初治重症肺结核患者早期危险因素分析及预测模型的构建

doi:10.19982/j.issn.1000-6621.20250064

摘要/Abstract

摘要：

目的: 探索初治重症肺结核患者的流行病学特点,分析发生重症的危险因素,为临床早期识别初治重症肺结核患者并改善预后提供依据。方法: 选取2024年1—6月首都医科大学附属北京胸科医院收治的217例初治肺结核患者作为研究对象,根据重症肺结核诊断标准分为初治重症组(107例)和初治非重症组(110例)。收集研究对象一般人口学信息、基础疾病、实验室检查结果、细菌学检测结果等资料。比较两组间各项指标的差异,采用多因素logistic回归模型分析初次诊断尚未开始治疗即发生重症肺结核的危险因素,并建立风险预测模型,绘制受试者工作特征(receiver operator characteristic, ROC)曲线,分析此模型对初治重症肺结核患者的预测价值。结果: 多因素logistic回归分析显示,心率、白蛋白、中性粒细胞与淋巴细胞比值、血钠、呼吸窘迫为初治肺结核患者发生重症的独立影响因素。心率增快(OR=1.205,95%CI:1.010~1.436)、中性粒细胞与淋巴细胞比值增加(OR=2.247,95%CI:1.133~4.455)和发生呼吸窘迫(OR=26.899,95%CI:1.713~289.780),肺结核患者出现重症的风险增加;白蛋白水平升高(OR=0.487,95%CI:0.270~0.876)和血钠水平升高(OR=0.489,95%CI:0.257~0.928),肺结核患者出现重症的风险降低。ROC曲线分析显示,5种因素联合检测时曲线下面积为0.995,预测初治重症肺结核患者的敏感度和特异度分别为96.2%和98.2%。结论: 心率、呼吸窘迫、白蛋白、中性粒细胞与淋巴细胞比值、血钠为初治肺结核患者发生重症的影响因素,且五者联合对初治重症肺结核患者的早期筛查和预防具有良好的预测价值。

关键词: 危重病, 结核, 肺, 因素分析, 统计学, 模型, 结构

Abstract:

Objective: To investigate the epidemiological characteristics of initially treated severe pulmonary tuberculosis, analyze its risk factors and establish a prediction model, which provides evidence for early clinical identification of initially treated severe pulmonary tuberculosis and improvement of clinical outcomes. Methods: A total of 217 patients with initially treated pulmonary tuberculosis admitted to Beijing Chest Hospital, Capital Medical University, between January 2024 to June 2024 were divided into two groups according to the diagnostic criteria for severe pulmonary tuberculosis: the initially treated severe group (107 patients) and the initially treated non-severe group (110 patients). The information including baseline data, basic diseases, laboratory tests and bacteriological evidence was retrospectively collected. The differences in clinical data between two groups were compared. Multivariate logistic regression analysis was performed to analyze the risk factors for severe pulmonary tuberculosis before treatment initiation, establish the risk prediction model and plot a receiver operator characteristic (ROC) curve to evaluate the predictive value of this model for initially treated severe tuberculosis patients. Results: Multivariate logistic regression analysis showed that heart rate, albumin, neutrophile-lymphocyte ratio (NLR), sodium, respiratory distress were independent risk factors for the initial treated severe pulmonary tuberculosis. An increased heart rate was associated with an increased risk of severe pulmonary tuberculosis (OR=1.205, 95%CI: 1.010-1.436). An increase in the ratio of NLR significantly increased the risk of disease (OR=2.247, 95%CI: 1.133-4.455). Respiratory distress was the strongest risk factor, with an OR as high as 26.899 (95%CI: 1.713-289.780). Higher albumin levels were associated with a reduced risk of severe disease (OR=0.487, 95%CI: 0.270-0.876), as were higher blood sodium levels (OR=0.489, 95%CI: 0.257-0.928). ROC curve analysis showed that the area under the curve was 0.995 when the five risk factors were combined, and the sensitivity and specificity of predicting the initial severe pulmonary tuberculosis were 96.2% and 98.2%, respectively. Conclusion: Heart rate, respiratory distress, albumin, NLR, sodium were independent risk factors for the initial treatment severe pulmonary tuberculosis. Moreover, the combination of these five factors can effectively predict the occur of severe pulmonary tuberculosis.

Key words: Critical illness, Tuberculosis, pulmonary, Factor analysis, statistical, Models, structural

中图分类号:

R521

薛玉, 郭树彬, 雷轩, 张静, 李文胜, 刘岩, 李欢, 刘志峰, 王伟, 文力. 初治重症肺结核患者早期危险因素分析及预测模型的构建[J]. 中国防痨杂志, 2025, 47(8): 1038-1043. doi: 10.19982/j.issn.1000-6621.20250064

Xue Yu, Guo Shubin, Lei Xuan, Zhang Jing, Li Wensheng, Liu Yan, Li Huan, Liu Zhifeng, Wang Wei, Wen Li. Construction and analysis of early warning and prediction model for risk factors of initially treated severe pulmonary tuberculosis[J]. Chinese Journal of Antituberculosis, 2025, 47(8): 1038-1043. doi: 10.19982/j.issn.1000-6621.20250064

图/表 5

图1

表1

表2

初治肺结核患者发生重症影响因素的单因素分析

因素	初治重症组(107例)	初治非重症组(110例)	统计检验值	P值
年龄(岁, $x ˉ$ ±s)	64.49±20.70	50.55±19.94	t=5.050	<0.001
体质量指数(kg/m², $x ˉ$ ±s)	17.57±2.47	19.72±2.17	t=4.167	<0.001
性别[例(构成比,%)]			χ²=0.758	0.384
男性	75(70.1)	71(64.5)
女性	32(29.9)	39(35.5)
病史[月,M(Q₁,Q₃)]	1.00(0.50,3.00)	1.38(0.75,6.00)	U=1.268	0.132
发热[例(发生率,%)]	62(57.9)	32(29.1)	χ²=18.390	<0.001
呼吸窘迫[例(发生率,%)]	73(68.2)	8(7.3)	χ²=86.135	<0.001
心率[次/min,M(Q₁,Q₃)]	101.00(87.00,120.00)	84.50(80.00,96.25)	U=―5.448	<0.001
基础疾病[例(发生率,%)]
其他肺部基础病	13(12.1)	6(5.5)	χ²=3.043	0.081
糖尿病	28(26.2)	21(19.1)	χ²=1.554	0.213
病原学检测[例(构成比,%)]			χ²=6.296	0.012
阳性	86(80.4)	72(65.5)
阴性	21(19.6)	38(34.5)
利福平耐药[例(耐药率,%)]	6(5.6)	5(4.5)	χ²=0.127	0.721
白细胞计数[×10⁹/L,M(Q₁,Q₃)]	7.67(5.72,13.98)	7.46(5.72,9.80)	U=1142.500	0.512
血红蛋白[g/L,M(Q₁,Q₃)]	109.00(90.00,122.00)	129.00(119.00,140.50)	U=―7.052	<0.001
血小板计数[×10⁹/L,M(Q₁,Q₃)]	250.00(147.75,289.50)	250.00(180.00,335.00)	U=1385.000	0.337
淋巴细胞计数[×10⁹/L,M(Q₁,Q₃)]	0.45(0.22,0.76)	0.68(0.35,1.03)	U=1590.500	0.020
单核细胞计数[×10⁹/L,M(Q₁,Q₃)]	0.26(0.11,0.47)	0.42(0.28,0.61)	U=1684.500	0.003
粒淋比[M(Q₁,Q₃)]	16.68(10.03,28.82)	8.29(5.95,16.17)	U=805.000	0.004
单淋比[M(Q₁,Q₃)]	0.59(0.40,0.82)	0.68(0.45,1.00)	U=1345.500	0.487
胆碱酯酶[IU/L,M(Q₁,Q₃)]	2906.00(2049.00,4113.00)	6528.00(5643.00,7698.00)	U=―11.111	<0.001
碱性磷酸酶[IU/L,M(Q₁,Q₃)]	119.50(107.00,169.50)	119.00(88.00,153.00)	U=1121.500	0.426
乳酸脱氢酶[IU/L,M(Q₁,Q₃)]	352.50(233.75,453.00)	243.50(193.50,326.00)	U=760.000	0.002
白蛋白[g/L,M(Q₁,Q₃)]	29.30(24.20,32.50)	41.30(38.20,44.10)	U=―11.644	<0.001
球蛋白[g/L,M(Q₁,Q₃)]	31.40(27.30,36.00)	26.00(23.10,28.90)	U=―6.803	<0.001
白蛋白/球蛋白( $x ˉ$ ±s)	0.93±0.24	1.62±0.36	t=16.320	<0.001
尿素氮[mmol/L,M(Q₁,Q₃)]	9.95(5.92,16.52)	5.81(4.26,8.27)	U=786.000	0.002
血钠(mmol/L, $x ˉ$ ±s)	133.50±7.18	139.80±2.92	t=8.499	<0.001
C-反应蛋白(mg/L, $x ˉ$ ±s)	78.36±50.20	15.78±23.89	t=11.590	<0.001
D-二聚体[ng/ml,M(Q₁,Q₃)]	3.63(1.62,5.81)	0.38(0.24,0.81)	U=9.441	<0.001
肺部病灶≥3个肺野或≥50%肺野[例(构成比,%)]	87(81.3)	49(44.5)	χ²=31.335	<0.001

表2

表3

初治肺结核患者发生重症影响因素的多因素logistic回归分析

因素	β值	s $x ˉ$ 值	Wald χ²值	P值	OR(95%CI)值
心率	0.186	0.090	4.301	0.038	1.205(1.010~1.436)
白蛋白	―0.720	0.300	5.767	0.016	0.487(0.270~0.876)
粒淋比	0.810	0.349	5.373	0.020	2.247(1.133~4.455)
血钠	―0.716	0.327	4.783	0.029	0.489(0.257~0.928)
呼吸窘迫	4.553	2.048	4.941	0.026	26.899(1.713~289.780)

表3

表4

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因素	曲线下面积	临界值	敏感度(%)	特异度(%)
心率	0.714	90.500	67.3	70.9
白蛋白	0.959	36.250	93.5	89.9
粒淋比	0.931	4.857	86.9	94.5
血钠	0.803	136.350	68.6	89.9
呼吸窘迫	0.805	0.500	68.2	92.7
五者联合	0.995	0.588	96.2	98.2