Published online May 28, 2024. doi: 10.3748/wjg.v30.i20.2657
Revised: April 22, 2024
Accepted: May 9, 2024
Published online: May 28, 2024
Processing time: 133 Days and 2.6 Hours
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 P < 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.
Core Tip: Patients with acute-on-chronic liver failure (ACLF) usually need to be hospitalized in intensive care unit for condition monitoring and organ support therapy where existing prognostic scores for ACLF have a limited predictive accuracy. In this study, we developed a new prognostic model [Medical Information Mart for Intensive Care (MIMIC) ACLF] using data in MIMIC database for patients with ACLF. MIMIC ACLF not only exhibited a satisfactory predictive accuracy and clinical utility in MIMIC cohort, but also performed well in external single and multiple-center validation cohorts. In addition, we performed a risk stratification and developed an online calculator based on MIMIC ACLF to facilitate its application in clinical practice.