3种营养指数预测慢性阻塞性肺疾病患者全因死亡率的研究

Three nutritional indices are effective predictors of all-cause mortality in patients with chronic obstructive pulmonary disease

摘要

目的：评估3项营养指标在预测慢性阻塞性肺疾病（chronic obstructive pulmonary disease,COPD）患者全因死亡率方面的有效性。方法：基于美国国家健康与营养调查（National Health and Nutrition Examination Survey,NHANES），本研究纳入了1999至2018年调查的1 640例COPD患者。通过受试者工作特征（receiver operating characteristic,ROC）曲线确定控制营养状况（controlling nutritional status,CONUT）评分、老年营养风险指数（geriatric nutritional risk index,GNRI）、和预后营养指数（prognostic nutritional index,PNI）的最佳临界值。采用ROC曲线下面积（areas under curve,AUC）及C指数评估营养指标的预测价值，并通过净重新分类指数（net reclassification improvement,NRI）和综合判别改善指数（integrated discrimination improvement,IDI）比较各营养指标的预测能力。采用Cox回归分析探讨3个营养指标与全因死亡率之间的关联。结果：对数秩检验显示，营养风险较高的患者总生存率较低（均P<0.001）。在调整所有协变量的多因素Cox回归中，CONUT评分（HR=1.31,95%CI=1.03～1.67,P=0.030）、GNRI(HR=2.02,95%CI=1.26～3.24,P=0.004)和PNI(HR=2.05,95%CI=1.53～2.75,P<0.001)与全因死亡率独立相关。结论：3项营养指标均为COPD患者全因死亡率的有效预测指标。相较于PNI,CONUT评分和GNRI的预测能力更强，因此更推荐用于COPD高危营养不良的常规筛查。

Abstract

Objective Malnutrition is prevalent among patients with chronic obstructive pulmonary disease（COPD） and closely associated with adverse outcomes. This study aimed to evaluate the effectiveness of three nutritional indices in predicting all-cause mortality among COPD patients. Methods Based on the National Health and Nutrition Examination Survey（NHANES），this study included 1640 patients with COPD surveyed from 1999 to 2018. The optimal cutoff values for controlling nutritional status（CONUT） score，geriatric nutritional risk index（GNRI），and prognostic nutritional index（PNI） were determined using receiver operating characteristic curves. The predictive value of these nutritional indices was assessed using the area under the receiver operating characteristic curve and C-index. Their predictive abilities were compared using the net reclassification improvement and integrated discrimination improvement. A Cox regression analysis was conducted to explore the association of the three nutritional indices with all-cause mortality. Results Log-rank tests revealed lower overall survival rates in patients with higher nutritional risks（P<0.001）. In multivariate Cox regression adjusting for all covariates，CONUT score（hazard ratio ［HR］=1.31，95%CI=1.03-1.67，P=0.030），GNRI（HR=2.02，95%CI=1.26-3.24，P=0.004），and PNI（HR=2.05，95%CI=1.53-2.75，P<0.001） were independently associated with all-cause mortality. Conclusion This study confirms that the three nutritional indices are effective predictors of all-cause mortality in COPD patients. Compared with PNI，CONUT score and GNRI demonstrate improved predictive abilities，and they are recommended for routine screening for high-risk malnutrition in COPD patients.

关键词

慢性阻塞性肺疾病 / 营养不良 / 全因死亡率 / 营养评价 / 美国国家健康与营养调查数据库

Key words

chronic obstructive pulmonary disease / malnutrition / all-cause mortality / nutrition assessment / NHANES database

基金资助

国家重点研发计划资助项目(2020YFC2008605;2020YFC2008600)

国家自然科学基金资助项目(82370055)