Prognostic value of risk scoring systems for cirrhotic patients with variceal bleeding

Table 1 Baseline characteristics of the included patients

Variables	Value
No. of patients	330
Age, mean ± SD, yr	54.9 ± 12.7
Male sex, n (%)	203 (61.5)
Etiology, n (%)
Viral	229 (69.4)
Alcohol	21 (6.4)
Autoimmune	34 (10.3)
Other	46 (13.9)
Laboratory tests, median (IQR)
White blood cells (109/L)	5.4 (3.6-7.8)
Hemoglobin (g/L)	80 (66-95)
Platelets (109/L)	77 (51-115)
INR	1.2 (1.1-1.4)
Total bilirubin (µmol/L)	22.6 (16.1-34.8)
ALT (IU/L)	23 (15-38)
AST (IU/L)	35 (25-56)
Albumin (g/L)	31.8 (28.4-35.3)
BUN (mmol/L)	8.7 (6.1-12.4)
Creatinine (µmol/L)	62.2 (48.5-77.2)
Sodium (mmol/L)	138.0 (134.9-140.3)
Vital signs, median (IQR)
SBP (mmHg)	110 (98-120)
DBP (mmHg)	65 (57-72)
Heart rate (beats/min)	88 (76-101)
Location of variceal bleeding, n (%)
Esophageal varices	295 (89.4)
Gastric varices	35 (10.6)
Grading of esophageal varices
Mild/ moderate/severe, n (%)	2 (0.7)/44 (14.9)/249 (84.4)
Types of gastric varices
GOV2/IGV1, n (%)	22 (62.9)/13 (37.1)
Ascites, n (%)	233 (70.6)
Hepatic encephalopathy, n (%)	28 (8.5)
Hepatocellular carcinoma, n (%)	73 (22.1)
Bacterial infection, n (%)	63 (19.1)
Portal vein thrombosis, n (%)	97 (29.4)
Hospital intervention, n (%)
Endoscopic therapy	141 (42.7)
TIPSS	21 (6.4)
Surgery	21 (6.4)
Charlson comorbidity index > 6, n (%)	45 (13.6)
Hospital stay (d), median (IQR)	13 (9-20)
Scoring system, median (IQR)
CTP	7 (6-9)
CTP grade A/B/C, n (%)	101 (30.6)/187 (56.7)/42 (12.7)
MELD	10 (9-13)
MELD-Na	12 (10-16)
CRS	2 (1-3)
GBS	12 (9-14)
mGBS	9 (7-11)
AIMS65	1 (0-1)
CANUKA	10 (8-12)

IQR: Interquartile range; INR: International normalized ratio; ALT: Alanine transaminase; AST: Aspartate transaminase; BUN: Blood urea nitrogen; SBP: Systolic blood pressure; DBP: Diastolic blood pressure; GOV2: Type 2 gastroesophageal varices; IGV1: Type 1 isolated gastric varices; TIPSS: Transjugular intrahepatic portosystemic stent shunt; CTP: Child-Turcotte-Pugh score; MELD: Model for end-stage liver disease; CRS: Clinical Rockall score; GBS: Glasgow-Blatchford score; mGBS: Modified Glasgow-Blatchford score; AIMS65: AIMS65 score; CANUKA: Canada-United Kingdom-Australia score.

Table 2 Clinical outcomes of the study population, n (%)

Outcomes	Value
In-hospital rebleeding	67 (20.3)
Admission to rebleeding (time interval, days), median (IQR)	5 (3-8)
Rebleeding occurred within 3 d	27 (40.3)
Rebleeding occurred within 7 d	47 (70.1)
Rebleeding occurred beyond 7 d	20 (29.9)
In-hospital mortality	35 (10.6)
In-hospital mortality with rebleeding	17 (25.4)
In-hospital mortality without rebleeding	18 (6.8)
In-hospital adverse outcomes	85 (25.8)

IQR: Interquartile range.

Table 3 Discrimination and calibration assessments of all the scoring systems for in-hospital adverse outcomes

Score	AUROC	95%CI	P value	AUROC difference	95%CI	P value	H-L test, P value
In-hospital rebleeding
CTP	0.717	0.648-0.787	< 0.001	Reference			0.134
CRS	0.716	0.638-0.793	< 0.001	0.0016	-0.0851-0.0883	0.9713	0.062
MELD-Na	0.680	0.609-0.752	< 0.001	0.0369	-0.0266-0.1000	0.2547	0.613
MELD	0.661	0.588-0.734	< 0.001	0.0560	-0.0026-0.1150	0.0610	0.386
CANUKA	0.656	0.579-0.732	< 0.001	0.0614	-0.0237- 0.1470	0.1575	0.186
AIMS65	0.642	0.565-0.719	< 0.001	0.0753	0.0120 - 0.1380	0.0196	0.321
GBS	0.617	0.534-0.699	0.003	0.1010	0.0153 - 0.1860	0.0208	0.041
mGBS	0.600	0.518-0.683	0.011	0.1170	0.0314 - 0.2020	0.0074	0.064
In-hospital mortality
CRS	0.883	0.822-0.943	< 0.001	Reference			0.166
CTP	0.878	0.825-0.931	< 0.001	0.0047	-0.0620-0.0714	0.8901	0.566
AIMS65	0.856	0.787-0.925	< 0.001	0.0269	-0.0390-0.0928	0.4232	0.175
MELD-Na	0.856	0.786-0.925	< 0.001	0.0271	-0.0453-0.0995	0.4630	0.636
MELD	0.840	0.767-0.914	< 0.001	0.0423	-0.0360- 0.1210	0.2900	0.472
mGBS	0.734	0.631-0.838	< 0.001	0.1480	0.0552-0.2420	0.0018	0.013
CANUKA	0.728	0.627-0.830	< 0.001	0.1540	0.0675-0.2410	0.0005	0.046
GBS	0.723	0.621-0.826	< 0.001	0.1590	0.0668-0.2520	0.0007	0.004
In-hospital adverse outcomes
CTP	0.784	0.725-0.843	< 0.001	Reference			0.218
CRS	0.775	0.709-0.841	< 0.001	0.0087	-0.0650-0.0824	0.8171	0.002
MELD-Na	0.739	0.675-0.803	< 0.001	0.0446	-0.0136-0.1030	0.1335	0.723
MELD	0.724	0.659-0.789	< 0.001	0.0598	0.0074-0.1120	0.0254	0.464
AIMS65	0.711	0.642-0.780	< 0.001	0.0728	0.0160-0.1300	0.0120	0.101
CANUKA	0.677	0.606-0.748	< 0.001	0.1070	0.0274-0.1860	0.0084	0.023
GBS	0.656	0.582-0.729	< 0.001	0.1280	0.0516-0.2050	0.0010	0.008
mGBS	0.649	0.574-0.723	< 0.001	0.1350	0.0586-0.2120	0.0005	0.024

AUROC: Area under the receiver operating characteristic curve; CI: Confidence interval; H-L: Hosmer-Lemeshow; CTP: Child-Turcotte-Pugh score; MELD: Model for end-stage liver disease; CRS: Clinical Rockall score; GBS: Glasgow-Blatchford score; mGBS: Modified Glasgow-Blatchford score; AIMS65: AIMS65 score; CANUKA: Canada-United Kingdom-Australia score.

Table 4 The predictive value indices for predicting in-hospital adverse outcomes in clinically useful scoring systems

Score	Youdenindex	Cut-off	SEN	95%CI	SPE	95%CI	PPV	95%CI	NPV	95%CI
In-hospital rebleeding
CTP	0.3851	> 7	74.6	62.5-84.5	63.9	57.8-69.7	34.5	29.8-39.4	90.8	86.6-93.8
CRS	0.3982	> 2	65.7	53.1-76.8	74.1	68.4-79.3	39.3	33.1-45.8	89.4	85.8-92.2
In-hospital mortality
CRS	0.6751	> 2	94.3	80.8-99.3	73.2	67.8-78.2	29.5	25.4-33.9	99.1	96.6-99.8
CTP	0.5632	> 7	94.3	80.8-99.3	62.0	56.2-67.6	22.8	20.0-25.8	98.9	96.0-99.7
AIMS65	0.6339	> 1	80.0	63.1-91.6	83.4	78.6-87.5	36.4	29.6-43.7	97.2	94.8-98.6
MELD-Na	0.5685	> 17	71.4	53.7-85.4	85.4	80.9-89.2	36.8	29.1-45.1	96.2	93.7-97.7
MELD	0.5157	> 12	74.3	56.7-87.5	77.3	72.1-81.9	28.0	22.6-34.1	96.2	93.5-97.8
mGBS	0.4349	> 10	68.6	50.7-83.1	74.9	69.6-79.8	24.5	19.4-30.4	95.3	92.5-97.1
CANUKA	0.3521	> 12	45.7	28.8-63.4	89.5	85.4-92.7	34.0	24.0-45.8	93.3	91.1-95.0
GBS	0.3700	> 12	74.3	56.7-87.5	62.7	56.9-68.2	19.1	15.6-23.2	95.4	92.1-97.3
In-hospital adverse outcomes
CTP	0.4699	> 7	78.8	68.6-86.9	68.2	61.9-73.9	46.2	41.0-51.5	90.3	85.9-93.4
CRS	0.5095	> 2	71.8	61.0-81.0	79.2	73.6-84.1	54.5	47.5-61.2	89.0	85.1-91.9
MELD-Na	0.3758	> 13	69.4	58.5-79.0	68.2	61.9-73.9	43.1	37.5-48.8	86.5	82.2-89.9
MELD	0.3241	> 13	45.9	35.0-57.0	86.5	81.6-90.5	54.2	44.4-63.6	82.2	79.0-84.9
AIMS65	0.3830	> 1	51.8	40.7-62.7	86.5	81.6-90.5	57.1	47.7-66.1	83.8	80.5-86.6

SEN: Sensitivity; SPE: Specificity; PPV: Positive predictive value; NPV: Negative predictive value; CI: Confidence interval; CTP: Child-Turcotte-Pugh score; MELD: Model for end-stage liver disease; CRS: Clinical Rockall score; GBS: Glasgow-Blatchford score; mGBS: Modified Glasgow-Blatchford score; AIMS65: AIMS65 score; CANUKA: Canada-United Kingdom-Australia score.