol/L	9	28	1.834	0.176
CO₂CP<21 or >29 mmol/L	8	23	2.135	0.144
Ca<2 or >2.70 mmol/L	9	19	4.233	0.040
PT>14.5 s	3	9	0.166	0.683
APTT>42.8 s	5	14	0.555	0.456
FIB<2 or >4 g/L	12	57	0.080	0.778
DD（XS）>0.5 ug/ml	7	32	0.068	0.795

表2 两组PCNL患者术后1 h生命体征和血液学指标比较（例）

项目	DD组	ND组	χ²值	P值
例数	61	309
T>38℃	9	7	16.3050	<0.0010
P<50 or >110 min^-1	4	9	1.805	0.179
B<12 or >24 min^-1	5	10	2.074	0.150
SBP<80 or >160 mmHg	6	9	4.624	0.032
DBP<50 or >100 mmHg	6	13	2.259	0.133
WBC<4 or >12×10⁹/L	18	73	0.951	0.329
NEUT%>75%	29	76	13.1960	<0.0010
RBC<4×10¹²/L	13	53	0.601	0.438
Hb<90 g/L	7	12	4.570	0.033
PLT<100 or >300×10⁹/L	2	23	0.819	0.365
GLU<3.9 or >6.1 mmol/L	10	27	3.317	0.069
BUN>7.2 mmol/L	10	32	1.845	0.174
SCr>133 umol/L	14	44	2.925	0.087
K<3.5 mmol/L	8	7	12.7530	<0.0010
Na<134 or >145 mmol/L	2	18	0.244	0.621
Cl<96 or>111 mmol/L	9	28	1.834	0.176
CO₂CP<21 or >29 mmol/L	8	23	2.135	0.144
Ca<2 or >2.70 mmol/L	9	19	4.233	0.040
PT>14.5 s	3	9	0.166	0.683
APTT>42.8 s	5	14	0.555	0.456
FIB<2 or >4 g/L	12	57	0.080	0.778
DD（XS）>0.5 ug/ml	7	32	0.068	0.795

图3 日间PCNL患者延迟出院风险预测列线图的内部校准曲线

表3 日间PCNL患者延迟出院的Logistic回归分析

变量	β	标准误	Wald χ²	P值	OR（95%CI）
年龄>65岁	1.384	0.409	11.477	0.001	3.992(1.792~8.892)
通道数量	1.144	0.361	10.054	0.002	3.139(1.548~6.367)
术中严重出血	2.502	0.758	10.882	0.001	12.207(2.761~53.973)
T>38℃	1.531	0.593	06.660	0.010	04.623(1.445~14.789)
NEUT%>75%	0.668	0.337	03.930	0.047	1.951(1.008~3.777)
K<3.5 mmol/L	1.699	0.614	07.654	0.006	05.469(1.641~18.226)

表3 日间PCNL患者延迟出院的Logistic回归分析

变量	β	标准误	Wald χ²	P值	OR（95%CI）
年龄>65岁	1.384	0.409	11.477	0.001	3.992(1.792~8.892)
通道数量	1.144	0.361	10.054	0.002	3.139(1.548~6.367)
术中严重出血	2.502	0.758	10.882	0.001	12.207(2.761~53.973)
T>38℃	1.531	0.593	06.660	0.010	04.623(1.445~14.789)
NEUT%>75%	0.668	0.337	03.930	0.047	1.951(1.008~3.777)
K<3.5 mmol/L	1.699	0.614	07.654	0.006	05.469(1.641~18.226)

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[15]	曹亚丽, 高雨萌, 张英谦, 李博, 杜军保, 金红芳. 儿童坐位不耐受的临床进展[J/OL]. 中华脑血管病杂志(电子版), 2024, 18(05): 510-515.

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Delayed discharge following day-surgery percutaneous nephrolithotomy: risk factor evaluation and nomogram construction

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Delayed discharge following day-surgery percutaneous nephrolithotomy: risk factor evaluation and nomogram construction