摘要
目的应用常规超声及三维斑点追踪成像技术构建血液透析患者自体动静脉内瘘(arteriovenous fistula,AVF)成熟预测模型,验证并评价诊断效能。方法本研究采用病例对照研究,以方便选取法选取重庆市中医院肾病科2021年7月至2024年6月行AVF的患者200例。收集患者临床、血管超声、心脏超声数据,经筛选纳入186例,根据AVF结局,将患者分为自然成熟组(111例)和非自然成熟组(75例)。比较2组数据,采用单因素及多因素Logistic回归分析筛选变量,建立AVF自然成熟预测模型(model1),绘制列线图,对model1进行内部验证并绘制校准图,以受试者工作特征曲线下面积(area under curve,AUC)及决策曲线评价模型效能。排除未做心脏三维斑点追踪成像的患者共104例,余下82例患者数据用以建立新预测模型,左室二维整体纵向应变(two-dimensional left ventricular global longitudinal strain,2DGLS)、左室三维整体纵向应变(three-dimensional left ventricular global longitudinal strain,3DGLS)、左室三维射血分数(three-dimensional left ventricular ejection fraction,3DEF)分别参与建立新模型,记为model2、model3、model4。通过AUC值、净重分类改善指数(net reclassification improvement index,NRI)及综合判别改善指数(integrated discrimination improvement index,IDI)与model1比较预测性能优劣。结果左室二维射血分数(two-dimensional left ventricular ejection fraction,2DEF)(OR=1.133,95%CI:1.058~1.213)、术前头静脉中段距皮深度(OR=1.453,95%CI:1.068~1.978)、术前头静脉远段内径(OR=2.141,95%CI:1.120~4.091)、术前肱动脉充血后阻力指数(OR=0.004,95%CI:0.000~0.140)、术后肱动脉流量(OR=1.004,95%CI:1.002~1.007)是AVF自然成熟的独立预测因子,建立的预测模型(model1)的AUC值为0.869(95%CI:0.817~0.921)。校准图中模拟曲线和实际曲线具有较好拟合度,平均绝对误差0.017。决策曲线表明阈值概率为0.1~1.0,模型净收益优于全干预和无干预策略。各新模型与model1比较,AUC值、IDI差异无统计学意义,model4与model1比较,NRI值差异有统计学意义(P<0.05)。结论2DGLS、3DGLS、3DEF与2DEF参与构建的AVF自然成熟的预测模型预测效能均较高,3DEF参与的模型的NRI优于2DEF参与的模型,表明其在特定阈值概率范围内可能具有更好的临床应用价值。
Objective To develop and validate a predictive model for autologous arteriovenous fistula(AVF)maturation in hemodialysis patients using conventional ultrasonography and three-dimensional speckle tracking imaging.Methods This case-control study enrolled 200 AVF patients from Chongqing Hospital of Traditional Chinese Medicine from July 2021 to June 2024.Clinical data,vascular ultrasound,and cardiac ultrasound parameters were systematically collected.After applying predefined inclusion criteria,186 patients were stratified into 2 cohorts based on arteriovenous fistula(AVF)maturation status:the spontaneous maturation group(n=111)and the assisted maturation requirement group(n=75).Comparative analysis between the 2 cohorts was conducted using univariate and multivariate logistic regression for variable selection,leading to the construction of a predictive model(model1)for spontaneous AVF maturation.A nomogram was subsequently developed based on model1.Internal validation was performed through 1000 bootstrap resamples with calibration curve analysis.Model discrimination was quantified by the area under the receiver operating characteristic curve(AUC),while clinical utility was assessed via decision curve analysis(DCA).After excluding 104 patients lacking three-dimensional speckle tracking echocardiography data,the remaining 82 subjects were included in novel predictive model development.Three strain parameters,two-dimensional global longitudinal strain(2DGLS),three-dimensional global longitudinal strain(3DGLS),and three-dimensional left ventricular ejection fraction(3DEF),were independently incorporated into multivariable logistic regression analyses to establish three distinct models(designated as model2,model3 and model4 respectively).Model comparisons employed AUC,net reclassification improvement(NRI),and integrated discrimination improvement(IDI).Results Independent predictors for model1 included:2DEF(OR=1.133,95%CI:1.058~1.213),mid-cephalic vein depth(OR=1.453,95%CI:1.068~1.978),distal cephalic vein diameter(OR=2.141,95%CI:1.120~4.091),post-occlusive brachial artery resistance index(OR=0.004,95%CI:0.000~0.140),and postoperative brachial flow(OR=1.004,95%CI:1.002~1.007).model1 demonstrated excellent discrimination(AUC=0.869,95%CI:0.817~0.921)and calibration(mean absolute error=0.017).DCA showed superior net benefit at 0.1~1.0 threshold probabilities.Compared with model1,non-significant improvements in AUC and IDI,while model4 achieved significant NRI improvements(P<0.05).Conclusion The prediction performance of AVF natural maturity prediction models constructed with 2DGLS,3DGLS,3DEF,or 2DEF is relatively high;The NRI of the model involving 3DEF is better than that of the model involving 2DEF,indicating that it may have better clinical application value within a specific threshold probability range.
作者
袁媛
罗朋
封雪
田甜
任德伟
任建丽
YUAN Yuan;LUO Peng;FENG Xue;TIAN Tian;REN Dewei;REN Jianli(Department of Ultrasound,the Second Affiliated Hospital of Chongqing Medical University,Chongqing;Department of Ultrasound,Chongqing Traditional Chinese Medicine Hospital,Chongqing,China;Department of Nephrology,Chongqing Traditional Chinese Medicine Hospital,Chongqing,China)
出处
《陆军军医大学学报》
北大核心
2025年第11期1243-1252,共10页
Journal of Army Medical University
基金
成都中医药大学“杏林学者”学科人才科研提升计划立项项目(YYZY2020067)。
关键词
常规超声
自体动静脉内瘘
三维斑点追踪成像技术
预测模型
血液透析
conventional ultrasonography
arteriovenous fistula
three-dimensional speckle tracking imaging
predictive model
hemodialysis
