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Mahmud N, Asrani SK, Kaplan DE, Ogola GO, Taddei TH, Kamath PS, Serper M. The Predictive Role of Model for End-Stage Liver Disease-Lactate and Lactate Clearance for In-Hospital Mortality Among a National Cirrhosis Cohort. Liver Transpl 2021; 27:177-189. [PMID: 37160007 PMCID: PMC7880877 DOI: 10.1002/lt.25913] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 08/28/2020] [Accepted: 09/22/2020] [Indexed: 02/06/2023]
Abstract
The burden of cirrhosis hospitalizations is increasing. The admission Model for End-Stage Liver Disease-lactate (MELD-lactate) was recently demonstrated to be a superior predictor of in-hospital mortality compared with MELD in limited cohorts. We identified specific classes of hospitalizations where MELD-lactate may be especially useful and evaluated the predictive role of lactate clearance. This was a retrospective cohort study of 1036 cirrhosis hospitalizations for gastrointestinal bleeding, infection, or other portal hypertension-related indications in the Veterans Health Administration where MELD-lactate was measured on admission. Performance characteristics for in-hospital mortality were compared between MELD-lactate and MELD/MELD-sodium (MELD-Na), with stratified analyses of MELD categories (≤15, >15 to <25, ≥25) and reason for admission. We also incorporated day 3 lactate levels into modeling and tested for an interaction between day 1 MELD-lactate and day 3 lactate clearance. MELD-lactate had superior discrimination for in-hospital mortality compared with MELD or MELD-Na (area under the curve [AUC] 0.789 versus 0.776 versus 0.760, respectively; P < 0.001) and superior calibration. MELD-lactate had higher discrimination among hospitalizations with MELD ≤15 (AUC 0.763 versus 0.608 for MELD, global P = 0.01) and hospitalizations for infection (AUC 0.791 versus 0.674 for MELD, global P < 0.001). We found a significant interaction between day 1 MELD-lactate and day 3 lactate clearance; heat maps were created as clinical tools to risk-stratify patients based on these clinical data. MELD-lactate had significantly superior performance in predicting in-hospital mortality among patients hospitalized for infection and/or with MELD ≤15 when compared with MELD or MELD-Na. Incorporating day 3 lactate clearance may further improve prognostication.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Sumeet K. Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | | | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | | | - Marina Serper
- Division of Gastroenterology and Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Leonard David Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA,Gastroenterology Section, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
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Park SJ, Park J, Lee MJ, Seo JS, Ahn JY, Cho JW. Time series analysis of delta neutrophil index as the predictor of sepsis in patients with acute poisoning. Hum Exp Toxicol 2019; 39:86-94. [PMID: 31558056 DOI: 10.1177/0960327119878244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Delta neutrophil index (DNI), which reflects the fraction of immature granulocytes, is used to detect infection and sepsis from noninfectious conditions, but few studies have evaluated in the early stage of acute poisoning. This retrospective observational study was performed on acute poisoning patients who visited to the emergency department (ED) and were consecutively admitted in intensive care units over 18-month period. The serial DNI, conventional inflammatory biomarkers, and culture results were obtained in the ED and after admission. The outcomes were the identification of sepsis, bacteremia, and 30-day mortality. Of 166 patients (mean age, 56.0 years) in this cohort, 59 (35.5%) had sepsis and 29 (17.5%) had bacteremia. Initial and peak DNI fractions 24 h after ED admission were strong independent predictors of sepsis development. Analysis of the area under the curve according to multiple receiver operating characteristics showed that DNI had a higher capability to predict sepsis than other parameters (0.815 for DNI, 0.700 for procalcitonin, 0.681 for C-reactive protein, and 0.741 for white blood cell). Using multivariable logistic regression analysis, it was found that DNI was an independent predictor of sepsis (95% confidence interval (CI) of odds: 1.03-1.18) and bacteremia (95% CI: 1.01-1.14). Therefore, initial and serial measurement of DNI may serve as useful risk predictor for development of sepsis or bacteremia in acute poisoning.
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Affiliation(s)
- S J Park
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - J Park
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - M J Lee
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - J S Seo
- Department of Emergency Medicine, Dongguk University Ilsan Hospital, College of Medicine, Dongguk University, Seoul, Republic of Korea
| | - J Y Ahn
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - J W Cho
- Department of Emergency Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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The delta neutrophil index (DNI) as a prognostic marker for mortality in adults with sepsis: a systematic review and meta-analysis. Sci Rep 2018; 8:6621. [PMID: 29700315 PMCID: PMC5919925 DOI: 10.1038/s41598-018-24211-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Accepted: 03/23/2018] [Indexed: 02/08/2023] Open
Abstract
We performed a meta-analysis to seek evidence for the usefulness of the delta neutrophil index (DNI) as a prognostic blood biomarker for mortality in the early stage of sepsis in adults. A literature search was performed using criteria set forth in a predefined protocol. Studies of adults with sepsis that provided a DNI measurement and that had mortality as the outcome, were included. Review articles, editorials, and non-human studies were excluded. The methodological quality of identified studies was assessed independently by two authors using the Quality in Prognosis Studies (QUIPS) tool. A total of 1,822 patients from eleven studies were ultimately included. Standardized mean differences between non-survivors and survivors were compared. An elevated DNI was associated with mortality in patients with sepsis (standardized mean difference [SMD] 1.22; 95% confidence interval 0.73–1.71; I2 = 91%). After excluding two studies—one that included paediatric patients and one with a disproportionately low mortality rate—heterogeneity was minimized (SMD 0.74, 95% confidence interval 0.53–0.94; I2 = 43%). Overall, the findings suggest that high DNI values are associated with mortality in septic patients.
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Lee H, Kim IK, Ju MK. Which patients with intestinal obstruction need surgery? The delta neutrophil index as an early predictive marker. Ann Surg Treat Res 2017; 93:272-276. [PMID: 29184881 PMCID: PMC5694719 DOI: 10.4174/astr.2017.93.5.272] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 04/24/2017] [Accepted: 04/28/2017] [Indexed: 12/22/2022] Open
Abstract
Purpose Predicting the need for surgical intervention among patients with intestinal obstruction is challenging. The delta neutrophil index (DNI) has been suggested as a useful marker of immature granulocytes, which indicate an infection or sepsis. In this study, we evaluated the impact of the DNI as an early predictor of operation among patients with intestinal obstruction. Methods A total of 171 patients who were diagnosed with postoperative intestinal obstruction were enrolled in this study. Medical records, including data for the initial CRP level, WBC count, and DNI were reviewed. Receiver operating characteristic (ROC) curves were generated to clarify the optimal DNI cutoff values for predicting an operation. Results Among the 171 patients, 38 (22.2%) needed surgical intervention. The areas under the initial CRP, WBC, and DNI ROC curves were 0.460, 0.449, and 0.543, respectively. The optimal cutoff value for predicting further surgical intervention according to the initial DNI level was 4.3%. The accuracy of the cutoff value was 74.9%, the sensitivity was 23.7%, and the specificity was 89.5% (positive predictive value, 23.7%; negative predictive value, 89.5%). In the multivariate analysis, initial DNI levels ≥ 4.3% were significantly associated with surgical intervention (odd ratio, 3.092; 95% confidence interval, 1.072–8.918; P = 0.037). Conclusion The initial DNI level in patients with intestinal obstruction may be a useful predictor for determining the need for surgical intervention.
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Affiliation(s)
- Haemin Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Im-Kyung Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Man Ki Ju
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Delta neutrophil index is an independent predictor of mortality in septic acute kidney injury patients treated with continuous renal replacement therapy. BMC Nephrol 2017; 18:94. [PMID: 28320333 PMCID: PMC5358045 DOI: 10.1186/s12882-017-0507-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 03/09/2017] [Indexed: 12/19/2022] Open
Abstract
Background Delta neutrophil index (DNI), representing an elevated fraction of circulating immature granulocytes in acute infection, has been reported as a useful marker for predicting mortality in patients with sepsis. The aim of this study was to evaluate the prognostic value of DNI in predicting mortality in septic acute kidney injury (S-AKI) patients treated with continuous renal replacement therapy (CRRT). Method This is a retrospective analysis of consecutively CRRT treated patients. We enrolled 286 S-AKI patients who underwent CRRT and divided them into three groups based on the tertiles of DNI at CRRT initiation (high, DNI > 12.0%; intermediate, 3.6–12.0%; low, < 3.6%). Patient survival was estimated with the Kaplan-Meier method and Cox proportional hazards models to determine the effect of DNI on the mortality of S-AKI patients. Results Patients in the highest tertile of DNI showed higher Acute Physiology and Chronic Health Evaluation II score (highest tertile, 27.9 ± 7.0; lowest tertile, 24.6 ± 8.3; P = 0.003) and Sequential Organ Failure Assessment score (highest tertile, 14.1 ± 3.0; lowest tertile, 12.1 ± 4.0; P = 0.001). The 28-day mortality rate was significantly higher in the highest tertile group than in the lower two tertile groups (P < 0.001). In the multiple Cox proportional hazard model, DNI was an independent predictor for mortality after adjusting multiple confounding factors (hazard ratio, 1.010; 95% confidence interval, 1.001–1.019; P = 0.036). Conclusion This study suggests that DNI is independently associated with mortality of S-AKI patients on CRRT.
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Vincent JL, Quintairos E Silva A, Couto L, Taccone FS. The value of blood lactate kinetics in critically ill patients: a systematic review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:257. [PMID: 27520452 PMCID: PMC4983759 DOI: 10.1186/s13054-016-1403-5] [Citation(s) in RCA: 293] [Impact Index Per Article: 36.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 07/01/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND The time course of blood lactate levels could be helpful to assess a patient's response to therapy. Although the focus of published studies has been largely on septic patients, many other studies have reported serial blood lactate levels in different groups of acutely ill patients. METHODS We performed a systematic search of PubMed, Science Direct, and Embase until the end of February 2016 plus reference lists of relevant publications. We selected all observational and interventional studies that evaluated the capacity of serial blood lactate concentrations to predict outcome. There was no restriction based on language. We excluded studies in pediatric populations, experimental studies, and studies that did not report changes in lactate values or all-cause mortality rates. We separated studies according to the type of patients included. We collected data on the number of patients, timing of lactate measurements, minimum lactate level needed for inclusion if present, and suggested time interval for predictive use. RESULTS A total of 96 studies met our criteria: 14 in general ICU populations, five in general surgical ICU populations, five in patients post cardiac surgery, 14 in trauma patients, 39 in patients with sepsis, four in patients with cardiogenic shock, eight in patients after cardiac arrest, three in patients with respiratory failure, and four in other conditions. A decrease in lactate levels over time was consistently associated with lower mortality rates in all subgroups of patients. Most studies reported changes over 6, 12 or 24 hrs, fewer used shorter time intervals. Lactate kinetics did not appear very different in patients with sepsis and other types of patients. A few studies suggested that therapy could be guided by these measurements. CONCLUSIONS The observation of a better outcome associated with decreasing blood lactate concentrations was consistent throughout the clinical studies, and was not limited to septic patients. In all groups, the changes are relatively slow, so that lactate measurements every 1-2 hrs are probably sufficient in most acute conditions. The value of lactate kinetics appears to be valid regardless of the initial value.
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Affiliation(s)
- Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| | - Amanda Quintairos E Silva
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Lúcio Couto
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium
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Ha SO, Park SH, Park SH, Park JS, Huh JW, Lim CM, Koh Y, Hong SB, Jang S. Fraction of immature granulocytes reflects severity but not mortality in sepsis. Scandinavian Journal of Clinical and Laboratory Investigation 2014; 75:36-43. [PMID: 25342241 DOI: 10.3109/00365513.2014.965736] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE In order to validate immature granulocytes as a universal biomarker, we have compared the clinical relevance of the proportion of immature granulocytes (IG%), measured using Sysmex XE-2100, with other biomarkers (white blood cell, C-reactive protein, lactate and procalcitonin). METHODS This single center, retrospective study included 184 patients with sepsis admitted to an emergency department. Patients were classified into two groups: Uncomplicated sepsis and complicated sepsis (severe sepsis and septic shock). IG% and other biomarkers were evaluated and compared for predicting sepsis severity, overt disseminated intravascular coagulation (DIC) and 28 day mortality. RESULTS In multivariate analysis, only IG% (odd ratio [OR] 2.530, p = 0.004) and lactate (OR 4.500, p < 0.001) could discriminate between complicated and uncomplicated sepsis. The optimal cut-off value for IG% and lactate was 0.5% and 2.0 mmol/L, respectively. In subgroup analyses of complicated sepsis, IG% was related to overt DIC. However, no single biomarker could predict 28-day mortality. CONCLUSIONS Given that IG% reflected sepsis severity and overt DIC without additional cost, IG% could be a useful biomarker in patients with sepsis. However, there is a limitation for using it as a novel biomarker in sepsis due to the disability of prediction for 28-day mortality.
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Affiliation(s)
- Sang Ook Ha
- Department of Emergency Medicine, Hallym University Medical Center , Kyoungki-do
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Lim TS, Kim BK, Lee JW, Lee YK, Chang S, Kim SU, Kim DY, Ahn SH, Han KH, Chon CY, Park JY. Use of the delta neutrophil index as a prognostic factor of mortality in patients with spontaneous bacterial peritonitis: implications of a simple and useful marker. PLoS One 2014; 9:e86884. [PMID: 24466280 PMCID: PMC3900662 DOI: 10.1371/journal.pone.0086884] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 12/16/2013] [Indexed: 12/26/2022] Open
Abstract
Background Spontaneous bacterial peritonitis (SBP) is a common and life-threatening infection in patients with advanced cirrhosis. The prognostic value of a novel marker, the delta neutrophil index (DNI), was investigated relative to mortality in patients with SBP. Materials & Methods Seventy-five patients with SBP were studied from April 2010 to May 2012. DNI at initial diagnosis of SBP was determined and compared with 30-day mortality rates. Results Of the patients, 87.7% were men, and the median age of all patients was 59.0 yrs. The area under the receiver-operating characteristic (ROC) curve of DNI for 30-day mortality was 0.701 (95% confidence interval [CI], 0.553–0.849; p = 0.009), which was higher than that of C-reactive protein (0.640, 95% CI, 0.494–0.786; p = 0.076) or the model for end-stage liver disease score (0.592, 95% CI, 0.436–0.748; p = 0.235). From the ROC curve, with the sum of sensitivity and specificity, the cutoff value of DNI was determined to be 5.7%. In the high-DNI group (DNI ≥5.7%), septic shock and 30-day mortality were more prevalent compared with the low-DNI group (84.2% vs. 48.2%, p = 0.007; 57.9% vs. 14.3%, p<0.001, respectively). Patients with an elevated DNI had a higher risk of 30-day mortality compared with those with a low DNI (4.225, 95% CI, 1.631–10.949; p = 0.003). Conclusion A higher DNI at the time of SBP diagnosis is an independent predictor of 30-day mortality in patients with SBP.
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Affiliation(s)
- Tae Seop Lim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea
| | - Jong Wook Lee
- Department of Laboratory Medicine, Incheon Baek Hospital, Incheon, Republic of Korea
| | - Young Ki Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sooyun Chang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Up Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea
| | - Do Young Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea
| | - Kwang-Hyub Han
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea
| | - Chae Yoon Chon
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, Republic of Korea
- Liver Cirrhosis Clinical Research Center, Seoul, Republic of Korea
- * E-mail:
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