Prognostic model for esophagogastric variceal rebleeding after endoscopic treatment in liver cirrhosis: A Chinese multicenter study

Abstract

Background: Rebleeding after recovery from esophagogastric variceal bleeding (EGVB) is a severe complication that is associated with high rates of both incidence and mortality. Despite its clinical importance, recognized prognostic models that can effectively predict esophagogastric variceal rebleeding in patients with liver cirrhosis are lacking.

Aim: To construct and externally validate a reliable prognostic model for predicting the occurrence of esophagogastric variceal rebleeding.

Methods: This study included 477 EGVB patients across 2 cohorts: The derivation cohort (n = 322) and the validation cohort (n = 155). The primary outcome was rebleeding events within 1 year. The least absolute shrinkage and selection operator was applied for predictor selection, and multivariate Cox regression analysis was used to construct the prognostic model. Internal validation was performed with bootstrap resampling. We assessed the discrimination, calibration and accuracy of the model, and performed patient risk stratification.

Results: Six predictors, including albumin and aspartate aminotransferase concentrations, white blood cell count, and the presence of ascites, portal vein thrombosis, and bleeding signs, were selected for the rebleeding event prediction following endoscopic treatment (REPET) model. In predicting rebleeding within 1 year, the REPET model exhibited a concordance index of 0.775 and a Brier score of 0.143 in the derivation cohort, alongside 0.862 and 0.127 in the validation cohort. Furthermore, the REPET model revealed a significant difference in rebleeding rates (P < 0.01) between low-risk patients and intermediate- to high-risk patients in both cohorts.

Conclusion: We constructed and validated a new prognostic model for variceal rebleeding with excellent predictive performance, which will improve the clinical management of rebleeding in EGVB patients.

Keywords: Esophagogastric variceal bleeding; Liver cirrhosis; Prognostic model; Risk stratification; Secondary prophylaxis; Variceal rebleeding.

Figure 1

Study flow chart. EGVB: Esophagogastric variceal bleeding.

Figure 2

The nomogram, time-dependent concordance index and calibration curve. A: The nomogram for predicting variceal rebleeding; B-E: Risk stratification was based on the total points: Low-risk group (score < 117.3, green background), medium-risk (score 1173-142.7, yellow background) and high-risk (score > 142.7, red background). The time-dependent concordance index (C-index) of the rebleeding event prediction following endoscopic treatment model compared with other existing scores/criteria for the predicting variceal rebleeding in the derivation cohort (B) and in the external validation cohort (D). Calibration curves for 6 weeks, 1 year, and 2 years variceal rebleeding prediction in the derivation cohort (C) and in the external validation cohort (E). WBC: White blood cell; AST: Aspartate aminotransferase; ALB: Albumin; REPET: Rebleeding event prediction following endoscopic treatment.

Figure 3

Area under receiver operating curve for variceal rebleeding in the derivation cohort and external cohort with 6 weeks, 1 year, and 2 years. A: Area under receiver operating curve for variceal rebleeding in the derivation cohort with 6 weeks; B: Area under receiver operating curve for variceal rebleeding in the derivation cohort with 1 year; C: Area under receiver operating curve for variceal rebleeding in the derivation cohort with 2 years; D: Area under receiver operating curve for variceal rebleeding in external cohort with 6 weeks; E: Area under receiver operating curve for variceal rebleeding in external cohort with 1 year; F: Area under receiver operating curve for variceal rebleeding in external cohort with 2 years. AUC: Area under the receiver operating curve; REPET: Rebleeding event prediction following endoscopic treatment; CTP: Child-Turcotte-Pugh; MELD: Model for end-stage liver disease; FIB-4: Fibrosis 4; ALBI: Albumin-bilirubin.

Figure 4

Decision curve analysis for variceal rebleeding in the derivation cohort and external cohort with 6 weeks, 1 year, and 2 years. A: Decision curve analysis for variceal rebleeding in the derivation cohort with 6 weeks; B: Decision curve analysis for variceal rebleeding in the derivation cohort with 1 year; C: Decision curve analysis for variceal rebleeding in the derivation cohort with 2 year; D: Decision curve analysis for variceal rebleeding in external cohort with 6 weeks; E: Decision curve analysis for variceal rebleeding in external cohort with 1 year; F: Decision curve analysis for variceal rebleeding in external cohort with 2 years. REPET: Rebleeding event prediction following endoscopic treatment; CTP: Child-Turcotte-Pugh; MELD: Model for end-stage liver disease; FIB-4: Fibrosis 4; ALBI: Albumin-bilirubin.

Figure 5

Risk stratification for variceal rebleeding. A: Optimal thresholds for prognostic scores (using X-tile software); B and C: The Kaplan-Meier curves for the different risk groups in the derivation (B) and validation cohorts (C).