Fisher Alexander, Fisher Leon, Srikusalanukul Wichat, Smith Paul N
Department of Geriatric Medicine, The Canberra Hospital, ACT Health, Canberra, Australia; Department of Orthopaedic Surgery, The Canberra Hospital, ACT Health, Canberra, Australia; Australian National University Medical School, Canberra, ACT, Australia.
Frankston Hospital, Peninsula Health, Melbourne, Australia.
Injury. 2018 Apr;49(4):829-840. doi: 10.1016/j.injury.2018.03.005. Epub 2018 Mar 8.
The data on predictive value of the routinely obtained preoperative biochemical parameters in hip fracture (HF) patients are limited. The aims of this study were to examine in older HF patients (1) the relationships between a broad set of routine laboratory parameters at admission and in-hospital mortality, and (2) evaluate the prognostic value the biomarkers and clinical characteristics (alone or in combination) provide to predict a fatal outcome.
In 1820 consecutive patients with low-trauma osteoporotic HF aged >60 years (mean age 82.8 ± 8.1 years; 76.4% women; 65% community-dwelling) 35 laboratory variables along with 20 clinical and socio-demographic characteristics at admission were analysed. The validation cohort included data on 455 older (≥60 years of age) HF patients (mean age 82.1 ± 8.0 years, 72.1% women).
The mortality rate was 6% (n = 109). On univariate analysis 14 laboratory and 8 clinical parameters have been associated with in-hospital mortality. Multiple regression analyses determined 7 variables at admission as independent indicators of a fatal outcome: 4 biomarkers (albumin <33 g/L; alanine aminotransferase/gamma-glutamyl transferase ratio [GGT/ALT] >2.5; parathyroid hormone [PTH] >6.8 pmol/L; 25(OH)vitamin D < 25 nmol/L) and 3 pre-fracture clinical conditions (history of myocardial infarction, chronic kidney disease [GFR <60 ml/min/1.73 m] and chronic obstructive pulmonary disease); the area under the receiver operating characteristic curve (AUC) was 0.75 (95%CI 0.70-0.80). The risk of in-hospital death was 1.6-2.6 times higher in subjects with any of these risk factors (RFs), and increased by 2.6-6.0-fold in patients with any two RFs (versus no RFs). The mortality rate increased stepwise as the number of RFs increased (from 0.43% -none RF to 16.8%- ≥4RF). The prognostic value of a single RF was low (AUC ≤0.635) but combination of 2 or more RFs improved the prediction significantly; AUC reached 0.84(95%CI 0.77-0.90) when ≥4 RFs (versus 0-1RF) were present. In the validated and main cohorts the number of predicted by 1, 2, 3 or ≥4 RFs and observed deaths were practically similar.
In HF patients, seven easily identifiable at admission characteristics, including 4 biomarkers, are strong and independent indicators of in-hospital mortality and can be used for risk stratification and individualised management.
关于髋部骨折（HF）患者常规术前生化参数预测价值的数据有限。本研究的目的是在老年HF患者中：（1）研究入院时一系列常规实验室参数与院内死亡率之间的关系；（2）评估生物标志物和临床特征（单独或联合）预测致命结局的预后价值。
对1820例年龄>60岁的低创伤性骨质疏松性HF连续患者（平均年龄82.8±8.1岁；76.4%为女性；65%为社区居住者）进行分析，测定入院时35项实验室指标以及20项临床和社会人口学特征。验证队列包括455例年龄≥60岁的老年HF患者（平均年龄82.1±8.0岁，72.1%为女性）的数据。
死亡率为6%（n=109）。单因素分析显示，14项实验室指标和8项临床参数与院内死亡率相关。多元回归分析确定入院时7项变量为致命结局的独立指标：4种生物标志物（白蛋白<33g/L；丙氨酸转氨酶/γ-谷氨酰转移酶比值[GGT/ALT]>2.5；甲状旁腺激素[PTH]>6.8pmol/L；25（OH）维生素D<25nmol/L）和3种骨折前临床情况（心肌梗死病史、慢性肾脏病[肾小球滤过率<60ml/min/1.73m²]和慢性阻塞性肺疾病）；受试者工作特征曲线下面积（AUC）为0.75（95%CI 0.70-0.80）。具有任何一种这些危险因素（RFs）的受试者院内死亡风险高1.6-2.6倍，具有任何两种RFs的患者死亡风险增加2.6-6.0倍（与无RFs者相比）。死亡率随着RFs数量的增加而逐步上升（从无RFs时的0.43%到≥4个RFs时的16.8%）。单一RF的预后价值较低（AUC≤0.635），但2种或更多RFs的联合可显著改善预测；当存在≥4个RFs（与0-1个RFs相比）时，AUC达到0.84（95%CI 0.77-0.90）。在验证队列和主要队列中，由1、2、3或≥4个RFs预测的死亡人数与观察到的死亡人数实际相似。
在HF患者中，入院时易于识别的7项特征，包括4种生物标志物，是院内死亡率的强有力独立指标，可用于风险分层和个体化管理。
