Comparison of the predictive value of scoring systems on the prognosis of cirrhotic patients with suspected infection

Abstract

Cirrhotic patients with infection are prone to develop sepsis or even septic shock rendering poorer prognosis. However, few methods are available to predict the prognosis of cirrhotic patients with infection although there are some scoring systems can be used to predict general patients with cirrhosis. Therefore, we aimed to explore the predictive value of scoring systems in determining the outcome of critically ill cirrhotic patients with suspected infection.This was a retrospective cohort study based on a single-center database. The prognostic accuracy of the systemic inflammatory response syndrome (SIRS) criteria, quick Sequential Organ Failure Assessment (qSOFA), chronic liver failure (CLIF)-SOFA, quick CLIF-SOFA (qCLIF-SOFA), CLIF-consortium organ failure (CLIF-C OF), Model for End-Stage Liver Disease (MELD), and Simplified Acute Physiology Score (SAPS) II were compared by using area under the receiver operating characteristic (AUROC) curve and net benefit with decision curve analysis. The primary endpoint was in-hospital mortality while the secondary endpoints were duration of hospital and intensive care unit (ICU) stay and ICU mortality.A total of 1438 cirrhotic patients with suspected infection were included in the study. Nearly half the patients (50.2%) were admitted to the ICU due to hepatic encephalopathy and the overall in-hospital mortality was 32.0%. Hospital and ICU mortality increased as the score of each scoring system increased (P < .05 for all trends). The AUROC of CLIF-SOFA (AUROC, 0.742; 95% confidence interval, CI, 0.714-0.770), CLIF-C OF (AUROC, 0.741; 95% CI, 0.713-0.769), and SAPS II (AUROC, 0.759; 95% CI, 0.733-0.786) were significantly higher than SIRS criteria (AUROC, 0.618; 95% CI, 0.590-0.647), qSOFA (AUROC, 0.612; 95% CI, 0.584-0.640), MELD (AUROC, 0.632; 95% CI, 0.601-0.662), or qCLIF-SOFA (AUROC, 0.680; 95% CI, 0.650-0.710) (P < .05 for all). In the decision curve analysis, the net benefit of implementing CLIF-SOFA and CLIF-C OF to predict the prognosis of cirrhotic patients with suspected infection were higher compared with SIRS, qSOFA, MELD, or qCLIF-SOFA.CLIF-SOFA and CLIF-C OF scores, as well as SAPS II were better tools than SIRS, qSOFA, MELD, or qCLIF-SOFA to evaluate the prognosis of critically ill cirrhotic patients with suspected infection.

Figure 1

Distribution of all the patients and in-hospital mortality according to the score levels of each scoring system. CLIF-C OF = CLIF-consortium organ failure, CLIF-SOFA = chronic liver failure-SOFA, MELD = Model for End-Stage Liver Disease, qCLIF-SOFA = quick CLIF-SOFA, qSOFA = quick Sequential Organ Failure Assessment, SAPS II = Simplified Acute Physiology Score II, SIRS = systemic inflammatory response syndrome.

Figure 2

Receiver operating characteristic curve showing the comparison of AUROC of each score (A); the skyblue-shaded diagonal cells indicated the AUROC of each score and below the AUROC data cells are p values for comparisons between scores (B). CLIF-C OF = CLIF-consortium organ failure, CLIF-SOFA = chronic liver failure-SOFA, MELD = Model for End-Stage Liver Disease, qCLIF-SOFA = quick CLIF-SOFA, qSOFA = quick Sequential Organ Failure Assessment, SAPS II = Simplified Acute Physiology Score II, SIRS = systemic inflammatory response syndrome.

Figure 3

Decision curve depicting the benefit of each score based on the risk threshold. The gray curve depicts the net benefit of recommending the intervention to everyone in the cohort regardless of risk, while the black horizontal line indicates the net benefit (at net benefit of zero) of without intervention in the cohort. CLIF-C OF = CLIF-consortium organ failure, CLIF-SOFA = chronic liver failure-SOFA, MELD = Model for End-Stage Liver Disease, qCLIF-SOFA = quick CLIF-SOFA, qSOFA = quick Sequential Organ Failure Assessment, SAPS II = Simplified Acute Physiology Score II, SIRS = systemic inflammatory response syndrome.