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

Abstract

Background: Acute liver failure (ALF) in dengue is rare but fatal. Early identification of patients who are at risk of ALF is the key strategy to improve survival.

Aim: To validate prognostic scores for predicting ALF and in-hospital mortality in dengue-induced severe hepatitis (DISH).

Methods: We retrospectively reviewed 2532 dengue patients over a period of 16 years (2007-2022). Patients with DISH, defined as transaminases > 10 times the normal reference level and DISH with subsequent ALF, were included. Univariate regression analysis was used to identify factors associated with outcomes. Youden's index in conjunction with receiver operating characteristic (ROC) analysis was used to determine optimal cut-off values for prognostic scores in predicting ALF and in-hospital death. Area under the ROC (AUROC) curve values were compared using paired data nonparametric ROC curve estimation.

Results: Of 193 DISH patients, 20 developed ALF (0.79%), with a mortality rate of 60.0%. International normalized ratio, bilirubin, albumin, and creatinine were independent predictors associated with ALF and death. Prognostic scores showed excellent performance: Model for end-stage liver disease (MELD) score ≥ 15 predicted ALF (AUROC 0.917, sensitivity 90.0%, specificity 88.4%) and ≥ 18 predicted death (AUROC 0.823, sensitivity 86.9%, specificity 89.1%); easy albumin-bilirubin (ALBI) score ≥ -30 predicted ALF and death (ALF: AUROC 0.835, sensitivity80.0%, specificity 72.2%; death: AUROC 0.808, sensitivity 76.9%, specificity 69.3%); ALBI score ≥ -2 predicted ALF and death (ALF: AUROC 0.806, sensitivity 80.0%, specificity 77.4%; death: AUROC 0.799, sensitivity 76.9%, specificity 74.3%). Platelet-ALBI score also showed good performance in predicting ALF and death (AUROC = 0.786 and 0.699, respectively). MELD and EZ-ALBI scores had similar performance in predicting ALF (Z = 1.688, P = 0.091) and death (Z = 0.322, P = 0.747).

Conclusion: MELD score is the best predictor of ALF and death in DISH patients. EZ-ALBI score, a simpler yet effective score, shows promise as an alternative prognostic tool in dengue patients.

Keywords: Clinical outcomes; Fulminant; Liver injury; Mortality prediction; Predictive models; Prognostic assessment.

Figure 1

Study algorithm. DISH: Dengue-induced severe hepatitis; ALF: Acute liver failure.

Figure 2

Area under receiver operating characteristic curve values of prognostic scores. A: Predicting acute liver failure (ALF) from dengue-induced severe hepatitis (DISH). Model for end-stage liver disease (MELD) scores had the best performance in predicting ALF [area under receiver operating characteristic curve (AUROC) 0.929], followed by easy albumin-bilirubin (ALBI), ALBI, and platelet-ALBI (PALBI) scores (AUROC 0.865, 0.832, and 0.797, respectively); B: Predicting death from DISH. MELD score had the best performance in predicting death (AUROC 0.822), followed by easy ALBI, ALBI, and PALBI scores (AUROC 0.807, 0.774, and 0.708, respectively). ROC: Receiver operating characteristic; MELD: Model for end-stage liver disease; EZ-ALBI: Easy albumin-bilirubin; ALBI: Albumin-bilirubin; PALBI: Platelet-albumin-bilirubin.