Department of Gastroenterology, The Second Hospital of Hebei Medical University, Shijiazhuang 050000, Hebei Province, China.
Department of Gastroenterology, Weixian People's Hospital, Xingtai 054700, Hebei Province, China.
World J Gastroenterol. 2024 May 28;30(20):2657-2676. doi: 10.3748/wjg.v30.i20.2657.
Cirrhotic patients with acute-on-chronic liver failure (ACLF) in the intensive care unit (ICU) have a poor but variable prognoses. Accurate prognosis evaluation can guide the rational management of patients with ACLF. However, existing prognostic scores for ACLF in the ICU environment lack sufficient accuracy.
To develop a new prognostic model for patients with ACLF in ICU.
Data from 938 ACLF patients in the Medical Information Mart for Intensive Care (MIMIC) database were used to develop a new prognostic model (MIMIC ACLF) for ACLF. Discrimination, calibration and clinical utility of MIMIC ACLF were assessed by area under receiver operating characteristic curve (AUROC), calibration curve and decision curve analysis (DCA), respectively. MIMIC ACLF was then externally validated in a multiple-center cohort, the Electronic Intensive Care Collaborative Research Database and a single-center cohort from the Second Hospital of Hebei Medical University in China.
The MIMIC ACLF score was determined using nine variables: ln (age) × 2.2 + ln (white blood cell count) × 0.22 - ln (mean arterial pressure) × 2.7 + respiratory failure × 0.6 + renal failure × 0.51 + cerebral failure × 0.31 + ln (total bilirubin) × 0.44 + ln (internationalized normal ratio) × 0.59 + ln (serum potassium) × 0.59. In MIMIC cohort, the AUROC (0.81/0.79) for MIMIC ACLF for 28/90-day ACLF mortality were significantly greater than those of Chronic Liver Failure Consortium ACLF (0.76/0.74), Model for End-stage Liver Disease (MELD; 0.73/0.71) and MELD-Na (0.72/0.70) (all < 0.001). The consistency between actual and predicted 28/90-day survival rates of patients according to MIMIC ACLF score was excellent and superior to that of existing scores. The net benefit of MIMIC ACLF was greater than that achieved using existing scores within the 50% threshold probability. The superior predictive accuracy and clinical utility of MIMIC ACLF were validated in the external cohorts.
We developed and validated a new prognostic model with satisfactory accuracy for cirrhotic patients with ACLF hospitalized in the ICU. The model-based risk stratification and online calculator might facilitate the rational management of patients with ACLF.
在重症监护病房（ICU）中，患有慢加急性肝衰竭（ACLF）的肝硬化患者预后较差，但预后情况存在差异。准确的预后评估可以指导 ACLF 患者的合理管理。然而，目前 ICU 环境下用于 ACLF 的预后评分缺乏足够的准确性。
为 ICU 中患有 ACLF 的患者开发一种新的预后模型。
使用来自医学信息监护（MIMIC）数据库的 938 例 ACLF 患者的数据来开发新的 ACLF 预后模型（MIMIC ACLF）。通过接收者操作特征曲线（AUROC）下面积、校准曲线和决策曲线分析（DCA）分别评估 MIMIC ACLF 的区分度、校准度和临床实用性。然后，在多个中心队列、电子重症监护协作研究数据库和中国河北医科大学第二医院的单一中心队列中对 MIMIC ACLF 进行外部验证。
MIMIC ACLF 评分由九个变量确定：ln（年龄）×2.2+ln（白细胞计数）×0.22-ln（平均动脉压）×2.7+呼吸衰竭×0.6+肾衰×0.51+脑衰竭×0.31+ln（总胆红素）×0.44+ln（国际标准化比值）×0.59+ln（血清钾）×0.59。在 MIMIC 队列中，MIMIC ACLF 对 28/90 天 ACLF 死亡率的 AUROC（0.81/0.79）显著大于慢性肝衰竭联盟 ACLF（0.76/0.74）、终末期肝病模型（MELD；0.73/0.71）和 MELD-Na（0.72/0.70）（均<0.001）。根据 MIMIC ACLF 评分，患者实际和预测的 28/90 天生存率之间的一致性非常好，优于现有评分。在 50%阈值概率内，MIMIC ACLF 的净收益大于现有评分。MIMIC ACLF 的卓越预测准确性和临床实用性在外部队列中得到了验证。
我们开发并验证了一种用于 ICU 中患有 ACLF 的肝硬化患者的新预后模型，该模型具有令人满意的准确性。基于模型的风险分层和在线计算器可能有助于 ACLF 患者的合理管理。
