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Novel prognostic score for patients with cirrhosis admitted to ICU

This month's issue of the American Journal of Gastroenterology reports on a calibrated prognostic model for patients with cirrhosis admitted to the intensive care unit, as compared with current models.

News image

Prognosis for patients with cirrhosis admitted to intensive care unit (ICU) is poor.

ICU prognostic models are more accurate than liver-specific models.

Professor Andrew Burroughs and colleagues from the United Kingdom identified predictors of mortality, and developed a novel prognostic score (Royal Free Hospital (RFH) score).

The team tested the score against established prognostic models, and the yet unvalidated Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) model.

Predictors of mortality were defined by logistic regression in a cohort of 635 consecutive patients with cirrhosis admitted to ICU up to 2012.

The RFH score was derived using a 75% training, and 25% validation set.

Classification accuracy was 77% in a validation sample
American Journal of Gastroenterology

The research team evaluated predictive accuracy and calibration using area under the receiver operating characteristic (AUROC) and goodness-of-fit χ2 for the RFH score, as well as for SOFA, Model for End-Stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE II), and Child-Pugh.

CLIF-SOFA was applied to a recent subset of patients.

The researchers found that in-hospital mortality was 52%.

Mortality improved over time but with a corresponding reduction in acuity of illness on admission.

Predictors of mortality in training set, which constituted the RFH score, included bilirubin, international normalized ratio, lactate, alveolar arterial partial pressure oxygen gradient, urea, while variceal bleeding as indication for admission conferred lesser risk.

The team observed that classification accuracy was 73% in training, and 77% in a validation sample, and did not change significantly across different eras of admission.

The AUROC for the derived model was 0.83 and the goodness-of-fit χ2 was 3.74.

The researchers noted tAUROC at for SOFA was 0.81, MELD was 0.79, APACHE II was 0.78, and Child-Pugh was 0.67.

In 2005–2012 cohort, AUROC was 0.74 for SOFA, 0.75 for CLIF-SOFA, and 0.78 for RFH.

Goodness-of-fit χ2 was 6.21 for SOFA, 9.18 for CLIF-SOFA, and 2.91 for RFH.

Professor Burroughs' team concludes, "RFH score demonstrated good discriminative ability and calibration."

"Internal validation supports its generalizability."

"CLIF-SOFA did not perform better than RFH and the original SOFA."

"External validation of our model should be undertaken to confirm its clinical utility."

Am J Gastroenterol 2014; 109: 554–562
15 April 2014

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