乳酸与白蛋白比值与危重阻塞性睡眠呼吸暂停患者28天死亡率的关联：基于MIMIC-IV数据库的回顾性队列研究

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中文摘要

背景： 阻塞性睡眠呼吸暂停（OSA）在危重患者中并不少见，尤其是在急性高碳酸血症性呼吸衰竭患者中。其高死亡率仍是重症监护环境中的重大挑战。OSA患者睡眠期间频繁发生呼吸暂停和呼吸衰竭，以及由此引起的间歇性低氧血症，伴随一系列全身病理生理变化。代谢失衡是该疾病潜在病理机制的关键特征。然而，乳酸与白蛋白比值（LAR）与OSA患者预后之间的关联仍有待充分阐明。迄今为止，评估这些指标预后能力的研究很少。其中大多数研究集中于中性粒细胞与淋巴细胞比值（NLR）和血小板与淋巴细胞比值（PLR），且结果相互矛盾，不足以充分阐明其临床意义。仅依赖乳酸可能无法完全反映患者的生理状况，而整合LAR可提供更全面、更准确的代谢状态描述。本研究旨在利用MIMIC-IV数据库数据，探讨LAR与ICU中OSA患者28天死亡率之间的关系。
方法： 从重症监护医学信息库IV（v.2.2）数据库中选取诊断为OSA的患者，通过特定ICD-9和ICD-10编码识别（详见方法部分）。为评估LAR的预测能力，采用了受试者工作特征（ROC）曲线分析、Kaplan-Meier（K-M）生存曲线分析、logistic回归分析和亚组分析。LAR既作为分类变量（基于最佳截断值）分析，也作为连续变量分析。
结果： 样本人群包括807例首次入住重症监护室的OSA患者。28天死亡率为20.44%。LAR的ROC曲线下面积（AUC）为0.730（95% CI：0.686-0.772），与OASIS（0.736；95% CI：0.695-0.776）相当，优于SOFA（0.637；95% CI：0.591-0.683；DeLong检验 p = 0.500）。LAR的最佳截断值为0.791。在K-M分析中，高LAR组预后较差（p < 0.001）。多因素logistic回归显示LAR与不良结局显著相关，作为二分类变量分析时比值比（OR）为3.00（95% CI：1.83-4.90，p < 0.001），作为连续变量分析时每单位增加OR为1.52（95% CI：1.27-1.82，p < 0.001）。亚组分析显示LAR与任何亚组之间均无统计学显著交互作用（交互作用p值：0.052-0.906）。
结论： LAR是一种合理且易于获取的生物标志物，与ICU中OSA患者的28天死亡率显著相关。这些发现仅适用于在ICU入院期间接受乳酸和白蛋白检测的OSA患者，结果不能推广至所有ICU OSA患者。

英文摘要

BACKGROUND: Obstructive sleep apnea (OSA) is not uncommon among critically ill patients, especially in those with acute hypercapnic respiratory failure. Its high mortality rate remains a major challenge in the intensive care setting. The frequent apnea and respiratory failure during sleep in OSA patients, along with the intermittent hypoxemia caused by it, are accompanied by a series of systemic pathological and physiological changes. Metabolic imbalance is a key characteristic of the underlying pathological mechanism of this disease. However, the association between lactate-to-albumin ratio (LAR) and the prognosis of OSA patients remains to be fully elucidated. To date, a paucity of studies has evaluated the prognostic capabilities of these indicators. The majority of these studies have focused on the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR), and the results are contradictory, insufficient to fully clarify their clinical significance. Relying solely on lactate may not fully reflect patients' physiological conditions, whereas integrating LAR can provide a more comprehensive and accurate description of the metabolic state. This study aims to explore the relationship between LAR and 28-day mortality rates in ICU patients with OSA, using data from the MIMIC-IV database.
METHODS: Patients diagnosed with OSA were selected from the Medical Information Mart for Intensive Care IV (v.2.2) database, identified by specific ICD-9 and ICD-10 codes (detailed in the Methods section). To assess the predictive power of LAR, receiver operating characteristic (ROC) curve analysis, Kaplan-Meier (K-M) survival curve analysis, logistic regression analysis, and subgroup analysis were employed. LAR was analyzed both as a categorical variable (based on the optimal cutoff) and as a continuous variable.
RESULTS: The sample population comprised 807 patients diagnosed with OSA who were admitted to the intensive care unit for the first time. The 28-day mortality rate was 20.44%. The area under the ROC curve (AUC) for LAR was 0.730 (95% CI: 0.686-0.772), which was comparable with OASIS (0.736; 95% CI: 0.695-0.776) and superior to SOFA (0.637; 95% CI: 0.591-0.683; DeLong test p = 0.500). The optimal cutoff value for LAR was 0.791. The high-LAR group demonstrated a poor prognosis in the K-M analysis (p < 0.001). Multivariate logistic regression demonstrated a significant association between LAR and unfavorable outcomes, with an odds ratio (OR) of 3.00 (95% CI: 1.83-4.90, p < 0.001) when analyzed as a dichotomous variable, and an OR of 1.52 per unit increase (95% CI: 1.27-1.82, p < 0.001) when analyzed as a continuous variable. Subgroup analysis revealed no statistically significant interaction between LAR and any subgroup (p for interaction: 0.052-0.906).
CONCLUSION: LAR is a rational and easily accessible biomarker that is significantly associated with 28-day mortality in ICU patients with OSA. These findings are only applicable to OSA patients who received lactate and albumin testing during ICU admission, and the results cannot be generalized to the entire population of ICU patients with OSA.