Proposal and Validation of a Clinically Relevant Modification of the Japanese Association for Acute Medicine Disseminated Intravascular Coagulation Diagnostic Criteria for Sepsis

Abstract

Background: Japanese Association for Acute Medicine (JAAM) disseminated intravascular coagulation (DIC) criteria were launched nearly 20 years ago. Following the revised conceptual definition of sepsis and subsequent omission of systemic inflammatory response syndrome (SIRS) score from the latest sepsis diagnostic criteria, we omitted the SIRS score and proposed a modified version of JAAM DIC criteria, the JAAM-2 DIC criteria.

Objectives: To validate and compare performance between new JAAM-2 DIC criteria and conventional JAAM DIC criteria for sepsis.

Methods: We used three datasets containing adult sepsis patients from a multicenter nationwide Japanese cohort study (J-septic DIC, FORECAST, and SPICE-ICU registries). JAAM-2 DIC criteria omitted the SIRS score and set the cutoff value at ≥3 points. Receiver operating characteristic (ROC) analyses were performed between the two DIC criteria to evaluate prognostic value. Associations between in-hospital mortality and anticoagulant therapy according to DIC status were analyzed using propensity score weighting to compare significance of the criteria in determining introduction of anticoagulants against sepsis.

Results: Final study cohorts of the datasets included 2,154, 1,065, and 608 sepsis patients, respectively. ROC analysis revealed that curves for both JAAM and JAAM-2 DIC criteria as predictors of in-hospital mortality were almost consistent. Survival curves for the anticoagulant and control groups in the propensity score-weighted prediction model diagnosed using the two criteria were also almost entirely consistent.

Conclusion: JAAM-2 DIC criteria were equivalent to JAAM DIC criteria regarding prognostic and diagnostic values for initiating anticoagulation. The newly proposed JAAM-2 DIC criteria could be potentially alternative criteria for sepsis management.

Fig. 1

Patient flow for the three datasets used in this study. DIC, disseminated intravascular coagulation; JAAM, Japanese Association for Acute Medicine; ROC, receiver operating characteristic.

Fig. 2

Receiver operating characteristic curves for original JAAM and modified JAAM-2 DIC criteria as predictors of in-hospital mortality. The solid line represents curves for JAAM-2, and the dotted line represents curves for original JAAM. ( A ) J-Septic DIC dataset, ( B ) FORECAST dataset, ( C ) SPICE dataset. DIC, disseminated intravascular coagulation; JAAM, Japanese Association for Acute Medicine.

Fig. 3

Adjusted estimated survival curves according to the original JAAM and modified JAAM-2 DIC status using the J-septic DIC dataset. ( A ) JAAM DIC score ≤ 3, ( B ) JAAM DIC score ≥ 4, ( C ) JAAM-2 DIC score ≤ 2, and ( D ) JAAM-2 DIC score ≥ 3. The solid line represents patients in the anticoagulant group, and the dotted line represents patients in the control group. DIC, disseminated intravascular coagulation; JAAM, Japanese Association for Acute Medicine.

Fig. 4

Adjusted estimated survival curves according to the original JAAM and modified JAAM-2 DIC status using the FORECAST dataset. ( A ) JAAM DIC score ≤ 3, ( B ) JAAM DIC score ≥ 4, ( C ) JAAM-2 DIC score ≤ 2, and ( D ) JAAM-2 DIC score ≥ 3. The solid line represents patients in the anticoagulant group, and the dotted line represents patients in the control group. DIC, disseminated intravascular coagulation; JAAM, Japanese Association for Acute Medicine.