Validation of prognostic scores for predicting acute liver failure and in-hospital death in patients with dengue-induced severe hepatitis

Table 1 Liver-specific prognostic score formulas

Score	Formula
MELD	3.78 × loge total bilirubin (mg/dL) + 11.2 × loge INR + 9.57 × loge creatinine (mg/dL) + 6.43
ALBI	0.66 × log10 total bilirubin (µmol/L) + [0.0085 × albumin (g/L)]
PALBI	2.02 × log10 total bilirubin (µmol/L) - 0.37 × [log10 total bilirubin (µmol/L)]2 - 3.48 × log10 platelets (1000/µL) + 1.01 × [log10 platelets (1000/µL)]2
EZ-ALBI	Total bilirubin (mg/dL) + [9 × albumin (g/dL)]

MELD: Model for end-stage liver disease; INR: International normalized ratio; ALBI: Albumin-bilirubin; PALBI: Platelet-albumin-bilirubin; EZ-ALBI: Easy albumin-bilirubin.

Table 2 Parameters at initial presentation

Parameter	All DISH patients (n = 198)	DISH without ALF (n = 174)	DISH with ALF (n = 24)	P value
Laboratory profiles
WBC count (103/L)	5.52 ± 3.85	5.24 ± 3.63	7.48 ± 4.78	0.007
Neu (103/L)	3.20 ± 2.78	2.99 ± 2.73	4.53 ± 2.86	0.021
INR	1.38 ± 0.64	1.16 ± 0.25	2.42 ± 0.85	< 0.001
Cr (mg/dL)	1.04 ± 1.01	0.91 ± 0.89	1.93 ± 1.30	< 0.001
Albumin (g/dL)	3.60 ± 0.54	3.69 ± 0.49	3.09 ± 0.55	< 0.001
TB (mg/dL)	1.95 ± 4.34	1.28 ± 1.54	6.34 ± 10.44	< 0.001
SGOT (U/L)	1515.86 ± 2258.05	1031.51 ± 1195.21	5007.25 ± 4275.91	< 0.001
SGPT (U/L)	683.64 ± 749.00	550.41 ± 458.53	1649.54 ± 1454.57	< 0.001
Liver prognostic scores
MELD score	12.20 ± 8.01	9.52 ± 4.46	24.71 ± 9.05	< 0.001
EZ-ALBI score	-30.27 ± 7.48	-31.81 ± 4.99	-20.95 ± 12.17	< 0.001
ALBI score	-2.17 ± 0.68	-2.29 ± 0.62	-1.48 ± 0.62	< 0.001
PALBI score	-1.06 ± 0.53	-1.15 ± 0.49	-0.61 ± 0.47	< 0.001

DISH: Dengue-induced severe hepatitis; ALF: Acute liver failure; WBC: White blood cell; Neu: Neutrophils; INR: International normalized ratio; Cr: Creatinine; TB: Total bilirubin; SGOT: Serum glutamate-oxaloacetate transaminase; SGPT: Serum glutamate-pyruvate transaminase; MELD: Model for end-stage liver disease; ALBI: Albumin-bilirubin; EZ-ALBI: Easy albumin-bilirubin; PALBI: Platelet-albumin-bilirubin.

Table 3 Univariate regression analysis of factors associated with severe adverse outcomes from dengue-induced severe hepatitis

Parameter	Acute liver failure			In-hospital mortality
	OR	95%CI	P value	OR	95%CI	P value
Clinical parameter
Presence of DSS	34.62	11.71-102.33	< 0.001	28.05	7.21-109.18	< 0.001
Laboratory parameters
INR	72.27	10.98-475.89	< 0.001	5.83	2.59-13.12	< 0.001
SGOT	1.00	1.00-1.00	< 0.001	1.00	1.00-1.00	< 0.001
SGPT	1.00	1.00-1.00	< 0.001	1.00	1.00-1.00	0.002
Albumin	0.11	0.04-0.31	< 0.001	0.15	0.05-0.44	< 0.001
Cr	2.08	1.31-3.31	0.002	1.52	1.00-2.31	0.051
Liver prognostic scores
MELD score	1.34	1.21-1.48	< 0.001	1.15	1.07–1.22	< 0.001
ALBI score	5.01	2.65-11.43	< 0.001	3.22	1.52-6.80	0.002
PALBI score	7.67	2.90-20.26	< 0.001	3.51	1.26-9.82	0.017
EZ-ALBI score	1.28	1.15-1.41	< 0.001	1.07	1.00-1.14	0.038

OR: Odds ratio; DSS: Dengue shock syndrome; INR: International normalized ratio; Cr: Creatinine; SGOT: Serum glutamate-oxaloacetate transaminase; SGPT: Serum glutamate-pyruvate transaminase; MELD: Model for end-stage liver disease; ALBI: Albumin-bilirubin; EZ-ALBI: Easy albumin-bilirubin; PALBI: Platelet-albumin-bilirubin.

Table 4 Multivariate regression analysis of factors associated with severe adverse outcomes of dengue-induced severe hepatitis

Parameter	Acute liver failure			In-hospital mortality
	OR	95%CI	P value	OR	95%CI	P value
Clinical parameters
Age	0.97	0.91-1.04	0.404	1.01	0.95-1.08	0.710
Presence of DSS	3.59	0.55-23.39	0.181	7.28	0.85-62.08	0.070
Baseline laboratory parameters
INR	19.54	3.37-113.38	< 0.001	3.86	1.13-13.18	0.031
TB	1.16	0.79-1.70	0.450	0.91	0.81-1.04	0.166
Albumin	0.40	0.08-1.94	0.254	0.54	0.10-3.05	0.480
Cr	1.17	0.73-1.88	0.511	1.22	0.76-1.97	0.409

OR: Odds ratio; DSS: Dengue shock syndrome; INR: International normalized ratio; TB: Total bilirubin; Cr: Creatinine.

Table 5 Diagnostic performance of each prognostic score in predicting acute liver failure and in-hospital death in patients with dengue-induced severe hepatitis

Prognostic score	Acute liver failure			In-hospital death
	AUROC	P value	Cutoff (sensitivity, specificity)	AUROC	P value	Cutoff (sensitivity, specificity)
MELD score	0.929	< 0.001	16 (87.5%, 89.3%)	0.822	< 0.001	18 (78.6%, 87.7%)
EZ-ALBI score	0.865	< 0.001	-30 (85.7%, 74.0%)	0.807	0.001	-30 (81.8%, 69.3%)
ALBI score	0.832	< 0.001	-2.00 (83.3%, 75.2%)	0.774	0.001	-2.00 (78.6%, 72.7%)
PALBI score	0.797	< 0.001	-0.78 (75.0%, 78.0%)	0.708	0.010	-0.81 (71.4%, 70.4%)

AUROC: Area under the receiver operating characteristic curve; MELD: Model for end-stage liver disease; ALBI: Albumin-bilirubin; EZ-ALBI: Easy albumin-bilirubin; PALBI: Platelet-albumin-bilirubin.