Nguyen Thanh Tat, Ngo Phuong Thi-Mai, Vo Luan Thanh
Department of Tuberculosis, Woolcock Institute of Medical Research, Ho Chi Minh 700000, Viet Nam.
Department of Infectious Diseases, The Children's Hospital 2, Ho Chi Minh 700000, Viet Nam.
World J Crit Care Med. 2024 Dec 9;13(4):98862. doi: 10.5492/wjccm.v13.i4.98862.
Dengue-associated acute liver failure (PALF) accounts for a high mortality rate in children admitted to the pediatric intensive care unit (PICU). To date, there is a lack of data on clinical algorithms for estimating the risk of mortality in pediatric patients with dengue-induced severe hepatitis (DISH).
To determine the prevalence of PALF and identify the predictors of mortality among patients with DISH.
This single-institution retrospective study was performed at a tertiary pediatric hospital in Vietnam between 2013 and 2022. The primary outcome was in-hospital mortality in pediatric patients with DISH, which was defined as either aspartate aminotransferase > 350 IU/L or alanine aminotransferase > 400 IU/L. Prognostic models for estimating the risk of death among patients with DISH were developed using a predefined set of clinical covariables and hepatic biomarkers on PICU admission and during the first 72 hours of admission. Area under the curve, multivariable logistic regression, and multiple imputation using the chained equation for missing values were performed. Backward stepwise model selection based on the Akaike information criterion was employed. Bootstrapping, calibration slope, and Brier score were used to assess the final models.
A total of 459 children with DISH were included in the analysis. The median patient age was 7.7 years (interquartile range: 4.3-10.1 years). The prevalence of dengue-associated PALF in children with DISH was 18.3%. Thirty-nine DISH patients developing PALF (8.5%) died. Hepatic biomarkers, including the international normalized ratio (INR) ≥ 2.11 and total serum bilirubin (≥ 1.7 mg/dL), showed high predictive values for mortality (all values < 0.001). Multivariable models showed the significant clinical predictors of death from dengue-induced PALF in patients with DISH, including reduced level of consciousness (pain and unresponsive levels on the Alert, Verbal, Pain, Unresponsive scale), high vasoactive-inotropic score (> 30), and elevated levels of blood lactate, INR, and serum bilirubin. The final prognostic model demonstrated high discrimination, Brier score, and an acceptable calibration slope.
The prevalence of PALF in children with DISH is 18.3%. We developed robust prognostic models to estimate the risk of death in hospitalized children with severe dengue-induced hepatitis.
登革热相关急性肝衰竭（PALF）在入住儿科重症监护病房（PICU）的儿童中死亡率很高。迄今为止，缺乏关于评估登革热诱发的严重肝炎（DISH）患儿死亡风险的临床算法数据。
确定PALF的患病率，并确定DISH患者的死亡预测因素。
这项单机构回顾性研究于2013年至2022年在越南一家三级儿科医院进行。主要结局是DISH患儿的院内死亡率，定义为天冬氨酸转氨酶>350 IU/L或丙氨酸转氨酶>400 IU/L。使用一组预定义的临床协变量和入住PICU时及入院后72小时内的肝脏生物标志物，建立了评估DISH患者死亡风险的预后模型。进行了曲线下面积、多变量逻辑回归分析，并使用链式方程对缺失值进行多次插补。采用基于赤池信息准则的向后逐步模型选择方法。使用自助法、校准斜率和Brier评分来评估最终模型。
共有459例DISH患儿纳入分析。患者中位年龄为7.7岁（四分位间距：4.3 - 10.1岁）。DISH患儿中登革热相关PALF的患病率为18.3%。39例发生PALF的DISH患者（8.5%）死亡。包括国际标准化比值（INR）≥2.11和总血清胆红素（≥1.7 mg/dL）在内的肝脏生物标志物对死亡率显示出较高的预测价值（所有P值<0.001）。多变量模型显示，DISH患者中登革热诱发PALF死亡的显著临床预测因素包括意识水平降低（警觉、语言、疼痛、无反应量表上的疼痛和无反应水平）、高血管活性药物 - 正性肌力评分（>30）以及血乳酸、INR和血清胆红素水平升高。最终的预后模型显示出高辨别力、Brier评分和可接受的校准斜率。
DISH患儿中PALF的患病率为18.3%。我们建立了可靠的预后模型，以评估住院的严重登革热诱发肝炎患儿的死亡风险。
