The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, Royal Free Hampstead NHS Trust and Institute of Liver and Digestive Health, University College London, London, UK.
Intensive Care Unit, Royal Free Hospital, Royal Free Hampstead NHS Trust, University College London, London, UK.
Am J Gastroenterol. 2014 Apr;109(4):554-62. doi: 10.1038/ajg.2013.466. Epub 2014 Feb 4.
Prognosis for patients with cirrhosis admitted to intensive care unit (ICU) is poor. ICU prognostic models are more accurate than liver-specific models. We identified predictors of mortality, developed a novel prognostic score (Royal Free Hospital (RFH) score), and tested it 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 (1989-2012). The RFH score was derived using a 75% training and 25% validation set. Predictive accuracy and calibration were evaluated using area under the receiver operating characteristic (AUROC) and goodness-of-fit χ(2) 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 (2005-2012) of patients.
In-hospital mortality was 52.3%. 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, were the following: bilirubin, international normalized ratio, lactate, alveolar arterial partial pressure oxygen gradient, urea, while variceal bleeding as indication for admission conferred lesser risk. Classification accuracy was 73.4% in training and 76.7% in 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 χ(2) was 3.74 (P=0.88). AUROC 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: SOFA: 0.74, CLIF-SOFA: 0.75, and RFH: 0.78. Goodness-of-fit χ(2) was: SOFA: 6.21 (P=0.63), CLIF-SOFA: 9.18 (P=0.33), and RFH: 2.91 (P=0.94).
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.
入住重症监护病房（ICU）的肝硬化患者预后较差。与肝脏特异性模型相比， ICU 预后模型更准确。我们确定了死亡率的预测因素，制定了新的预后评分（皇家自由医院（RFH）评分），并对其进行了评估与现有预后模型和尚未验证的慢性肝衰竭-序贯器官衰竭评估（CLIF-SOFA）模型进行比较。
使用 635 例连续肝硬化患者队列（1989-2012 年）中的逻辑回归确定死亡率的预测因素。使用 75%的训练集和 25%的验证集得出 RFH 评分。使用受试者工作特征曲线下的面积（AUROC）和 RFH 评分的拟合优度χ²评估预测准确性和校准，以及 SOFA、终末期肝病模型（MELD）、急性生理学和慢性健康评估（APACHE II）和 Child-Pugh。CLIF-SOFA 应用于最近的患者子集（2005-2012 年）。
院内死亡率为 52.3%。随着时间的推移，死亡率有所改善，但入院时疾病的严重程度相应降低。在训练集中，死亡率的预测因素为胆红素、国际标准化比值、乳酸、肺泡动脉部分氧分压梯度、尿素，而入院时静脉曲张出血的指示则降低了风险。在训练和验证样本中的分类准确性分别为 73.4%和 76.7%，且在不同入院时期均无显著变化。该模型的 AUROC 为 0.83，拟合优度 χ²为 3.74（P=0.88）。SOFA 的 AUROC 为 0.81，MELD 为 0.79，APACHE II 为 0.78，Child-Pugh 为 0.67。在 2005-2012 年队列中，AUROC 为：SOFA：0.74，CLIF-SOFA：0.75，RFH：0.78。拟合优度 χ²为：SOFA：6.21（P=0.63），CLIF-SOFA：9.18（P=0.33），RFH：2.91（P=0.94）。
RFH 评分显示出良好的判别能力和校准能力。内部验证支持其通用性。CLIF-SOFA 并未比 RFH 和原始 SOFA 表现更好。应进行模型的外部验证，以确认其临床实用性。
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