The future of critical care: AI-powered mortality prediction for acute variceal gastrointestinal bleeding and acute non-variceal gastrointestinal bleeding patients.

BACKGROUND

Acute upper gastrointestinal bleeding (AUGIB) is one of the most common critical diseases encountered in the intensive care unit (ICU), with a mortality rate ranging from 15 to 20%. Accurate stratification of acute gastrointestinal bleeding into acute variceal gastrointestinal bleeding (AVGIB) and acute non-variceal gastrointestinal bleeding (ANGIB) subtypes is clinically essential as distinct entities require markedly different therapeutic approaches and even divergent prognostic implications. AUGIB characterized by hemorrhagic shock, hypotension, multiple organ dysfunction (MODS), and even circulatory failure is life-threatening. Machine learning (ML) prediction model can be an effective tool for mortality prediction, enabling the timely identification of high-risk patients and improving outcomes.

METHODS

A total of 3,050 acute upper gastrointestinal bleeding (AUGIB) patients were included in our research from the MIMIC-IV database, among which 625 patients were classified as AVGIB and 2,425 patients were categorized as ANGIB. Patients' clinical features, intervention methods, vital signs, scores, and important laboratory results were collected. The Synthetic Minority Over-sampling Technique-Edited Nearest Neighbors (SMOTE-ENN) and Adaptive Synthetic Sampling (ADASYN) were adopted to address the imbalance of the dataset. As many as 12 machine learning (ML) algorithms, namely, logistic regression (LR), decision tree (DT), random forest (RF), gradient boosting (GB), AdaBoost, XGBoost, Naive Bayes (NB), support vector machine (SVM), light gradient-boosting machine (LightGBM), K-nearest neighbors (KNN), extremely randomized trees (ET), and voting classifier (VC), were performed. The model performance was evaluated using accuracy, precision, recall, F1-score, and area under the receiver operating characteristic curve (AUC). Shapley Additive exPlanations (SHAP) analysis was conducted to identify the most influential features contributing to mortality prediction.

RESULTS

In terms of AVGIB patients, extremely randomized trees model demonstrated excellent predictive value among other ML models, with the AUC of 0.996 ± 0.007, accuracy of 0.996 ± 0.009, precision of 0.957 ± 0.024, recall of 0.988 ± 0.012, and F1 score of 0.972 ± 0.007. The top 10 primary feature variables of ET model were whether combined with acute kidney failure, transfusion of albumin, vasoactive drugs, transfusion of plasma, transfusion of platelet, the max of international normalized ratio (INR), the max of prothrombin time (PT), and the max of activated partial thromboplastin time (APTT). In case of ANGIB patients, gradient boosting model proven to be the optimal machine learning models, with the AUC of 0.985 ± 0.002, accuracy of 0.948 ± 0.009, precision of 0.949 ± 0.009, recall of 0.968 ± 0.009, and F1 score of 0.959 ± 0.007. Similarly, the top 10 feature variables of GB model were Glasgow Coma Scale (GCS) score, vasoactive drugs, acute kidney failure, AIMS65 score, APACHE-II score, mechanical ventilation, the minimum of lactate, chronic liver disease, and the minimum and maximum of APTT. The SHAP visualization shows the weights of two ML models feature variables and the average sharp values of variables. Meanwhile, SHAP waterfall outputs the model prediction process with true positive and negative patients. Most importantly, two website prognostic prediction platforms were developed to enhance clinical accessibility: the ET model for AVGIB patients available at https://10zr656do5281.vicp.fun while the GB model for ANGIB patients accessible at http://10zr656do5281.vicp.fun.

CONCLUSION

The ET model provides a reliable prognostic tool for AVGIB patients, while the GB model serves as a robust tool for ANGIB patients in predicting in-hospital mortality. By systematically integrating clinical features, risk stratification scores, vital signs, and invention measures, the ML models may deliver comprehensive predictions that benefit for clinical decision-making and potentially enhance clinical outcomes in the near future.