AKI-CLIF-SOFA: a novel prognostic score for critically ill cirrhotic patients with acute kidney injury

A prediction model for 30-day mortality of sepsis patients based on intravenous fluids and electrolytes

To establish a prediction model for the 30-day mortality in sepsis patients. The data of 1185 sepsis patients were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) and all participants were randomly divided into the training set (n = 829) and the testing set (n = 356). The model was established in the training set and verified in the testing set. After standardization of the data, age, gender, input, output, and variables with statistical difference between the survival group and the death group in the training set were involved in the extreme gradient boosting (XGBoost) model. Subgroup analysis was performed concerning age and gender in the testing set. In the XGBoost model with variables related to intravenous (IV) fluid management and electrolytes for the 30-day mortality of sepsis patients, the area under the curve (AUC) was 0.868 (95% confidence interval [CI]: 0.867-0.869) in the training set and 0.781 (95% CI: 0.779-0.782) in the testing set. The sensitivity was 0.815 (95% CI: 0.774-0.857) in the training set and 0.755 (95% CI: 0.686-0.825) in the testing set. The specificity was 0.761 (95% CI: 0.723-0.798) in the training set, and 0.737 (95% CI: 0.677-0.797) in the testing set. In the XGBoost forest model without variables related to IV fluid management and electrolytes for the 30-day mortality of sepsis patients, in the training set, the AUC was 0.830 (95% CI: 0.829-0.831), the sensitivity was 0.717 (95% CI: 0.669-0.765), the specificity was 0.797 (95% CI: 0.762-0.833), and the accuracy was 0.765 (95% CI: 0.736-0.794). In the testing set, the AUC was 0.751 (95% CI: 0.750-0.753), the sensitivity was 0.612 (95% CI: 0.533-0.691), the specificity was 0.756 (95% CI: 0.698-0.814), and the accuracy was 0.697(95% CI: 0.649-0.744). The prediction model including variables associated with IV fluids and electrolytes had good predictive value for the 30-day mortality of sepsis patients.

Lactate and Bilirubin Index: A New Indicator to Predict Critically Ill Cirrhotic Patients’ Prognosis

Objectives. We aimed to perform external validation of the prognostic value of the lactate and bilirubin (LB) index, a new indicator, and compare the ability of the LB index and other scoring systems to predict both short- and long-term mortality in critically ill cirrhotic patients. Materials and Methods. A number of 479 cirrhotic patients admitted into ICU were included in our research. We measured prognostic scores in the first 24 hours including LB index, Child–Pugh, SOFA, CLIF-SOFA, and MELD scores. The LB index was calculated as follows: ln [1000 × lactate (mmol/L) × bilirubin (µmol/L)]/2. The primary outcomes were 28-day and 3-year all-cause mortality. Multivariate logistic regression analyses were used to investigate the independent association between the LB index and the mortality in critically ill cirrhotic patients. The area under the receiver operating characteristic curve was used to assess the prediction accuracy of short- and long-term mortality of the clinical score. Calibration of the score was evaluated by Hosmer–Lemeshow goodness-of-fit test for significance. Results. Multivariate logistic regression analysis identified that the LB index (odds ratio: 5.487, 95% confidence interval: 3.542–8.501, $P<0.001$ ) was the strongest predictor for 28-day mortality. The LB index gave the highest area under the curve (0.791, 95% confidence interval: 0.747–0.836) in predicting 28-day mortality. For predicting 3-year mortality, the model for end-stage liver disease (MELD) score showed better discrimination ability with an area under the curve of 0.726 (95% confidence interval: 0.680–0.771). The risk of mortality significantly increased when the clinical scores were ≥ the optimal cutoff values. Conclusions. The LB index, a simple prognostic indicator, performs well in predicting critically ill cirrhotic patients’ short-term prognosis, while, for long-term prognosis, the MELD score is more appropriate.

Prognostic value of international normalized ratio to albumin ratio among critically ill patients with cirrhosis

BACKGROUND AND AIM

Critically ill patients with cirrhosis are at an increased risk of mortality. Our study aimed to externally validate the ability of the prothrombin time-international normalized ratio to albumin ratio (PTAR), an objective and simple scoring system, to predict 90-day mortality in critically ill patients with cirrhosis.

PATIENTS AND METHODS

A total of 865 patients were entered into the study, and all the participants were followed up for at least 90 days. Clinical parameters on the first day of intensive care unit admission were included to compare survivors with nonsurvivors.

RESULTS

After multivariable adjustment, the association between the risk of 90-day mortality and PTAR remained statistically significant with a hazard ratio of 2.71 (95% confidence interval: 1.99-3.68). The PTAR score showed good discrimination ability for predicting 90-day mortality with an area under receiver operating characteristic curve of 0.72 (95% confidence interval: 0.68-0.75). To improve its feasibility, we regrouped the PTAR scores into three levels of risk (low risk: <0.55, intermediate risk: 0.55-1.00, and high risk: ≥1.00); the 90-day mortality rates were 20.1% (74/368), 41.7% (168/403), and 73.4% (69/94), respectively.

CONCLUSION

The PTAR score system is a convenient and practical tool for predicting the prognosis of critically ill patients with cirrhosis.

Metabolic Acidosis in Critically Ill Cirrhotic Patients with Acute Kidney Injury

Background and Aims: The metabolic acid-base disorders have a high incidence of acute kidney injury (AKI) in critically ill cirrhotic patients (CICPs). The aims of our study were to ascertain the composition of metabolic acidosis of CICPs with AKI and explore its relationship with hospital mortality. Methods: Three-hundred and eighty consecutive CICPs with AKI were eligible for the cohort study. Demographic, clinical and laboratory parameters were recorded and arterial acid-base state was analyzed by the Stewart and Gilfix methodology. Results: Net metabolic acidosis, lactic acidosis, acidosis owing to unmeasured anions, acidemia, and dilutional acidosis were less frequent in the non-survival group compared to the survival group of CICPs. The presence of acidemia, acidosis owing to unmeasured anions, and lactic acidosis were independently associated with increased risk of intensive care unit 30-day mortality, with hazard ratios of 2.11 (95% confidence interval (CI): 1.43-3.12), 3.38 (95% CI: 2.36-4.84), and 2.16 (95% CI: 1.47-3.35), respectively. After full adjustment for confounders, the relationship between acidosis owing to unmeasured anions with hospital mortality was still significant, with hazard ratio of 2.29 (95% CI: 1.22-4.30). Furthermore, arterial lactate concentration in combination with chronic liver failure-sequential organ failure assessment and BE_UMA had the strongest ability to differentiate 30-day mortality (area under the receiver operating characteristic curve: 0.79, 95% CI: 0.74-0.83). Conclusions: CICPs with AKI exhibit a complex metabolic acidosis during intensive care unit admission. Lactic acidosis and BE_UMA, novel markers of acid-base disorders, show promise in predicting mortality rate of CICPs with AKI.

Serum lactate level accurately predicts mortality in critically ill patients with cirrhosis with acute kidney injury

BACKGROUND AND AIM

Serum lactate levels are routinely measured in critically ill patients with cirrhosis, and hyperlactatemia is a common finding, but its prognostic value remains controversial. Our aim was to examine whether serum lactate level could be used as a predictor of outcome in critically ill patients with cirrhosis (CICP) with acute kidney injury (AKI).

PATIENTS AND METHODS

In this study, we included 480 consecutive patients with cirrhosis admitted to ICU, complicated with AKI, and were followed up for 365 days. Patients were divided into four groups (Q1-Q4) by serum lactate quartiles: Q1≤1.8 mg/dl, Q2=1.9-2.4 mg/dl, Q3=2.5-4.0 mg/dl, and Q4≥4.1 mg/dl. The hazard ratio (HR) and 95% confidence intervals (CIs) for hospital mortality were calculated across each quartile of serum lactate, using the Q1 as reference, and four models were built to adjust for the HR of mortality.

RESULTS

Compared with patients in the survival group, nonsurvivors had higher serum lactate levels. Mortality rate increased progressively as the serum lactate level increased (Q1: 56.06%, Q2: 62.16%, Q3: 72.73% and Q4: 75.86%), and this relationship remained statistically significant after rigorous control of confounding factors in Q2, Q3, and Q4 with HRs of 1.03 (95% CI: 0.73-1.46), 1.40 (95% CI: 1.01-1.95), and 1.84 (95% CI: 1.28-2.64), respectively.

CONCLUSION

Our study brings a new perspective to the role of lactate monitoring in CICP with AKI. Elevated serum lactate levels are associated with a higher mortality rate in CICP with AKI. Elevated serum lactate levels should be part of rapid diagnosis and initiation of therapy to improve clinical outcome.

Data collection and research with MargheritaTre

OBJECTIVE

MargheritaTre is an electronic health record developed by the Italian Group for the Evaluation of Interventions in Intensive Care Medicine designed to support clinical practice in intensive care units (ICUs) and ensure high-quality data for research purposes.

APPROACH

MargheritaTre was developed in collaboration with clinical experts, researchers, and IT specialists. It is currently installed in 40 ICUs and its database contains complete records of more than 65,000 patients. To facilitate data analysis, information is mostly stored in structured or partially structured form.

MAIN RESULTS

Data collected with MargheritaTre allow one to conduct research studies on complex clinical problems from manifold perspectives and with different levels of detail, such as epidemiological studies, analyses of the process of care and physiopathological investigations, at both single-organ and organism level. In this paper we describe some of the first projects based on this electronic health record to illustrate its potential for research.

SIGNIFICANCE

The MargheritaTre database is a huge and rapidly growing mine of data that will be exploited by our laboratory and shared with other groups to address complex and innovative research and clinical questions. The ultimate aim of these projects is the improvement of the quality of care and patient outcomes, through the development of expert systems integrated in the electronic health record to support clinical practice.

Remodeling the model for end-stage liver disease for predicting mortality risk in critically ill patients with cirrhosis and acute kidney injury

Serum creatinine measurement demonstrates a poor specificity and sensitivity for the early diagnosis of acute kidney injury (AKI) in patients with cirrhosis. The existing model for end‐stage liver disease (MELD) score reveals multiple pitfalls in critically ill patients with cirrhosis and acute kidney injury (CAKI). The aim of this study was to re‐evaluate the role of creatinine values in the existing MELD score and to develop a novel score for CAKI, named the “acute kidney injury–model for end‐stage liver disease score” (AKI‐MELD score). We extracted 651 CAKI from the Multiparameter Intelligent Monitoring in Intensive Care database. A time‐dependent Cox regression analysis was performed for developing remodeled MELD scores (Reweight‐MELD score, Del‐Cr‐MELD score, and AKI‐MELD score). The area under the receiver operating characteristic curve provided the discriminative power of scoring models related to outcome. The hazard ratio of creatinine was 1.104 (95% confidence interval [CI], 0.945‐1.290; P = 0.211). Reweight‐MELD score and Del‐Cr‐MELD score (decreasing the weight of creatinine) were superior to the original MELD score (all P < 0.001). The new AKI‐MELD score consists of bilirubin, the international normalized ratio, and the ratio of creatinine in 48 hours to creatinine at admission. It had competitive discriminative ability for predicting mortality (area under the receiver operating characteristic curve, 0.720 [95% CI, 0.653‐0.762] at 30 days, 0.688 [95% CI, 0.630‐0.742] at 90 days, and 0.671 [95% CI, 0.612‐0.725] at 1 year). Further, AKI‐MELD score had significantly higher predictive ability in comparison with MELD score, MELD‐Na score, and Updated MELD score (all P < 0.001). Conclusion: The predictive value of creatinine for CAKI should be re‐evaluated. AKI‐MELD score is a potentially reliable tool to determine the prognosis for mortality of CAKI. (Hepatology Communications 2017;1:748–756)