目的 探索维持性血液透析(maintenance haemodialysis，MHD)患者骨折发生的影响因素。 方法 前瞻性选取西安市中医医院2020年8月—2022年12月收治的MHD患者，以7:3比例随机分为建模组与验证组，根据建模组患者是否发生骨折将建模组分为骨折组和非骨折组。多因素Logistic回归分析MHD患者发生骨折的危险因素；R软件构建预测MHD患者发生骨折的列线图模型。绘制ROC曲线评估预测患者发生骨折的列线图模型区分度；绘制校准曲线评估模型的一致性。 结果 共纳入358例患者，其中建模组251例，验证组107例。建模组38例患者发生骨折，骨折发生率为15.14%。骨折组年龄≥65岁、性别女、全段甲状旁腺激素(iPTH)≥300 ng/L占比高于非骨折组(χ2=13.014、11.765、10.158，P＜0.001、0.001、0.001)，服用活性维生素D、骨骼肌质量指数低于非骨折组(χ2/t=13.553，6.138，均P＜0.001)。骨折发生类型最多的为椎体压缩性骨折(31.58%)，其次为髋部骨折(23.68%)。多因素Logistic回归分析得出：年龄(OR=11.150，95% CI：3.790～32.086，P＜0.001)、性别(OR=5.443，95% CI：1.977～14.985，P=0.001)、iPTH(OR=31.784，95% CI：9.457～106.826，P＜0.001)是MHD患者发生骨折的危险因素，骨骼肌质量指数(OR=0.421，95% CI：0.200～0.885，P=0.022)、服用活性维生素D(OR=0.055，95% CI：0.014～0.206，P＜0.001)是保护因素。建模组AUC为0.872，H-L检验χ2=7.124，P=0.704。验证组AUC为0.924，H-L检验χ2=6.353，P=0.687。 结论 年龄、性别、iPTH是MHD患者发生骨折的危险因素，骨骼肌质量指数、服用活性维生素D是保护因素。以此构建的列线图模型可较好预测MHD患者发生骨折的风险。
Objective To investigate the influencing factors of fracture occurrence in maintenance hemodialysis (MHD) patients. Methods A prospective cohort of MHD patients admitted to Xi'an Hospital of Traditional Chinese Medicine from August 2020 to December 2022 was selected and randomly divided into a modeling group and a validation group in a 7:3 ratio. The modeling group was further categorized into fracture and non-fracture subgroups based on fracture occurrence. Multivariate logistic regression was used to analyze risk factors for fractures in MHD patients. A nomogram model for predicting fracture risk was constructed using R software. Receiver operating characteristic (ROC) curves were plotted to evaluate the discriminative ability of the nomogram, and calibration curves were generated to assess model consistency. Results A total of 358 patients were included, with 251 in the modeling group and 107 in the validation group. In the modeling group, 38 patients (15.14%) experienced fractures. The fracture group had higher proportions of patients aged ≥65 years, females, and those with intact parathyroid hormone (iPTH) ≥300 ng/L compared to the non-fracture group (χ²=13.014, 11.765, 10.158; P＜0.001, 0.001, 0.001, respectively). The fracture group also showed lower rates of active vitamin D supplementation and lower skeletal muscle mass index (χ²/t = 13.553, 6.138; both P＜0.001). The most common fracture type was vertebral compression fractures (31.58%), followed by hip fractures (23.68%). Multivariate logistic regression identified that the risk factors were age ≥65 years (OR=11.150, 95% CI: 3.790～32.086; P＜0.001), female sex (OR=5.443, 95% CI: 1.977～14.985; P=0.001), and iPTH ≥300 ng/L (OR=31.784, 95% CI: 9.457～106.826; P＜0.001); while higher skeletal muscle mass index (OR=0.421, 95% CI: 0.200～0.885; P=0.022) and active vitamin D supplementation (OR=0.055, 95% CI: 0.014～0.206; P＜0.001) were protective factors. The area under the ROC curve (AUC) was 0.872 for the modeling group (Hosmer-Lemeshow test: χ²=7.124, P=0.704) and 0.924 for the validation group (Hosmer-Lemeshow test: χ²=6.353, P=0.687), indicating good discrimination and calibration. Conclusion Age, female sex, and elevated iPTH are independent risk factors for fractures in MHD patients, while higher skeletal muscle mass index and active vitamin D supplementation serve as protective factors. The constructed nomogram model demonstrated good predictive performance for fracture risk in this population.
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