术前营养相关指标对上尿路尿路上皮癌根治术后生存结局的预测价值

Comparison of preoperative nutritional scoring systems for predicting survival in up- per tract urothelial carcinoma

摘要

目的：探讨术前营养相关指标与上尿路尿路上皮癌（upper tract urothelial carcinoma，UTUC）患者根治性肾输尿管切除术（radical nephroureterectomy，RNU）后生存结局的相关性，并比较不同营养评分体系的预测效能。方法：选择2007年1月至2021年4月在北京大学人民医院接受 RNU 治疗 UTUC 患者的病例资料进行回顾性分析，收集术前临床病理资料及实验室指标，计算老年营养风险指数（geriatric nutritional risk index，GNRI）、预后营养指数（prognostic nutritional index，PNI）、控制营养状态评分（controlling nutritional status，CONUT），以及甘油三酯-总胆固醇-体重指数（triglycerides-total cholesterol-body weight index，TCBI）。采用 Cox 比例风险模型进行单因素和多因素分析，单因素分析中 (P<0.05) 的变量通过向后逐步回归法（基于 Akaike 信息准则）筛选纳人多因素模型并构建列线图，以总生存期（overall survival，OS）和癌症特异性生存期（cancer-specific survival，CSS）为主要终点指标，采用Kaplan-Meier 法绘制生存曲线并进行 Log-rank 检验，应用时间依赖性受试者工作特征曲线（time-dependent receiver operating characteristic curve，time-dependent ROC）评估各营养指标预测效能。结果：研究共纳入 481 例 UTUC 患者。多因素分析显示，OS 的独立影响因素包括病理分期 T3/T4 期、N1/N2 期、WHO/ISUP（World Health Organization/International Society of Urological Pathology）高级别、估算的肾小球滤过率（estimated glomerular filtration rate，eGFR）、输血、输尿管末端处理、GNRI 及 PNI P<0.05 ；CSS 的独立影响因素包括病理分期 T2~T4 期、N1/N2 期、术式（腹腔镜）、输血、GNRI 及 PNI（P<0.05）。基于独立影响因素构建的列线图具有良好的校准度，GNRI< 98 组、PNI< 52组患者 OS 和 CSS 明显缩短（Log-rank  ^1*）。60个月时，GNRI 和 PNI 预测 OS 的曲线下面积（area under the curve，AUC）分别为 0.623 和 0.632 ，预测 CSS 的 AUC 分别为 0.632 和 0.645 。时间依赖性 ROC 分析显示，GNRI 和PNI 两指标对 CSS 的预测效能较为稳定，对 OS 的预测能力随随访时间延长呈轻度增强趋势。结论：术前 GNRI 和PNI 与 UTUC 患者 RNU 术后 OS 和 CSS 独立相关，在不同随访阶段均具有稳定的预测能力。

Abstract

Objective：To investigate the association between preoperative nutritional indicators and survival outcomes in patients with upper tract urothelial carcinoma（UTUC）undergoing radical nephroureterectomy（RNU），and to compare the predictive performance of different nutritional scoring systems. Methods：A retrospective analysis was conducted on UTUC patients who underwent RNU.Nu- tritional scores[geriatric nutritional risk index（GNRI），prognostic nutritional index（PNI），controlling nutritional status（CONUT），triglycerides-total cholesterol-body weight index（TCBI）]were calculated. Variables with P<0.05 in univariable Cox regression were entered into multivariable analysis using back- ward stepwise selection based on the Akaike Information Criterion（AIC）to identify independent predictors and construct a nomogram.Kaplan-Meier curves with log-rank tests and time-dependent ROC curves were applied for survival analysis.A two-sided P<0.05 was considered statistically significant. Results：A total of 481 UTUC patients were included.Multivariable analysis identified pathological T3/ T4 stage，N1/N2 stage，high World Health Organization/International Society of Urological Pathology （WHO/ISUP）grade，estimated glomerular filtration rate（eGFR），blood transfusion，ureteral manage- ment，GNRI，and PNI as independent predictors of overall survival（OS）（(P<0.05)）.Independent pre- dictors of cancer-specific survival（CSS）included pathological T2-T4 stage，N1/N2 stage，laparoscopic surgical approach，blood transfusion，GNRI，and PNI P<0.05.The nomogram constructed based on these independent predictors demonstrated good calibration.Patients with GNRI< 98 or PNI< 52 had sig- nificantly shorter OS and CSS（Log-rank）.At the end of 60 months，the area under the curve （AUC）values of GNRI and PNI for predicting OS were 0.623 and 0.632 ，respectively，and for predicting CSS were 0.632 and 0.645 ，respectively.Time-dependent ROC analysis showed that both indicators had stable predictive performance for CSS，while their predictive ability for OS showed a mild increasing trend over the follow-up time. Conclusion：Preoperative GNRI and PNI are independently associated with OS and CSS in patients with UTUC after RNU，demonstrating stable predictive performance across different fol- low-up periods.

关键词

上尿路尿路上皮癌 / 术前营养 / 总生存期 / 癌症特异性生存期

Key words

Upper tract urothelial carcinoma / Preoperative nutrition / Overall survival / Cancer-specific survival

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基金资助

科技创新2030—＂癌症、心脑血管、呼吸和代谢性疾病防治研究＂国家科技重大专项(2024ZD0525700)

国家自然科学基金(82471866)

国家自然科学基金(82472912)

北京市自然科学基金(L252190)