Performance of SOFA, qSOFA and SIRS to predict septic shock after percutaneous nephrolithotomy

Prognostic accuracy of SOFA, MEWS, and SIRS criteria in predicting the mortality rate of patients with sepsis: A meta-analysis

BACKGROUND

In recent years, some studies classified patients with sepsis and predicted their mortality by using some evaluation scales. Several studies reported significant differences in the predictive values of several tools, and the non-uniformity of the cut-off value.

OBJECTIVE

To determine and compare the prognostic accuracy of Sequential Organ Failure Assessment (SOFA) score, Modified Early Warning Score (MEWS), and Systemic Inflammatory Response Syndrome (SIRS) criteria in predicting the mortality of patients with sepsis.

METHODS

This study comprised of systematic literature review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We searched PubMed, Embase, Web of Science and Cochrane Library databases from their establishment to July 31, 2022. The research articles published in the index journals provide sufficient data (true positive, false positive, true negative, and false negative results) for patients with sepsis. The combined sensitivity and specificity of the 95% confidence interval (CI) were calculated using the bivariate random effect model (BRM). The hierarchical overall subject working characteristics (HSROC) curve was drawn to evaluate the accuracy of the overall prognosis.

RESULTS

Data of 55 088 patients from 32 studies were included in this meta-analysis. SOFA had an intermediate sensitivity of 0.73 (95% CI: 0.67-0.78) and a specificity of 0.70 (0.63-0.76). SIRS criteria had the highest sensitivity of 0.75 (0.66-0.82) and the lowest specificity of 0.40 (0.29-0.52). MEWS had the lowest sensitivity of 0.49 (0.40-0.59) and the highest specificity of 0.82 (0.78-0.86).

CONCLUSIONS

Among SOFA, MEWS, and SIRS criteria, SOFA showed moderate sensitivity and specificity for predicting mortality in patients with sepsis, the highest sensitivity of SIRS and the strongest specificity of MEWS for predicting mortality in patients with sepsis. The future research direction is to combine the relevant indicators of MEWS and SIRS to develop a measurement tool with high reliability and validity.

RELEVANCE TO CLINICAL PRACTICE

The review provides useful insights into the prognostic accuracy of different assessment tools in predicting mortality in sepsis patients, which will help clinicians choose the most appropriate tool for early identification and treatment of sepsis. The findings may also contribute to the development of more accurate and reliable prognostic models for sepsis.

SIRS, SOFA, qSOFA, and NEWS in the diagnosis of sepsis and prediction of adverse outcomes: a systematic review and meta-analysis

BACKGROUND

We compared Systemic Inflammatory Response Syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Quick Sepsis-related Organ Failure Assessment (qSOFA), and National Early Warning Score (NEWS) for sepsis diagnosis and adverse outcomes prediction.

METHODS

Clinical studies that used SIRS, SOFA, qSOFA, and NEWS for sepsis diagnosis and prognosis assessment were included. Data were extracted, and meta-analysis was performed for outcome measures, including sepsis diagnosis, in-hospital mortality, 7/10/14-day mortality, 28/30-day mortality, and ICU admission.

RESULTS

Fifty-seven included studies showed good overall quality. Regarding sepsis prediction, SIRS demonstrated high sensitivity (0.85) but low specificity (0.41), qSOFA showed low sensitivity (0.42) but high specificity (0.98), and NEWS exhibited high sensitivity (0.71) and specificity (0.85). For predicting in-hospital mortality, SOFA demonstrated the highest sensitivity (0.89) and specificity (0.69). In terms of predicting 7/10/14-day mortality, SIRS exhibited high sensitivity (0.87), while qSOFA had high specificity (0.75). For predicting 28/30-day mortality, SOFA showed high sensitivity (0.97) but low specificity (0.14), whereas qSOFA displayed low sensitivity (0.41) but high specificity (0.88).

CONCLUSIONS

NEWS independently demonstrates good diagnostic capability for sepsis, especially in high-income countries. SOFA emerges as the optimal choice for predicting in-hospital mortality and can be employed as a screening tool for 28/30-day mortality in low-income countries.

Development and validation of the UCSS score, a novel method to predict septic shock after PCNL

OBJECTIVE

To develop an objective and easily recognizable model to predict septic shock following percutaneous nephrolithotomy (PCNL).

SUBJECTS AND METHODS

First, we identified differences between 431 patients who underwent PCNL with or without septic shock. These data were used to develop existing models and examine their improvement. Multivariate analysis was applied to identify risk factors of septic shock after PCNL based on the scores allocated to the PCNL postoperative test indicators. Finally, we developed a predictive nomogram using the selected factors and compared its performance with that of the existing nomograms SOFA, qSOFA, and SIRS.

RESULTS

Twelve (2.8%) of the patients met the criteria for postoperative septic shock after PCNL. Baseline data analysis revealed differences in sex, preoperative drainage, urinary culture, and urinary leukocyte between groups. After transforming patient data into measurement-level data, we investigated each index score in these conditions, and found that the incidence of septic shock generally increased with the score. Multivariate analysis and early optimization screening revealed that septic shock factors could be predicted using platelets, leukocytes, bilirubin, and procalcitonin levels. We further compared the prediction accuracy of urinary calculi-associated septic shock (UCSS), SOFA, qSOFA, and SIRS scores using the AUC of the ROC curve. As compared to SIRS [AUC 0.938 (95% CI 0.910-0.959)] and qSOFA [AUC 0.930 (95% CI 0.901-0.952)], UCSS [AUC 0.974 (95% Cl 0.954-0.987)] and SOFA [AUC 0.974 (95% CI 0.954-0.987)] scored better at discriminating septic shock after PCNL. We further compared the ROC curves of UCSS with SOFA (95% CI - 0.800 to 0.0808, P = 0.992), qSOFA (95% CI - 0.0611 to 0.0808, P = 0.409), and SIRS (95% CI - 0.0703 to 0.144, P = 0.502), finding that UCSS was non-inferior to these models.

CONCLUSIONS

UCSS, a new convenient and cost-effective model, can predict septic shock following PCNL and provide more accurate discriminative and corrective capability than existing models by including only objective data. The predictive value of UCSS for septic shock after PCNL was greater than that of qSOFA or SIRS scores.

Regulatory effect of Pseudomonas aeruginosa mannose-sensitive hemagglutinin on inflammation and immune function in percutaneous nephrolithotomy patients with upper urinary tract calculi complicated with infection

Objective

To study the effect of an injection of Pseudomonas aeruginosa mannose-sensitive hemagglutinin (PA-MSHA) on inflammation and immune function in patients with upper urinary tract calculi complicated by infection who have undergone percutaneous nephrolithotomy.

Methods

We retrospectively recorded the clinical data of patients with upper urinary tract calculi complicated by infection who have undergone Percutaneous nephrolithotomy(PCNL) in the Department of Urology, 2nd Affiliation Hospital of Kunming Medical University, from March to December 2021. Clinical data include general condition, laboratory index, CT, postoperative body temperature, heart rate, respiration, SIRS, sepsis, etc. Patients were divided into treated and control groups according to whether they had received a preoperative PA-MSHA injection. The two groups were compared for indices of inflammation and complications of infection after PCNL. Pre- and post-operative lymphocyte subsets and immunoglobulin changes were compared.

Results

115 patients were included in the study, including 43 in the treatment group and 72 in the control group. After Propensity Score Matching, 90 patients were divided into treatment (n=35) and control (n=55) groups. The postoperative inflammation index was higher in the treatment group than in the control group (P<0.05). The incidence of postoperative SIRS was higher in the treatment group than control (P<0.05). There were no cases of sepsis in either group. The double-positive T cells lymphocyte subsets were higher in the treatment group than in the control group ((P<0.05). Pre- and post-operative changes in immune function: total T lymphocyte count reduced, NK and NKT cell count increased in the control group, double-positive T cell count increased in the treatment group, IgG, IgA, IgM, complement C3 and C4 count reduced in both groups post-operatively.

Conclusion

This study found that patients with upper urinary tract calculi and infection treated with antibiotic-based PA-MSHA before percutaneous nephrolithotomy had an increased inflammatory response after surgery, which may play a role in the prevention and treatment of sepsis. The percentage of double-positive T cells in the peripheral blood was increased after PA-MSHA treatment, which may have an immunomodulatory and protective effect in PCNL patients with stones complicated by infection.

Development and Validation of the Prediction Model of Sepsis in Patients After Percutaneous Nephrolithotomy and Sepsis Progresses to Septic Shock

Background: To study the predictors of sepsis and the progression of sepsis to septic shock in patients after percutaneous nephrolithotomy (PCNL) and to establish and validate predictive models. Methods: The patients were assigned to either the development cohort or the validation cohort depending on their hospital. In the development cohort, univariate and multivariate logistic regression analyses were used to screen independent risk factors for sepsis after PCNL and sepsis progression to septic shock. Nomogram prediction models were established according to the related independent risk factors. Areas under the receiver operating characteristic curves, calibration plots, and decision curve analysis (DCA) were used to estimate the discrimination, calibration, and clinical usefulness of the prediction models, respectively. The two sets of models were further validated on the validation cohort. Results: In the development cohort, the risk factors for sepsis after PCNL were diabetes, urine nitrite, staghorn calculi, HU value, albumin-globulin ratio, and high-sensitivity C-reactive protein/albumin ratio. The pre- and postoperative white blood cell counts were risk factors for the progression of sepsis to septic shock. The area under the ROC curve value for predicting sepsis risk was 0.891 and that for predicting septic shock risk was 0.981 in the development cohort; in the validation cohort, these values were 0.893 and 0.996, respectively. In the development cohort, the calibration test p values in the sepsis and septic shock cohorts were 0.946 and 0.634, respectively; in the validation cohort, these values were 0.739 and 0.208, respectively. DCA of the model in the sepsis and septic shock cohorts showed threshold probabilities of 10%-90% in the development cohort; in the validation cohort, these values were 10%-90%. Conclusion: The individualized nomogram prediction models can help improve the early identification of patients who are at higher risk of developing sepsis after PCNL and the progression of sepsis to septic shock to avoid further damage.

International Alliance of Urolithiasis (IAU) Guideline on percutaneous nephrolithotomy

The International Alliance of Urolithiasis (IAU) would like to release the latest guideline on percutaneous nephrolithotomy (PCNL) and to provide a clinical framework for surgeons performing PCNLs. These recommendations were collected and appraised from a systematic review and assessment of the literature covering all aspects of PCNLs from the PubMed database between January 1, 1976, and July 31, 2021. Each generated recommendation was graded using a modified GRADE methodology. The quality of the evidence was graded using a classification system modified from the Oxford Center for Evidence-Based Medicine Levels of Evidence. Forty-seven recommendations were summarized and graded, which covered the following issues, indications and contraindications, stone complexity evaluation, preoperative imaging, antibiotic strategy, management of antithrombotic therapy, anesthesia, position, puncture, tracts, dilation, lithotripsy, intraoperative evaluation of residual stones, exit strategy, postoperative imaging and stone-free status evaluation, complications. The present guideline on PCNL was the first in the IAU series of urolithiasis management guidelines. The recommendations, tips and tricks across the PCNL procedures would provide adequate guidance for urologists performing PCNLs to ensure safety and efficiency in PCNLs.

A model for sepsis prediction after retrograde intrarenal surgery and the use of the preoperative/postoperative white blood cell ratio to predict progression from sepsis to septic shock

OBJECTIVES

To study the predictors of sepsis and progression to septic shock after RIRS; to establish and validate predictive models accordingly.

METHODS

In total, 1220 patients were included in the study during. Eight hundred forty-eight patients were assigned to the development cohort and 372 to the validation cohort according to medical record. Univariate and multivariate logistic regression analyses were used to screen independent risk factors for post-RIRS (Retrograde intrarenal surgery) sepsis and progression to septic shock. Nomogram prediction models were established according to the related independent risk factors. Areas under the receiver operating characteristic curves, calibration plots, and DCA (Decision curve analysis) were used to estimate the discrimination, calibration and clinical usefulness of the prediction model, respectively.

RESULTS

In the development cohort, sepsis occurred in 59 patients, 16 of whom developed septic shock. Multivariate logistic regression analyses showed that the independent risk factors for sepsis after RIRS were preoperative D-J stent implantation, hydronephrosis > 6.25 HU (Hounsfield units), AGR (Albumin/globulin ratio) < 1.95, hs-CRP/Alb (High-sensitivity C-reactive protein/albumin ratio) > 0.060, operating time > 67.5 min, and urinary nitrite positivity. The preoperative/postoperative WBC ratio > 1.5 was an independent risk factor for progression from sepsis to septic shock. In the development cohort, the AUC (Area under curve) for predicting sepsis risk was 0.845, and the AUC for predicting septic shock risk was 0.896; in the validation cohort, the corresponding values were 0.896 and 0.974, respectively. In the development cohort, the calibration test P values in the sepsis and septic shock cohorts, respectively, were 0.921 and 0.817; in the validation cohort, these values were 0.882 and 0.859. DCA of the model in the sepsis and septic shock cohorts showed threshold probabilities of 10-90% in the development cohort and 10-50% and 10-20% in the validation cohort.

CONCLUSION

These individualized nomogram prediction models can improve the early identification of patients at risk for developing sepsis after RIRS or progressing from sepsis to septic shock.

Predictive values of the SOFA score and procalcitonin for septic shock after percutaneous nephrolithotomy

To investigate the value of combination of the Sequential Organ Failure Assessment (SOFA) score and procalcitonin (PCT) for prediction of septic shock after percutaneous nephrolithotomy (PCNL). A total of 1328 patients receiving PCNL for renal calculi were allocated into control group (without septic shock) and septic shock group, and related data were retrospectively collected. Univariate analysis was firstly performed, and the variables with two sided P < 0.10 were then included in logistic regression analysis to determine independent risk factors. Receiver operating characteristic (ROC) curve was utilized to evaluate the predictive values. Area under curve (AUC) was compared using Z test. Postoperative septic shock was developed in 61 patients (4.6%) and not developed in 1267 patients (95.3%). Multivariate analysis demonstrated that SOFA score (OR: 1.316, 95% CI 1.125–1.922), PCT (OR: 1.205, 95% CI 1.071–1.696) and operative time (OR: 1.108, 95% CI 1.032–1.441) were independent risk factors for septic shock with adjustment for sex, history of urolithiasis surgery, positive history of urine culture and history of PCNL. The ROC curves demonstrated that the AUCs of SOFA score and PCT for predicting septic shock after PCNL were 0.896 (95% CI 0.866–0.927) and 0.792 (95% CI 0.744–0.839), respectively. The AUC of their combination was 0.971 (95% CI 0.949–0.990), which was higher than those of individual predictions (vs 0.896, Z = 4.086, P < 0.001; vs 0.792, Z = 6.983, P < 0.001). Both the SOFA score and PCT could be applied in predicting septic shock after PCNL, and their combination could further elevate the diagnostic ability.

A Novel Nomogram for Predicting Post-Operative Sepsis for Patients With Solitary, Unilateral and Proximal Ureteral Stones After Treatment Using Percutaneous Nephrolithotomy or Flexible Ureteroscopy

Background

The postoperative sepsis is a latent fatal complication for both flexible ureteroscopy (fURS) and percutaneous nephrolithotomy (PNL). An effective predictive model constructed by readily available clinical markers is urgently needed to reduce postoperative adverse events caused by infection. This study aims to determine the pre-operative predictors of sepsis in patients with unilateral, solitary, and proximal ureteral stones after fURS and PNL.

Methods

We retrospectively enrolled 910 patients with solitary proximal ureteral stone with stone size 10–20 mm who underwent fURS or PNL from Tongji Hospital's database, including 412 fURS cases and 498 PNL cases. We used the least absolute shrinkage and selection operator (LASSO) regression and multivariate logistic regression analysis to identify the risk factors for sepsis. Finally, a nomogram was assembled utilizing these risk factors.

Results

In this study, 49 patients (5.4%) developed sepsis after fURS or PNL surgery. Lasso regression showed postoperative sepsis was associated with gender (female), pre-operative fever, serum albumin (<35 g/L), positive urine culture, serum WBC (≥10,000 cells/ml), serum neutrophil, positive urine nitrite and operation type (fURS). The multivariate logistic analysis indicated that positive urine culture (odds ratio [OR] = 5.9092, 95% CI [2.6425–13.2140], p < 0.0001) and fURS (OR = 1.9348, 95% CI [1.0219–3.6631], p = 0.0427) were independent risk factors of sepsis and albumin ≥ 35g/L (OR = 0.4321, 95% CI [0.2054–0.9089], p = 0.0270) was independent protective factor of sepsis. A nomogram was constructed and exhibited favorable discrimination (area under receiver operating characteristic curve was 0.78), calibration [Hosmer–Lemeshow (HL) test p = 0.904], and net benefits displayed by decision curve analysis (DCA).

Conclusions

Patients who underwent fURS compared to PNL or have certain pre-operative characteristics, such as albumin <35 g/L and positive urine culture, are more likely to develop postoperative sepsis. Cautious preoperative evaluation and appropriate operation type are crucial to reducing serious infectious events after surgery, especially for patients with solitary, unilateral, and proximal ureteral stones sized 10–20 mm.

Predictive accuracy of the modified SOFA score, SIRS criteria, and qSOFA score for uroseptic shock after mini-percutaneous nephrolithotomy

The purpose of this study was to determine the plausibility and utility of utilizing a modified SOFA (mSOFA) score for predicting uroseptic shock after mini-percutaneous nephrolithotomy. A cohort of 707 patients who received mini-PCNL from August 2019 to December 2020 was retrospectively evaluated. The area under receiver operating characteristic curve (AUROC) was used to compare the predictive value of septic shock between mSOFA, systemic inflammatory response syndrome (SIRS) and qSOFA. Among 707 patients, 24 patients experienced uroseptic shock after mini-PCNL. Compared with the no uroseptic shock group, the proportion of females and rates of preoperative urine culture, renal pelvis urine culture and stone culture positivity were higher in the uroseptic shock group, with high levels of preoperative C-reactive protein (CRP) and postoperative procalcitonin (PCT). In the uroseptic shock group, the mSOFA score increased by two or more points in 83.3%; 79.2% had at least two SIRS criteria, and 100% had a qSOFA score of at least one point. mSOFA score (AUROC = 0.866, 95% CI: 0.779-0.954) exhibited greater discrimination for uroseptic shock after PCNL than SIRS (AUROC = 0.838, 95% CI: 0.742-0.943) and qSOFA (AUROC = 0.851, 95% CI: 0.811-0.892). In conclusion, the predictive value of the modified SOFA score for uroseptic shock after mini-PCNL was greater than that of the qSOFA score or SIRS.

Molecular mechanisms in septic shock (Review)

Sepsis is a clinical syndrome defined by the presence of infection and systemic inflammatory response to infection and results from a complex interaction between the host and infectious agents. It is characterized by the activation of multiple inflammatory pathways, with an increased risk of mortality. The incidence of sepsis has been on an ever-increasing pathway in recent years. Sepsis can be induced by several clinical situations that predispose to its occurrence: malignant tumors, organ transplantation, AIDS, radiation therapy, burns, sores, polytrauma, diabetes mellitus, hepatic failure, renal failure, malnutrition, catheters or different invasive devices, and urinary catheters. The microorganisms involved in the pathogenesis of sepsis are Gram-positive cocci (Staphylococci, Streptococci) and Gram-negative bacilli (Klebsiella, Pseudomonas aeruginosa, E. coli), fungi (Candida), parasites, and viruses. Among mechanisms involved in septic shock production, two pathological phenomena appear: the profound decompensation of circulation and metabolic disturbances that evolve towards an irreversible state. The intimate mechanism of shock involves the activation of monocytes, macrophages and neutrophils by lipopolysaccharides of Gram-negative bacteria. The microvascular bed is directly involved in the etiopathogenesis of disorders of acute inflammatory states associated with or without sepsis. A better comprehension of sepsis pathophysiology, especially the molecular mechanisms of septic shock, allows for new therapeutic perspectives.

National Early Warning Score in Predicting Severe Adverse Outcomes of Emergency Medicine Patients: A Retrospective Cohort Study

Background

For emergency triage, it is very important to identify patient severity according to their vital signs and chief complaint. Several studies have examined the predictive value of the National Early Warning Score (NEWS) for specific emergency patients and have shown it to be effective. However, few have studied the utility of NEWS in emergency triage for general emergency medicine patients. The aim of this research was to investigate the performance of NEWS in emergency triage with regard to predicting adverse outcomes.

Methods

This was a retrospective cohort study carried out at a tertiary care center hospital in Jinhua, China. A total of 62,403 patients attending the emergency department (ED) from January to December 2018 were included. The NEWS, Modified Early Warning Score (MEWS), and quick Sepsis Related Organ Failure Assessment (qSOFA) score were obtained from emergency triage. Multivariate logistic regression analysis was performed to evaluate the associations between the NEWS, MEWS, and qSOFA, as well as those between other parameters with ED mortality. The predictive performances for emergency observation, death, and intensive care unit (ICU) admission of NEWS, MEWS and qSOFA were compared to the area under the receiver operating characteristic curve (AUROC).

Results

Of the total participants, 6502 were placed under emergency observation, 106 died in the ED, 638 were admitted to the ICU, and 324 died in-hospital. The NEWS, qSOFA, age, and gender were significantly associated with ED mortality. NEWS was significantly better at discriminating all outcomes, and the area under the curve and 95% confidence intervals for ED mortality, observation in ED, composite of ED mortality and ICU admission, and in-hospital mortality were 0.862 (0.859-0.865), 0.691 (0.687-0.695), 0.859 (0.856-0.861), and 0.805 (0.802-0.808), respectively.

Conclusion

NEWS shows good performance in discriminating critical emergency patients in ED triage for emergency medicine patients.

Hounsfield unit attenuation value can differentiate pyonephrosis from hydronephrosis and predict septic complications in patients with obstructive uropathy

We aimed to assess the role of computerized tomography attenuation values (Hounsfield unit-HU) for differentiating pyonephrosis from hydronephrosis and for predicting postoperative infectious complications in patients with obstructive uropathy. We analysed data from 122 patients who underwent nephrostomy tube or ureteral catheter placement for obstructive uropathy. A radiologist drew the region of interest for quantitative measurement of the HU values in the hydronephrotic region of the affected kidney. Descriptive statistics and logistic regression models tested the predictive value of HU determination in differentiating pyonephrosis from hydronephrosis and in predicting postoperative sepsis. A HU cut-off value of 6.3 could diagnose the presence of pyonephrosis with 71.6% sensitivity and 71.5% specificity (AUC 0.76; 95%CI: 0.66-0.85). At multivariable logistic regression analysis HU ≥ 6.3 (p ≤ 0.001) was independently associated with pyonephrosis. Patients who developed sepsis had higher HU values (p ≤ 0.001) than those without sepsis. A HU cut-off value of 7.3 could diagnose the presence of sepsis with 76.5% sensitivity and 74.3% specificity (AUC 0.79; 95%CI: 0.71-0.90). At multivariable logistic regression analysis, HU ≥ 7.3 (p ≤ 0.001) was independently associated with sepsis, after accounting for clinical and laboratory parameters. Measuring HU values of the fluid of the dilated collecting system may be useful to differentiate pyonephrosis from hydronephrosis and to predict septic complications in patients with obstructive uropathy.