糖尿病患者急性脑梗死取栓术后发生对比剂肾病的影响因素及预测模型建立

doi:10.3877/cma.j.issn.2095-3216.2024.04.002

目的

探讨糖尿病患者急性脑梗死取栓术后发生对比剂肾病的影响因素，并建立预测模型。

方法

对2018年9月至2024年6月于徐州医科大学附属医院就诊的因急性脑梗死行机械取栓术的152例糖尿病患者进行回顾性分析。按照是否确诊对比剂肾病将其分为对比剂肾病组(37例)和非对比剂肾病组(115例)。采用Logistic回归方法分析影响对比剂肾病发生的影响因素。采用R语言方法构建预测模型列线图，构建临床决策曲线评估其临床应用价值。绘制受试者操作特征曲线以评价该列线图模型在对比剂肾病发生中的预测作用。

结果

单因素分析显示，两组患者在对比剂剂量、手术时长、白细胞计数、中性粒细胞计数、纤维蛋白原、甘油三酯-葡萄糖指数方面具有统计学差异(P均<0.05)。多因素Logistic回归分析显示，对比剂剂量(OR＝1.054，95%CI：1.014～1.096，P＝0.008)、甘油三酯-葡萄糖指数(OR＝3.554，95%CI：1.550～8.154，P＝0.003)、纤维蛋白原(OR＝3.358，95%CI：1.633～6.904，P＝0.001)是对比剂肾病的独立危险因素。受试者操作特征曲线分析显示，甘油三酯-葡萄糖指数、纤维蛋白原、对比剂剂量三者联合预测对比剂肾病时，曲线下面积为0.857、灵敏度为86.5%、特异性为77.4%。

结论

对比剂剂量、甘油三酯-葡萄糖指数及纤维蛋白原是糖尿病患者急性脑梗死取栓术后发生对比剂肾病的独立危险因素。构建的列线图模型对糖尿病患者急性脑梗死取栓术后发生对比剂肾病有一定的预测价值。

关键词: 急性脑梗死, 糖尿病, 取栓术, 对比剂肾病, 甘油三酯-葡萄糖指数, 纤维蛋白原

Objective

To investigate the influencing factors and prediction modeling of contrast-induced nephropathy (CIN) after thrombectomy in diabetic patients with acute cerebral infarction.

Methods

A retrospective analysis was performed on 152 diabetic patients who underwent mechanical thrombectomy for acute cerebral infarction in the Affiliated Hospital of Xuzhou Medical University from September 2018 to June 2024. The patients were divided into CIN group (37 cases) and non-CIN group (115 cases) according to whether CIN was confirmed. Logistic regression method was used to analyze the influencing factors of CIN development. R language method was used to construct the prediction model nomogram, and clinical decision curve was constructed to evaluate its clinical application value. The receiver operating characteristic curve was drawn to evaluate the predictive role of the model in the development of CIN.

Results

Univariate analysis showed that there were statistically significant differences in contrast dose, operation duration, white blood cell count, neutrophil count, fibrinogen, and triglyceride-glucose index between the two groups (P<0.05). Multivariate logistic regression analysis showed that the dose of contrast (OR=1.054, 95%CI: 1.014-1.096, P=0.008), triglyceride-glucose index (OR=3.554, 95%CI: 1.550-8.154, P=0.003), and fibrinogen (OR=3.358, 95%CI: 1.633-6.904, P=0.001) were independent risk factors for CIN. The receiver operating characteristic curve analysis showed that when triglyceride-glucose index, fibrinogen, and contrast dose were combined to predict CIN, the area under the curve was 0.857, with the sensitivity being 86.5%, and the specificity 77.4%.

Conclusion

The contrast dose, triglyceride-glucose index, and fibrinogen were the independent risk factors for CIN after thrombectomy in the diabetic patients with acute cerebral infarction. The nomogram model constructed had a certain value in predicting the occurrence of CIN after thrombectomy in the diabetic patients with acute cerebral infarction.

Key words: Acute cerebral infarction, Diabetes, Thrombectomy, Contrast-induced nephropathy, Triglyceride-glucose index, Fibrinogen

表1 糖尿病患者急性脑梗死取栓术后两组一般资料及临床资料比较

项目	CIN组(37例)	非CIN组(115例)	χ²/t/z值	P值
年龄(岁)	68.54±11.98	67.57±10.97	0.460	0.646
性别(男)[例(%)]	24(64.9)	71(61.7)	0.117	0.733
高血压[例(%)]	25(67.6)	68(59.1)	0.839	0.360
心房颤动[例(%)]	14(37.8)	31(27.0)	1.590	0.207
服用二甲双胍[例(%)]	23(62.2)	58(50.4)	1.547	0.214
取栓部位[例(%)]			3.889	0.274
颈内动脉	9(24.3)	19(16.52)
大脑中动脉	11(29.7)	53(46.1)
椎动脉	9(24.3)	18(15.7)
基底动脉	8(21.6)	25(21.7)
手术时间(min)	125.24±56.74	94.65±35.14	3.094	0.003
对比剂剂量(ml)	110.00±24.26	90.70±19.10	4.418	<0.001
白细胞计数(×10⁹/L)	10.30±3.48	8.38±2.76	3.435	0.001
血小板计数(×10⁹/L)	218.78±71.46	200.64±55.47	1.608	0.110
中性粒细胞计数(×10⁹/L)	8.24±3.69	6.45±2.74	2.715	0.009
FIB(g/L)	3.56±0.88	2.76±0.65	5.999	<0.001
空腹血糖(mmol/L)	10.64±3.35	7.93±2.54	4.510	<0.001
甘油三酯(mmol/L)	1.28(1.12，1.73)	1.17(0.81，1.51)	－2.202	0.043
术前肌酐(μmol/L)	76.86±36.44	66.86±23.99	1.925	0.056
术前eGFR(ml/min·1.73 m²)	97.90±28.70	103.46±19.13	－1.224	0.227
术后血清肌酐(μmol/L)	134.73±52.75	69.40±22.40	7.325	<0.001
术后eGFR(mL/min·1.73 m²)	56.83±22.18	99.68±16.67	－10.497	<0.001
TyG指数	8.38±1.59	7.85±1.43	4.283	<0.001

表1 糖尿病患者急性脑梗死取栓术后两组一般资料及临床资料比较

项目	CIN组(37例)	非CIN组(115例)	χ²/t/z值	P值
年龄(岁)	68.54±11.98	67.57±10.97	0.460	0.646
性别(男)[例(%)]	24(64.9)	71(61.7)	0.117	0.733
高血压[例(%)]	25(67.6)	68(59.1)	0.839	0.360
心房颤动[例(%)]	14(37.8)	31(27.0)	1.590	0.207
服用二甲双胍[例(%)]	23(62.2)	58(50.4)	1.547	0.214
取栓部位[例(%)]			3.889	0.274
颈内动脉	9(24.3)	19(16.52)
大脑中动脉	11(29.7)	53(46.1)
椎动脉	9(24.3)	18(15.7)
基底动脉	8(21.6)	25(21.7)
手术时间(min)	125.24±56.74	94.65±35.14	3.094	0.003
对比剂剂量(ml)	110.00±24.26	90.70±19.10	4.418	<0.001
白细胞计数(×10⁹/L)	10.30±3.48	8.38±2.76	3.435	0.001
血小板计数(×10⁹/L)	218.78±71.46	200.64±55.47	1.608	0.110
中性粒细胞计数(×10⁹/L)	8.24±3.69	6.45±2.74	2.715	0.009
FIB(g/L)	3.56±0.88	2.76±0.65	5.999	<0.001
空腹血糖(mmol/L)	10.64±3.35	7.93±2.54	4.510	<0.001
甘油三酯(mmol/L)	1.28(1.12，1.73)	1.17(0.81，1.51)	－2.202	0.043
术前肌酐(μmol/L)	76.86±36.44	66.86±23.99	1.925	0.056
术前eGFR(ml/min·1.73 m²)	97.90±28.70	103.46±19.13	－1.224	0.227
术后血清肌酐(μmol/L)	134.73±52.75	69.40±22.40	7.325	<0.001
术后eGFR(mL/min·1.73 m²)	56.83±22.18	99.68±16.67	－10.497	<0.001
TyG指数	8.38±1.59	7.85±1.43	4.283	<0.001

表2 单因素Logistic回归分析糖尿病患者急性脑梗死取栓术后发生对比剂肾病的相关因素

项目	回归系数	标准误差	瓦尔德值	OR(95%CI)	P值
TyG指数	1.307	0.342	14.628	3.696(1.892～7.223)	<0.001
白细胞计数(×10⁹/L)	0.200	0.063	10.049	1.222(1.079～1.383)	0.002
中性粒细胞计数(×10⁹/L)	0.182	0.062	8.676	1.200(1.063～1.354)	0.003
FIB(g/L)	1.431	0.317	20.366	4.183(2.247～7.788)	<0.001
手术时间(min)	0.016	0.005	10.995	1.016(1.007～1.026)	0.001
对比剂剂量(ml)	0.042	0.010	18.165	1.043(1.023～1.063)	<0.001

表2 单因素Logistic回归分析糖尿病患者急性脑梗死取栓术后发生对比剂肾病的相关因素

项目	回归系数	标准误差	瓦尔德值	OR(95%CI)	P值
TyG指数	1.307	0.342	14.628	3.696(1.892～7.223)	<0.001
白细胞计数(×10⁹/L)	0.200	0.063	10.049	1.222(1.079～1.383)	0.002
中性粒细胞计数(×10⁹/L)	0.182	0.062	8.676	1.200(1.063～1.354)	0.003
FIB(g/L)	1.431	0.317	20.366	4.183(2.247～7.788)	<0.001
手术时间(min)	0.016	0.005	10.995	1.016(1.007～1.026)	0.001
对比剂剂量(ml)	0.042	0.010	18.165	1.043(1.023～1.063)	<0.001

表3 多因素Logistic回归分析糖尿病患者急性脑梗死取栓术后发生对比剂肾病的相关因素

项目	回归系数	标准误差	瓦尔德值	OR(95%CI)	P值
TyG指数	1.268	0.424	8.963	3.554(1.550～8.154)	0.003
FIB(g/L)	1.211	0.368	10.852	3.358(1.633～6.904)	0.001
对比剂剂量(ml)	0.053	0.020	7.128	1.054(1.014～1.096)	0.008

表3 多因素Logistic回归分析糖尿病患者急性脑梗死取栓术后发生对比剂肾病的相关因素

项目	回归系数	标准误差	瓦尔德值	OR(95%CI)	P值
TyG指数	1.268	0.424	8.963	3.554(1.550～8.154)	0.003
FIB(g/L)	1.211	0.368	10.852	3.358(1.633～6.904)	0.001
对比剂剂量(ml)	0.053	0.020	7.128	1.054(1.014～1.096)	0.008

图1 甘油三酯-葡萄糖指数、纤维蛋白原、对比剂剂量及三者联合对糖尿病患者取栓术后发生对比剂肾病预测价值的受试者操作特征曲线注：TyG指数：甘油三酯-葡萄糖指数；Nomogram：列线图；AUC：曲线下面积

表4 受试者操作特征曲线分析结果

项目	最佳截断值	灵敏度(%)	特异度(%)	约登指数	曲线下面积(95%CI)	P值
TyG指数	>8.83	86.5	53.9	0.404	0.724(0.630～0.819)	<0.001
FIB(g/L)	>2.98	86.5	71.3	0.578	0.799(0.721～0.877)	<0.001
对比剂剂量(ml)	>105.00	48.6	85.2	0.338	0.729(0.634～0.824)	<0.001
三者联合	>0.20	86.5	77.4	0.639	0.857(0.786～0.928)	<0.001

表4 受试者操作特征曲线分析结果

项目	最佳截断值	灵敏度(%)	特异度(%)	约登指数	曲线下面积(95%CI)	P值
TyG指数	>8.83	86.5	53.9	0.404	0.724(0.630～0.819)	<0.001
FIB(g/L)	>2.98	86.5	71.3	0.578	0.799(0.721～0.877)	<0.001
对比剂剂量(ml)	>105.00	48.6	85.2	0.338	0.729(0.634～0.824)	<0.001
三者联合	>0.20	86.5	77.4	0.639	0.857(0.786～0.928)	<0.001

图2 基于Logistic回归分析预测对比剂肾病的列线图模型注：TyG指数：甘油三酯-葡萄糖指数；CIN：对比剂肾病

图3 列线图模型的校准曲线

图4 列线图模型的临床决策曲线注：TyG指数：甘油三酯-葡萄糖指数；Nomogram：列线图；None：为水平等于0的线条，是所有患者均不进行治疗时的收益曲线，表示所有患者均不进行干预净收益为0；ALL：对所有患者均进行干预的临床净收益曲线

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Influencing factors and prediction modeling of contrast-induced nephropathy after thrombectomy in diabetic patients with acute cerebral infarction

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Influencing factors and prediction modeling of contrast-induced nephropathy after thrombectomy in diabetic patients with acute cerebral infarction