肺结核合并糖尿病患者营养不良预测模型的构建与验证

doi:10.19982/j.issn.1000-6621.20240140

摘要/Abstract

摘要：

目的: 探究肺结核合并糖尿病患者发生营养不良的影响因素,构建并验证列线图预测模型。 方法: 采用便利抽样法收集2021年10月至2023年9月入住南京市第二医院结核科的401例肺结核合并糖尿病患者的临床资料,按照7∶3的比例将患者分为建模组(281例)和验证组(120例)。采用logistic回归分析构建列线图预测模型,使用受试者工作特征曲线(ROC)曲线下面积(AUC)和Hosmer-Lemeshow拟合优度检验评价模型的预测效能和校准度。 结果: 年龄(OR=3.796, 95%CI: 1.159~12.627)、病程>1个月(OR=5.711, 95%CI: 1.879~17.274)、糖化血红蛋白(OR=5.951, 95%CI: 1.517~23.269)、查尔森并发症指数(OR=8.079, 95%CI: 2.345~27.681)、衰弱状况≥3分(OR=9.145, 95%CI: 2.404~34.172)是发生营养不良的独立危险因素。将上述变量构建列线图预测模型,预测模型的Hosmer-Lemeshow检验结果显示,P=0.625,AUC为0.897,约登指数为0.584,最佳临界值为0.615。验证组的敏感度为67.5%,特异度为93.8%,预测正确率为85.0%。 结论: 本研究构建的列线图模型具有一定的预测价值及临床适用性,为临床工作早期识别营养不良并给予针对性的营养干预措施提供参考。

关键词: 结核,肺, 糖尿病, 营养不良, 预测, 列线图

Abstract:

Objective: To explore the influencing factors of malnutrition in patients with pulmonary tuberculosis complicated with diabetes mellitus, construct and verify a nomogram prediction model. Methods: The clinical data of 401 patients with tuberculosis combined with diabetes admitted to the Tuberculosis Department of Nanjing Second Hospital from October 2021 to September 2023 were collected with convenience sampling. The patients were divided into modeling group (n=281) and validation group (n=120) according to a ratio of 7∶3. Logistic regression analysis was performed to construct a nomogram prediction model. Area under curve (AUC) and Hosmer-Lemeshow goodness of fit test were used to evaluate the prediction efficiency and calibration degree of the model. Results: Age (OR=3.796, 95%CI: 1.159-12.627), duration of disease >1 month (OR=5.711, 95%CI: 1.879-17.274), glycosylated hemoglobin (OR=5.951, 95%CI: 1.517-23.269), Charlson comorbidity index (OR=8.079, 95%CI: 2.345-27.681) and FRAIL (fatigue, resistance, ambulation, illness and loss) score ≥3 (OR=9.145, 95%CI: 2.404-34.172) were independent risk factors for malnutrition. The above variables were used to construct a nomogram prediction model. Hosmer-Lemeshow test of the model showed that P=0.625, AUC=0.897, the Youden index was 0.584 and the optimal critical value was 0.615. The sensitivity of the verification group was 67.5%, the specificity was 93.8%, and the prediction accuracy was 85.0%. Conclusion: The nomogram model constructed in this study has certain predictive value and clinical applicability, could provide reference for early identification of malnutrition and thereafter taking targeted nutrition intervention measures in clinical work.

Key words: Tuberculosis, pulmonary, Diabetes mellitus, Malnutrition, Forecasting, Nomograms

中图分类号:

R521
R587.1

刘玲, 曾谊, 王进, 刘晓玲, 刘艳, 林霏申, 郭晶. 肺结核合并糖尿病患者营养不良预测模型的构建与验证[J]. 中国防痨杂志, 2024, 46(8): 903-909. doi: 10.19982/j.issn.1000-6621.20240140

Liu Ling, Zeng Yi, Wang Jin, Liu Xiaoling, Liu Yan, Lin Feishen, Guo Jing. Construction and evaluation of a model for predicting malnutrition in patients with pulmonary tuberculosis and diabetes mellitus[J]. Chinese Journal of Antituberculosis, 2024, 46(8): 903-909. doi: 10.19982/j.issn.1000-6621.20240140

图/表 6

表1

表2

肺结核合并糖尿病患者发生营养不良的单因素分析

指标	非营养不良组(178例)	营养不良组(103例)	统计检验值	P值
年龄[岁, M(Q₁,Q₃)]	53.7(48.0,62.0)	71.3(67.0,79.0)	Z=-3.287	<0.001
吸烟[例(构成比,%)]			χ²=3.845	0.048
否	131(73.60)	66(64.08)
是	47(26.40)	37(35.92)
病程[例(构成比,%)]			χ²=20.163	<0.001
≤1个月	74(41.57)	12(11.65)
>1个月	104(58.43)	91(88.35)
肺部病灶范围[例(构成比,%)]			χ²=1.558	0.212
单一肺叶病变	99(55.62)	60(58.25)
多肺叶病变	79(44.38)	43(41.75)
合并肺外结核[例(构成比,%)]			χ²=0.268	0.761
否	154(86.52)	91(88.35)
是	24(13.48)	12(11.65)
患者类型[例(构成比,%)]			χ²=0.000	0.975
初治	142(79.78)	85(82.52)
复治	36(20.22)	18(17.48)
血红蛋白[g/L, M(Q₁,Q₃)]	114.0(101.0,126.0)	105.6(90.0,119.0)	Z=-2.114	0.035
C反应蛋白[mg/L,M(Q₁,Q₃)]	11(7,16)	14(11,19)	Z=-2.359	0.018
糖化血红蛋白[%, M(Q₁,Q₃)]	8.3(6.5,10.4)	11.4(8.9,14.6)	Z=-3.288	<0.001
淋巴细胞计数[×10⁹/L, M(Q₁,Q₃)]	4.3(2.8,5.9)	4.5(2.8,6.2)	Z=-1.043	0.516
查尔森并发症指数[分,M(Q₁,Q₃)]	2(1,3)	2(2,3)	Z=-5.153	<0.001
衰弱状况[例(构成比,%)]			χ²=10.672	<0.001
无衰弱	58(32.58)	21(20.39)
衰弱前期	67(37.64)	36(34.96)
衰弱期	53(29.78)	46(44.65)
自理能力得分(分, $x ˉ$ ±s)	95.30±6.78	81.90±4.63	t=2.091	0.037

表2

表3

表4

肺结核合并糖尿病患者发生营养不良影响因素的多因素logistic回归分析

因素	β值	s $x ˉ$ 值	Wald χ²值	P值	OR值	95%CI值
年龄	0.071	0.604	4.879	0.026	3.796	1.159~12.627
病程>1个月	0.576	0.537	9.475	0.002	5.711	1.879~17.274
糖化血红蛋白	0.074	0.694	6.671	0.010	5.951	1.517~23.269
查尔森并发症指数	0.081	0.629	11.057	0.001	8.079	2.345~27.681
衰弱状况≥3分	0.079	0.673	10.645	0.001	9.145	2.404~34.172
常数	-6.333	0.968	23.724	<0.001	-	-

表4

图1

图2

参考文献 30

[1]	Ugarte-Gil C, Curisinche M, Herrera-Flores E, et al. Situation of the tuberculosis-diabetes comorbidity in adults in Peru: 2016—2018. Rev Peru Med Exp Salud Publica, 2021, 38(2): 254-260. doi:10.17843/rpmesp.2021.382.67647. pmid: 34468572
[2]	邓国防, 成诗明. 浅谈我国结核病与糖尿病共病治疗管理现状. 中国防痨杂志, 2021, 43(1): 23-25. doi:10.3969/i.issn.1000-6621.2021.01.005.
[3]	Traub J, Reiss L, Aliwa B, et al. Malnutrition in patients with liver cirrhosis. Nutrients, 2021, 13(2): 540. doi:10.3390/nu130205409.
[4]	Sacerdote A, Dave P, Lokshin V, et al. Type 2 Diabetes Mellitus, Insulin Resistance, and Vitamin D. Curr Diab Rep, 2019, 19(10): 101. doi:10.1007/s11892-019-1201-y.
[5]	Ma L, Chen X, Gao M. Analysis on the Risk Factors of Malnutrition in Type 2 Diabetes Mellitus Patients with Pulmonary Tuberculosis. Infect Drug Resist, 2022, 15: 7555-7564. doi:10.2147/IDR.S381392. pmid: 36575673
[6]	罗小青, 段思雨, 林铭钰, 等. 结核病并发糖尿病住院患者的营养风险及其影响因素. 中国防痨杂志, 2021, 43(1): 42-46. doi:10.3969/i.issn.1000-6621.2021.01.009.
[7]	熊六波, 罗梦, 贺建清. 肺结核与2型糖尿病共病患者营养不良调查及临床特点研究. 中国呼吸与危重监护杂志, 2024, 23(3): 173-177. doi:10.7507/1671-6205.202311056.
[8]	Zhao X, Yuan Y, Lin Y, et al. Vitamin D status of tuberculosis patients with diabetes mellitus in different economic areas and associated factors in China. PLoS One, 2018, 13(11): e0206372. doi:10.1371/journal.pone.0206372.
[9]	夏万元. 线性回归和logistic回归模型样本量计算的图示化探索研究. 重庆: 重庆医科大学, 2019.
[10]	中华人民共和国国家卫生和计划生育委员会. WS 288— 2017 肺结核诊断. 2017-11-09.
[11]	中华医学会糖尿病学分会. 中国2型糖尿病防治指南(2020年版). 中华糖尿病杂志, 2021, 13(4): 315-409. doi:10.19538/j.nk2021090106.
[12]	方雪娥, 毛燕君. 肺结核患者营养管理护理实践专家共识. 中国防痨杂志, 2024, 46(5): 495-501. doi:10.19982/j.issn.1000-6621.20240071.
[13]	杨宇, 练玉颖, 赵铟. 全球领导人营养不良倡议标准、患者全面主观营养评估及血清白蛋白在肿瘤患者营养不良诊断中的一致性研究. 实用临床医药杂志, 2022, 26(2): 82-87. doi:10.7619/jcmp.20212940.
[14]	刘一典. 复治肺结核病诊断和治疗专家共识. 中国防痨杂志, 2021, 43(12): 1226-1238. doi:10.3969/j.issn.1000-6621.2021.12.002.
[15]	Charlson ME, Carrozzino D, Guidi J, et al. Charlson Comorbidity Index: A Critical Review of Clinimetric Properties. Psychother Psychosom, 2022, 91(1): 8-35. doi:10.1159/000521288. pmid: 34991091
[16]	Yamato Y, Kamiya K, Hamazaki N, et al. Utility of the Fatigue, Resistance, Ambulation, Illness, and Loss of weight Scale in Older Patients with Cardiovascular Disease. J Am Med Dir Assoc, 2022, 23(12): 1971-1976.e2. doi:10.1016/j.jamda.2022.08.006.
[17]	George JT, Miraclin AT, Sathyendra S, et al. Pulmonary tuberculosis and diabetes mellitus: Clinical profile and outcomes. Int J Mycobacteriol, 2022, 11(4): 400-406. doi:10.4103/ijmy.ijmy_154_22. pmid: 36510925
[18]	Armstrong LR, Kammerer JS, Haddad MB. Diabetes mellitus among adults with tuberculosis in the USA, 2010—2017. BMJ Open Diabetes Res Care, 2020, 8(1): e001275. doi:10.1136/bmjdrc-2020-001275.
[19]	Kichloo A, Shaka H, El-Amir Z, et al. In-patient outcomes of patients with diabetic ketoacidosis and concurrent protein energy malnutrition: A national database study from 2016 to 2017. Postgrad Med, 2021, 133(8): 854-859. doi:10.1080/00325481.2021.1916231.
[20]	Ter Beek L, Bolhuis MS, Jager-Wittenaar H, et al. Malnutrition assessment methods in adult patients with tuberculosis: a systematic review. BMJ Open, 2021, 11(12): e049777. doi:10.1136/bmjopen-2021-049777.
[21]	丁芹, 张胜康, 任斐, 等. 耐药肺结核患者的营养状况调查及影响因素分析: 一项多中心、大样本研究. 中国防痨杂志, 2023, 45(9): 826-832. doi:10.19982/j.issn.1000-6621.20230047.
[22]	孔含含, 张娇红, 曾剑锋, 等. 老年肺结核患者衰弱风险预测模型的构建及验证. 中国防痨杂志, 2024, 46(1): 85-91. doi:10.19982/j.issn.1000-6621.20230329.
[23]	Akkerman OW, Ter Beek L, Centis R, et al. Rehabilitation, optimized nutritional care, and boosting host internal milieu to improve long-term treatment outcomes in tuberculosis patients. Int J Infect Dis, 2020, 92S: S10-S14. doi:10.1016/j.ijid.2020.01.029.
[24]	林芳, 刘素贞, 江海燕. 老年2型糖尿病患者营养不良的影响因素分析. 预防医学, 2024, 36(1): 61-64,69. doi:10.19485/j.cnki.issn2096-5087.2024.01.016.
[25]	Raphael A, Friger M, Biderman A. Seasonal variations in HbA1c among type 2 diabetes patients on a semiarid climate between the years 2005—2015. Prim Care Diabetes, 2021, 15(3): 502-506. doi:10.1016lj.pcd.2020.11.013. pmid: 33309124
[26]	把明勤. 术前NRS2002和PNI营养筛查方法在消化道肿瘤术后并发症预测中的价值分析. 合肥:安徽医科大学, 2024.
[27]	高婷婷, 陈天娇, 时诗柔. 老年糖尿病群体衰弱现状及其影响因素. 中华老年多器官疾病杂志, 2024, 23(2): 114-117. doi:10.11915/i.issn.1671-5403.2024.02.022.
[28]	Singh A, Kukreti R, Saso L, et al. Mechanistic insight into oxidative stres-riggered signaling pathways and type 2 diabetes. Molecules, 2022, 27(3): 950. doi:10.3390/molecules27030950.
[29]	Akan S, Aktas G. Relationship between frailty.according to three fail cores,and clinical and laboratory parameters of the geriatric patients with type 2 Diabetes Mellitus. Rev Assoc Med Bras(1992), 2022, 68(8): 1073-1077. doi:10.1590/1806-9282.20220271.
[30]	邓猛聪, 王昕, 吴尚纯, 等. 受试者工作特征曲线(ROC曲线)的应用分析. 中国计划生育学杂志, 2024, 32(2): 467-473. doi:10.3969/i.issn.1004-8189.2024.02.045.

评分	合并症项目
1	心肌梗死(有发作史,并不仅仅是心电图改变)、充血性心力衰竭、周围血管疾病、脑血管疾病、痴呆、慢性肺病、结缔组织疾病、消化性溃疡疾病、轻度肝病、无终末器官损伤的糖尿病
2	偏瘫、中度或重度肾脏疾病、糖尿病伴有终末期器官损害、无转移肿瘤、白血病、淋巴瘤
3	中度或重度肝病
6	转移性实体瘤病、艾滋病

变量	赋值
年龄	原值输入
吸烟	否=0;是=1
病程	≤1个月=0;>1个月=1
血红蛋白(g/L)	原值输入
C反应蛋白(mg/L)	原值输入
糖化血红蛋白(%)	原值输入
查尔森并发症指数(分)	原值输入
衰弱状况	无衰弱期=0;衰弱前期=1;衰弱期=2
自理能力得分	原值输入