Serum lactate dehydrogenase is predictive of persistent organ failure in acute pancreatitis

Early Predictive Value of Different Indicators for Persistent Organ Failure in Acute Pancreatitis: A Systematic Review and Network Meta-Analysis

GOALS

In this study, we conducted this network meta-analysis (based on the ANOVA model) to evaluate the predictive efficacy of each early predictor.

BACKGROUND

Persistent organ failure (POF) is one of the determining factors in patients with acute pancreatitis (AP); however, the diagnosis of POF has a long-time lag (>48 h). It is of great clinical significance for the early noninvasive prediction of POF.

STUDY

We conducted a comprehensive and systematic search in PubMed, Cochrane library, Embase, and Web of Science to identify relevant clinical trials, case-control studies, or cohort studies, extracted the early indicators of POF in studies, and summarized the predictive efficacy of each indicator through network meta-analysis. The diagnostic odds ratio (DOR) was used to rank the prediction efficiency of each indicator.

RESULTS

We identified 23 studies in this network meta-analysis, including 10,393 patients with AP, of which 2014 patients had POF. A total of 10 early prediction indicators were extracted. The mean and 95% CI lower limit of each predictive indicator were greater than 1.0. Albumin had the largest diagnostic odds ratio, followed by high-density lipoprotein-cholesterol (HDL-C), Ranson Score, beside index for severity in acute pancreatitis Score, acute physiology and chronic health evaluation II, C-reactive protein (CRP), Interleukin 6 (IL-6), Interleukin 8 (IL-8), Systemic Inflammatory Response Syndrome (SIRS) and blood urea nitrogen.

CONCLUSIONS

Albumin, high-density lipoprotein-cholesterol, Ranson Score, and beside index for severity in acute pancreatitis Score are effective in the early prediction of POF in patients with AP, which can provide evidence for developing effective prediction systems. However, due to the limitations of the extraction method of predictive indicators in this study, some effective indicators may not be included in this meta-analysis.

Establishment and validation of early prediction model for hypertriglyceridemic severe acute pancreatitis

BACKGROUND

The prevalence of hypertriglyceridaemia-induced acute pancreatitis (HTG-AP) is increasing due to improvements in living standards and dietary changes. However, currently, there is no clinical multifactor scoring system specific to HTG-AP. This study aimed to screen the predictors of HTG-SAP and combine several indicators to establish and validate a visual model for the early prediction of HTG-SAP.

METHODS

The clinical data of 266 patients with HTG-SAP were analysed. Patients were classified into severe (N = 42) and non-severe (N = 224) groups according to the Atlanta classification criteria. Several statistical analyses, including one-way analysis, least absolute shrinkage with selection operator (LASSO) regression model, and binary logistic regression analysis, were used to evaluate the data.

RESULTS

The univariate analysis showed that several factors showed no statistically significant differences, including the number of episodes of pancreatitis, abdominal pain score, and several blood diagnostic markers, such as lactate dehydrogenase (LDH), serum calcium (Ca2+), C-reactive protein (CRP), and the incidence of pleural effusion, between the two groups (P < 0.000). LASSO regression analysis identified six candidate predictors: CRP, LDH, Ca2+, procalcitonin (PCT), ascites, and Balthazar computed tomography grade. Binary logistic regression multivariate analysis showed that CRP, LDH, Ca2+, and ascites were independent predictors of HTG-SAP, and the area under the curve (AUC) values were 0.886, 0.893, 0.872, and 0.850, respectively. The AUC of the newly established HTG-SAP model was 0.960 (95% confidence interval: 0.936-0.983), which was higher than that of the bedside index for severity in acute pancreatitis (BISAP) score, modified CT severity index, Ranson score, and Japanese severity score (JSS) CT grade (AUC: 0.794, 0.796, 0.894 and 0.764, respectively). The differences were significant (P < 0.01), except for the JSS prognostic indicators (P = 0.130). The Hosmer-Lemeshow test showed that the predictive results of the model were highly consistent with the actual situation (P > 0.05). The decision curve analysis plot suggested that clinical intervention can benefit patients when the model predicts that they are at risk for developing HTG-SAP.

CONCLUSIONS

CRP, LDH, Ca2+, and ascites are independent predictors of HTG-SAP. The prediction model constructed based on these indicators has a high accuracy, sensitivity, consistency, and practicability in predicting HTG-SAP.

Repetitive Cerulein-Induced Chronic Pancreatitis in Growing Pigs-A Pilot Study

Chronic pancreatitis (CP) is an irreversible and progressive inflammatory disease. Knowledge on the development and progression of CP is limited. The goal of the study was to define the serum profile of pro-inflammatory cytokines and the cell antioxidant defense system (superoxidase dismutase-SOD, and reduced glutathione-GSH) over time in a cerulein-induced CP model and explore the impact of these changes on selected cytokines in the intestinal mucosa and pancreatic tissue, as well as on selected serum biochemical parameters. The mRNA expression of CLDN1 and CDH1 genes, and levels of Claudin-1 and E-cadherin, proteins of gut barrier, in the intestinal mucosa were determined via western blot analysis. The study showed moderate pathomorphological changes in the pigs' pancreas 43 days after the last cerulein injection. Blood serum levels of interleukin (IL)-1-beta, IL-6, tumor necrosis factor alpha (TNF-alpha), C-reactive protein (CRP), lactate dehydrogenase (LDH), gamma-glutamyl transpeptidase (GGTP), SOD and GSH were increased following cerulein injections. IL-1-beta, IL-6, TNF-alpha and GSH were also increased in jejunal mucosa and pancreatic tissue. In duodenum, decreased mRNA expression of CDH1 and level of E-cadherin and increased D-lactate, an indicator of leaky gut, indicating an inflammatory state, were observed. Based on the current results, we can conclude that repetitive cerulein injections in growing pigs not only led to CP over time, but also induced inflammation in the intestine. As a result of the inflammation, the intestinal barrier was impaired.

EASIX Is an Accurate and Easily Available Prognostic Score in Critically Ill Patients with Advanced Liver Disease

Acute-on-chronic liver failure (ACLF) is associated with high mortality. Objective prognostic scores are important for treatment decisions. EASIX (Endothelial Activation and Stress Index) is a simple biomarker consisting of LDH, platelets, and creatinine, reflecting endothelial dysfunction after allogeneic stem cell transplantation. Considering endothelial dysfunction in the pathogenesis of ACLF, this study aimed to test the discriminative ability of EASIX in advanced liver disease. We retrospectively analysed the prognostic potential of EASIX to predict 28-day and 3-month mortality in a total of 188 liver cirrhotic patients requiring treatment at the intensive care unit. We evaluated the ability of EASIX to rule out early infections and predict the need for hemodialysis. EASIX performed moderately better than established scores in predicting 28-day mortality (AUC = 0.771) and was nearly equivalent (AUC = 0.791) to SOFA and APACHE-II in the prediction of 3-month mortality. Importantly, EASIX showed better diagnostic potential in ruling out clinically apparent infections than common proinflammatory markers (AUC = 0.861, p < 0.001) and showed suitable accuracy in predicting the need for hemodialysis (AUC = 0.833). EASIX is an accurate, objective and easily assessable biomarker for predicting mortality and complications in patients with advanced liver disease.

Revisiting the Ranson score in acute pancreatitis: Is the drop in hematocrit a worrisome sign?

BACKGROUND

The Ranson score has 11 parameters that are complex and laborious to implement. In this study, we aimed to create a revised Ranson score by modifying the parameters in Ranson.

METHODS

A total of 938 patients diagnosed with acute pancreatitis (AP) between 2014 and 2021 were included in the study. The parameters of the Ranson score were included in the univariate and multivariate analyses. According to the results, some of these parameters were modified, and then the revised Ranson score was created.

RESULTS

The revised Ranson system was created with nine parameters by modifying the hematocrit parameter at 48 hours and excluding the aspartate aminotransferase parameter from the scoring system. For in-hospital mortality, the area under the curve value of the revised Ranson was 0.959 (95% CI: 0.931-0.986), and it was significantly higher compared to the three scoring systems evaluated. At a cut-off value of 3.5, the revised Ranson had a sensitivity and specificity of 91.7% and 89.1%, respectively, for mortality.

CONCLUSION

The revised Ranson scoring system had better predictive ability for all clinical outcomes compared to the original Ranson in our large sample of 938 patients. However, the revised version should be further validated by prospective and multicenter studies.

DIFFERENTIAL DIAGNOSIS BETWEEN BILIARY AND NONBILIARY ACUTE PANCREATITIS: WHAT IS THE IMPORTANCE OF LABORATORY TESTS?

BACKGROUND

The differential diagnosis of the causal factors of acute pancreatitis is fundamental for its clinical follow-up, becoming relevant to establishing laboratory criteria that elucidate the difference between biliary and nonbiliary causes.

AIM

The aim of this study was to establish criteria based on laboratory tests for the differential diagnosis between acute pancreatitis of biliary and nonbiliary causes and to identify laboratory tests with sufficient sensitivity to propose the creation of an algorithm for differential diagnosis between the causes.

METHODS

The research consisted of observational analysis, with a cross-sectional design of laboratory tests of two groups of patients with acute pancreatitis: group A: nonbiliary cause and group B: biliary cause. Hematocrit, white blood cell count, lactate dehydrogenase, glucose, lipase, amylase, total bilirubin, oxalacetic transaminase, pyruvic transaminase, gamma-glutamyltransferase, and alkaline phosphatase were investigated. Data were submitted to nonparametric tests and receiver operating characteristics.

RESULTS

Hematocrit values, number of leukocytes, lactate dehydrogenase, and glucose showed no significant difference between the groups (p>0.1). Lipase, amylase, total bilirubin, oxalacetic transaminase, pyruvic transaminase, gamma-glutamyltransferase, and alkaline phosphatase values showed a significant difference between groups (p<0.05). The oxalacetic transaminase, pyruvic transaminase, and alkaline phosphatase tests were most sensitive in determining the biliary cause, allowing the establishment of a cutoff point by the receiver operating characteristic test: pyruvic transaminase: 123.0 U/L (sensitivity: 69.2%; specificity: 81.5%), oxalacetic transaminase: 123.5 U/L (sensitivity: 57.3%; specificity: 78.8%), and alkaline phosphatase: 126.5 U/L (sensitivity: 66.1%; specificity: 69.4%), from which the probability of a correct answer increases.

CONCLUSION

It was possible to establish criteria based on laboratory tests for the differential diagnosis between acute pancreatitis of biliary and nonbiliary origin; however, the tests did not show enough sensitivity to propose the creation of an algorithm for differential diagnosis between the same causes.

Relationship between serum lactate dehydrogenase and mortality after cardiac arrest: A retrospective cohort study

Serum lactate dehydrogenase (LDH) has been identified as an independent risk factor for predicting all-cause mortality in patients with multiple diseases. However, the prognostic value of LDH levels in post-cardiac arrest patients remains uncertain. This study aimed to assess the association between LDH and mortality in intensive care unit (ICU) patients after cardiac arrest. This retrospective observational study is based on data from the Dryad Digital Repository, which included 374 consecutive adult patients after cardiac arrest. Patients were divided into 2 groups based on median LDH values. A multivariate Cox proportional hazards model was established to assess the independent relationship between LDH and ICU mortality. Cumulative mortality was compared using Kaplan-Meier curves. The cohort included 374 patients, of which 51.9% (194/374) died in the ICU. The overall death rate from cardiac arrest was significantly higher for patients with LDH ≥ 335 IU/L (59.6%) than for those with LDH < 335 IU/L (44.1%). In multiple Cox regression models, hazard ratios (HR) and corresponding 95% confidence intervals (CI) for logLDH and the 2 LDH groups were 1.72 (1.07, 2.78) and 1.42 (1.04, 1.93), respectively. Participants with LDH ≥ 335IU/L had a higher incidence of ICU mortality than LDH < 335 IU/L, as shown by the Kaplan-Meier curves (P = .0085). Subgroup analysis revealed that the association between LDH and ICU mortality was vitally stable, with all P interactions from different subgroups >.05. Serum LDH levels are positively associated with ICU mortality in patients after cardiac arrest, especially for patients with LDH ≥ 335 IU/L.

Mean corpuscular hemoglobin predicts the length of hospital stay independent of severity classification in patients with acute pancreatitis

Mean corpuscular hemoglobin (MCH) is a common blood routine test index. To explore the relationship between MCH and length of hospital stay in patients with acute pancreatitis (AP), we included 273 patients with AP without coronary heart disease, diabetes, hypertension and anemia in this study. All data were separated into three groups according to the length of hospital stay. Gender (p = 0.017) and severity classification (p < 0.001) were significantly correlated with length of hospital stay among three groups. Notably, MCH level was significant different among three groups (p = 0.009). Thus, all data were separated into two groups according to MCH level, and significant increases in the length of hospital stay were observed between two groups (p = 0.030). A positive correlation between length of hospital stay and MCH was observed (r = 0.172, p = 0.004). Multiple linear regression analysis showed that MCH was independent correlated with the length of hospital stay, no matter whether severity classification of AP was included (beta = 0.248, p < 0.001; beta = 0.212, p < 0.001). Our results demonstrated that the length of hospital stay was correlated with MCH level in patients with AP, and MCH level at admission may predict the length of hospital stay independent of severity classification in AP. These results may provide a potential evaluation basis for the management of patients with AP.

5 ALA Is a Potent Lactate Dehydrogenase Inhibitor But Not a Substrate: Implications for Cell Glycolysis and New Avenues in 5 ALA-Mediated Anticancer Action

Simple Summary

In the present work, we found that 5-ALA, a natural precursor of heme, can hinder cell glycolysis, which is the main path of energy production for most cancer cells. More specifically, we found that 5-ALA can block an enzyme involved in glycolysis, called lactate dehydrogenase (LDH). We found that 5-ALA has a potency of LDH inhibition comparable to other established LDH inhibitors, such as oxamate or tartronic acid. Nevertheless, 5-ALA has a high accumulation rate in cancers and specifically in the incurable brain cancer glioblastoma multiforme (GBM), which is an important advantage. In fact, because of its high specificity to GBM, 5-ALA is used in the clinic to accurately guide the resection of the tumours, through the light emission of its photoactive product protoporphyrin IX (PpIX). PpIX is the penultimate step in the heme production. Importantly, we show here that continuous administration of 5-ALA killed GBM cells according to their dependence on glycolysis. We additionally found that 20% of externally administered 5-ALA is engaged in the inhibition of LDH, as when LDH was pre-loaded by another inhibitor, tartronic acid, then the cell production of PpIX from 5-ALA was increased by 20%. Since PpIX is an important drug for photodynamic therapy of cancer (excitation by light of PpIX produces oxygen by-products that can kill cancer cells), we additionally discovered that preloading LDH with its inhibitor tartronic acid before performing 5-ALA PDT increases the cancer cell death by 15%.

Abstract

In a course of metabolic experiments, we determined that the addition of δ-aminolevulinic acid (5-ALA) to a panel of glioblastoma multiforme (GBM) cells caused a steep reduction in their glycolytic activity. This reduction was accompanied by a decrease in adenosine triphosphate (ATP) production from glycolysis. These results suggested that 5-ALA is an inhibitor of glycolysis; due to the structural similarity of 5-ALA to the established lactate dehydrogenase (LDH) inhibitors oxamate (OXM) and tartronate (TART), we initially investigated LDH inhibition by 5-ALA in silico. The modelling revealed that 5-ALA could indeed be a competitive inhibitor of LDH but not a substrate. These theoretical findings were corroborated by enzymatic and cell lysate assays in which 5-ALA was found to confer a potent LDH inhibition comparable to that of OXM and TART. We subsequently evaluated the effect of 5-ALA-induced glycolysis inhibition on the viability of GBM cells with diverse metabolic phenotypes. In the Warburg-type cell lines Ln18 and U87, incubation with 5-ALA elicited profound and irreversible cell death (90–98%) at 10 mM after merely 24 h. In T98G, however, which exhibited both high respiratory and glycolytic rates, LD95 was achieved after 72 h of incubation with 20 mM 5-ALA. We additionally examined the production of the 5-ALA photosensitive metadrug protoporphyrin IX (PpIX), with and without prior LDH inhibition by TART. These studies revealed that ~20% of the 5-ALA taken up by the cells was engaged in LDH inhibition. We subsequently performed 5-ALA photodynamic therapy (PDT) on Ln18 GBM cells, again with and without prior LDH inhibition with TART, and found a PDT outcome enhancement of ~15% upon LDH pre-inhibition. We expect our findings to have a profound impact on contemporary oncology, particularly for the treatment of otherwise incurable brain cancers such as GBM, where the specific accumulation of 5-ALA is very high compared to the surrounding normal tissue.

Red cell distribution width to serum albumin ratio as an early prognostic marker for severe acute pancreatitis: A retrospective study

BACKGROUND AND STUDY AIMS

The ability to predict severe acute pancreatitis (SAP) at an early stage is crucial for reducing the associated complications and mortality. In this study, we compared the ratio of red cell distribution width to albumin (RDW-to-ALB) using predictive scoring systems, such as the Ranson score, BISAP, and MCTSI, to develop a simple and accurate method of predicting SAP.

PATIENTS AND METHODS

We included 212 patients with mild acute pancreatitis (MAP) and 89 with SAP between January 2013 and December 2018. The differences in the general characteristics and biochemical analysis as well as the various predictive scores were compared between the two groups. We evaluated the sensitivity and specificity between the RDW-to-ALB ratio, RDW, ALB, and multiple predictive scores in patients with early acute pancreatitis (AP) by using the receiver operating characteristic (ROC) curve.

RESULTS

The RDW-to-ALB ratio (%) of patients with SAP was higher than that of patients with MAP (0.43 ± 0.08 vs. 0.32 ± 0.04, p < 0.001). Patients with SAP had higher Ranson, BISAP, and MCTSI scores than those with MAP. The ROC curve revealed that, when the RDW-to-ALB ratio (%) was >0.36, the sensitivity and specificity of the predicted SAP were 80.0% and 80.7%, respectively. Further statistical analysis found that the RDW-to-ALB ratio and Ranson, BISAP, and MCTSI scores were consistent in predicting SAP effectiveness (P > 0.05).

CONCLUSIONS

The RDW-to-ALB ratio has a promising predictive power for SAP, and its effectiveness is comparable with those of Ranson, BISAP, and MCTSI scores.

Development and validation of a prediction model for moderately severe and severe acute pancreatitis in pregnancy

BACKGROUND

The severity of acute pancreatitis in pregnancy (APIP) is correlated with higher risks of maternal and fetal death.

AIM

To develop a nomogram that could predict moderately severe and severe acute pancreatitis in pregnancy (MSIP).

METHODS

Patients with APIP admitted to West China Hospital between January 2012 and December 2018 were included in this study. They were divided into mild acute pancreatitis in pregnancy (MAIP) and MSIP. Characteristic parameters and laboratory results were collected. The training set and test set were randomly divided at a ratio of 7:3. Least absolute shrinkage and selection operator regression was used to select potential prognostic factors. A nomogram was developed by logistic regression. A random forest model was used to validate the stability of the prediction factors. Receiver operating characteristic curves and calibration curves were used to evaluate the model’s predictive performance.

RESULTS

A total of 190 patients were included in this study. A total of 134 patients (70.5%) and 56 patients (29.5%) were classified as having MAIP and MSIP, respectively. Four independent predictors (lactate dehydrogenase, triglyceride, cholesterol, and albumin levels) were identified for MSIP. A nomogram prediction model based on these factors was established. The model had areas under the curve of 0.865 and 0.853 in the training and validation sets, respectively. The calibration curves showed that the nomogram has a good consistency.

CONCLUSION

A nomogram including lactate dehydrogenase, triglyceride, cholesterol, and albumin levels as independent predictors was built with good performance for MSIP prediction.

Establishment of Early Multi-Indicator Prediction Models of Moderately Severe Acute Pancreatitis and Severe Acute Pancreatitis

Background

It is critical to accurately identify patients with severe acute pancreatitis (SAP) and moderately SAP (MSAP) in a timely manner. The study was done to establish two early multi-indicator prediction models of MSAP and SAP.

Methods

Clinical data of 469 patients with acute pancreatitis (AP) between 2015 and 2020, at the First Affiliated Hospital of Fujian Medical University, and between 2012 and 2020, at the Affiliated Union Hospital of Fujian Medical University, were retrospectively analyzed. The unweighted predictive score (unwScore) and weighted predictive score (wScore) for MSAP and SAP were derived using logistic regression analysis and were compared with four existing systems using receiver operating characteristic curves.

Results

Seven prognostic indicators were selected for incorporation into models, including white blood cell count, lactate dehydrogenase, C-reactive protein, triglyceride, D-dimer, serum potassium, and serum calcium. The cut-offs of the unwScore and wScore for predicting severity were set as 3 points and 0.513 points, respectively. The unwScore (AUC = 0.854) and wScore (AUC = 0.837) were superior to the acute physiology and chronic health evaluation II score (AUC = 0.526), the bedside index for severity in AP score (AUC = 0.766), and the Ranson score (AUC = 0.693) in predicting MSAP and SAP, which were equivalent to the modified computed tomography severity index score (AUC = 0.823).

Conclusions

The unwScore and wScore have good predictive value for MSAP and SAP, which could provide a valuable clinical reference for management and treatment.

Reduction in O-GlcNAcylation Mitigates the Severity of Inflammatory Response in Cerulein-Induced Acute Pancreatitis in a Mouse Model

Acute pancreatitis (AP) involves premature trypsinogen activation, which mediates a cascade of pro-inflammatory signaling that causes early stages of pancreatic injury. Activation of the transcription factor κB (NF-κB) and secretion of pro-inflammatory mediators are major events in AP. O-GlcNAc transferase (OGT), a stress-sensitive enzyme, was recently implicated to regulate NF-κB activation and inflammation in AP in vitro. This study aims to determine whether a pancreas-specific transgenic reduction in OGT in a mouse model affects the severity of AP in vivo. Mice with reduced pancreatic OGT (OGT^Panc+/-) at 8 weeks of age were randomized to cerulein, which induces pancreatitis, or saline injections. AP was confirmed by elevated amylase levels and on histological analysis. The histological scoring demonstrated that OGT^Panc+/- mice had decreased severity of AP. Additionally, serum lipase, LDH, and TNF-α in OGT^Panc+/- did not significantly increase in response to cerulein treatment as compared to controls, suggesting attenuated AP induction in this model. Our study reveals the effect of reducing pancreatic OGT levels on the severity of pancreatitis, warranting further investigation on the role of OGT in the pathology of AP.

Nomogram for Predicting Persistent Organ Failure With Acute Pancreatitis in Pregnancy

BACKGROUND

Acute pancreatitis in pregnancy (APIP) with persistent organ failure (POF) poses a high risk of death for mother and fetus. This study sought to create a nomogram model for early prediction of POF with APIP patients.

METHODS

We conducted a cross-sectional study on APIP patients with organ failure (OF) between January 2012 and March 2021. 131 patients were collected. Their clinical courses and pregnancy outcomes were obtained. Risk factors for POF were identified by univariate and multivariate logistic regression analysis. Prediction models with POF were built and nomogram was plotted. The performance of the nomogram was evaluated by using a bootstrapped-concordance index and calibration plots.

RESULTS

Hypertriglyceridemia was the most common etiology in this group of APIP patients, which accounted for 50% of transient organ failure (TOF) and 72.3% of POF. All in-hospital maternal death was in the POF group (P<0.05), which also had a significantly higher perinatal mortality rate than the TOF group (P<0.05). Univariate and multivariate logistic regression analysis determined that lactate dehydrogenase, triglycerides, serum creatinine, and procalcitonin were independent risk factors for predicting POF in APIP. A nomogram for POF was created by using the four indicators. The area under the curve was 0.875 (95%CI: 0.80-0.95). The nomogram had a bootstrapped-concordance index of 0.85 and was well-calibrated.

CONCLUSIONS

Hypertriglyceridemia was the leading cause of organ failure-related APIP. Lactate dehydrogenase, triglycerides, serum creatinine, and procalcitonin were the independent risk factors of POF in APIP. Our nomogram model showed an effective prediction of POF with the four indicators in APIP patients.

Establishment and validation of a prognostic model for hepatitis B virus‑related acute-on-chronic liver failure patients with bacterial infection

BACKGROUND

Bacterial infection is one of the most frequent complications in acute-on-chronic liver failure (ACLF), which leads to high mortality. However, a specific prognostic model for ACLF patients with bacterial infection has not been well established.

AIM

To establish and validate a nomogram for predicting 30-day mortality of hepatitis B virus-related ACLF (HBV-ACLF) patients with bacterial infection.

METHODS

A total of 513 ACLF patients for HBV reactivation were enrolled in the prospective cohort, and 224 patients with bacterial infection were for derivation. Independent predictors were identified using multivariate logistic model and then assembled into a nomogram to predict 30-day mortality. The performance of the nomogram was assessed based on its calibration, discrimination and clinical utility in a retrospective cohort of 192 HBV-ACLF patients with bacterial infection.

RESULTS

Age, total bilirubin, lactate dehydrogenase, international normalized ratio and soluble interleukin-2 receptor were shown to be independent risk factors for 30-day mortality of HBV-ACLF patients with bacterial infection and the nomogram was constructed. The nomogram showed a good calibration and discrimination in the derivation cohort, with an area under the receiver operating characteristic curve (AUC) of 0.883. Application of the nomogram in the validation cohort also showed a good calibration and discrimination, with the AUC of 0.852. Decision curve analysis confirmed the clinical utility of the nomogram.

CONCLUSION

The nomogram was established and validated for predicting 30-day mortality of HBV-ACLF patients with bacterial infection, which may facilitate optimal therapeutic strategies to improve the prognosis of these patients.

Clinical Characteristics of Adult Hemophagocytic Lymphohistiocytosis in the Emergency Department

Purpose

To determine the clinical manifestations and results of adult hemophagocytic lymphohistiocytosis (HLH) patients in our emergency department.

Methods

We retrospectively evaluated patients with HLH from 1 April 2018 to 31 December 2020. The clinical data of these patients (basic information, symptoms, vital signs, laboratory results, HLH diagnostic criteria, H Score, main treatments, outcomes) were collected.

Results

Thirty-three patients (23 males and 10 females; 40.55±18.78 years) with 34 clinical episodes (one male had two clinical episodes and died during the second episode) were enrolled. Twenty-five patients were placed in a “survivor” group, and nine patients were categorized into a “deceased” group. Fever, splenomegaly, hemoglobin <90 g/L and platelet count <100×10⁹/L most commonly met the diagnostic standard for HLH. The H Score results in the survival group and deceased group was 212.4±37.18 and 252.1±40.95, respectively. Viral infection was the most common reason for HLH, followed by immune-system disease and cancer. Laboratory tests showed that deceased-group patients had multiple-organ dysfunction. Multivariate logistic regression showed that the lactate dehydrogenase (lactate dehydrogenase) level (P = 0.039; odds ratio, 0.999) was significantly related to death.

Conclusion

In the emergency department, HLH should be considered for critically ill patients with fever, splenomegaly, low hemoglobin and low platelet count. The H Score might be useful to diagnose HLH quickly. In our study, 26.47% of HLH patients died in the emergency department, and patients with a significantly increased lactate dehydrogenase level had a markedly increased risk of death.

Granny Smith Apple Extract Lowers Inflammation and Improves Antioxidant Status in L-arginine-induced Exocrine Pancreatic Dysfunction in Rats

Objectives

Granny Smith is a cultivated hybrid variety of apple with a high antioxidant content relative to all other species of apple. Acute pancreatitis (AP) is an instantly emerging inflammatory condition with a high mortality rate. The preferred treatment is restricted to symptomatic relief and supportive care. The present study was undertaken to evaluate the favorable effects of Granny Smith apple extract (GSAE) as a prophylactic treatment for L-arginine-induced AP in rats.

Materials and Methods

Male Sprague Dawley rats were divided in to five groups (n=6): Normal control (saline), disease control (a single dose of L-arginine 2.5 g/kg I.P.), positive control (pelatonin 10 mg/kg I.P.), and GSAE I and II (200 mg/kg and 400 mg/kg, orally, respectively). All groups were treated for 7 days. At the end of the study, blood samples were collected from the retro-orbital plexus, serum separated, and subjected to estimation of biomarker enzymes such as amylase, lipase, antioxidant enzymes, etc. The animals were then sacrificed, and the pancreas was isolated and subjected to estimation of tissue biomarkers, DNA fragmentation assay, and histopathological studies.

Results

Serum levels of amylase and lipase were significantly (p<0.001) reduced in L-arginine-treated rats. Similar results were also observed with tissue inflammatory markers such as malondialdehyde, nitrate, etc. There was a dramatic increase (p<0.001) in the overall antioxidant enzyme levels when compared with disease control rats. Histopathological examination of pancreatic tissue showed an intact structural feature of acinar cells in the extract-treated group of rats, which was further in pact with the intact DNA found in the DNA fragmentation assay.

Conclusion

Thus, GSAE treatment was found to be beneficial in lowering the inflammatory conditions of AP by improving the overall antioxidant levels, and a further investigation into its exact molecular mechanism is needed.

Dibutyl phthalate induces allergic airway inflammation in rats via inhibition of the Nrf2/TSLP/JAK1 pathway

Dibutyl phthalate (DBP), an important plastic contaminant in the environment, is known to cause organ toxicity. Although current research has shown that DBP-induced organ toxicity is associated with oxidative stress, the toxic effect of DBP on the lungs have not been fully elucidated. Therefore, we investigated the potential mechanism by which DBP induces pulmonary toxicity using a model of DBP-induced allergic airway inflammation in rats. The results showed that chronic exposure to DBP induced histopathological damage, inflammation, oxidative stress, apoptosis, and increased the protein levels of thymic stromal lymphopoietin (TSLP) and its downstream protein Janus kinase 1 (JAK1) and signal transducer and activator of transcription 6 (STAT6). Moreover, DBP exposure inhibited nuclear factor-erythroid-2-related factor 2 (Nrf2) and levels of its target genes NAD(P)H quinone oxidoreductase 1 (NQO1) and heme oxygenase-1 (HO-1). Additionally, using in vitro experiments, we found that DBP induced oxidative stress, reduced cell viability, and inhibited the Nrf2/HO-1/NQO1 pathway in mouse alveolar type II epithelial cell line. Overall, these data demonstrate that DBP induces allergic airway inflammation in rats via inhibition of the Nrf2/TSLP/JAK1 pathway.

Serum hydroxybutyrate dehydrogenase as an early predictive marker of the severity of acute pancreatitis: a retrospective study

BACKGROUND

To investigate the value of serum hydroxybutyrate dehydrogenase (HBDH) level, an isozyme of lactate dehydrogenase, in evaluating the severity of acute pancreatitis (AP).

METHODS

Patients diagnosed with AP from January 2013 to December 2018 were included in this retrospective study. Patients were divided into the normal serum HBDH levels group (n-HBDH group) and the high serum HBDH levels group (h-HBDH group) according to the criteria HBDH ≥ 182 U/L after admission. The demographic parameters, laboratory data and the severity of AP in the two groups were compared. The receiver operating curve (ROC) was used to evaluate the efficacy of serum HBDH in predicting persistent organ failure and systemic inflammatory response syndrome (SIRS).

RESULTS

A total of 260 AP patients were enrolled, including 176 cases in the n-HBDH group and 84 cases in the h-HBDH group. The incidence of SIRS and organ failure in the h-HBDH group were significantly higher than those in n-HBDH group (both P < 0.001). In addition, the HBDH level was significantly decreased in 110 patients who were re-measured after AP treatment. The serum HBDH levels were positively correlated with Atlanta classification, Ranson score, and BISAP score (all P < 0.05). ROC analysis showed that a serum HBDH cut-off point of 195.0 U/L had optimal predictive value for the development of persistent organ failure (AUC = 0.778) and 166.5 U/L for the development of SIRS (AUC = 0.724).

CONCLUSION

The elevated serum HBDH in early stage of AP is closely related to the adverse prognosis of AP patients, which can be used as a potential early biomarker for predicting the severity of AP.

Assessment of the course of acute pancreatitis in the light of aetiology: a systematic review and meta-analysis

The main causes of acute pancreatitis (AP) are biliary disease, alcohol consumption, hypertriglyceridaemia (HTG) and endoscopic retrograde cholangiopancreatography (ERCP). The aim of this meta-analysis was to evaluate the effects of these aetiological factors on the severity and outcome of AP. Pubmed and Embase were searched between 01/01/2012 and 31/05/2020. Included articles involved adult alcoholic, biliary, HTG- or post-ERCP AP (PAP) patients. Primary outcome was severity, secondary outcomes were organ failures, intensive care unit admission, recurrence rate, pancreatic necrosis, mortality, length of hospital stay, pseudocyst, fluid collection and systematic inflammatory response syndrome. Data were analysed from 127 eligible studies. The risk for non-mild (moderately severe and severe) condition was the highest in HTG-induced AP (HTG-AP) followed by alcoholic AP (AAP), biliary AP (BAP) and PAP. Recurrence rate was significantly lower among BAP vs. HTG-AP or AAP patients (OR = 2.69 and 2.98, 95% CI 1.55–4.65 and 2.22–4.01, respectively). Mortality rate was significantly greater in HTG-AP vs. AAP or BAP (OR = 1.72 and 1.50, 95% CI 1.04–2.84 and 0.96–2.35, respectively), pancreatic necrosis occurred more frequently in AAP than BAP patients (OR = 1.58, 95% CI 1.08–2.30). Overall, there is a potential association between aetiology and the development and course of AP. HTG-AP is associated with the highest number of complications. Furthermore, AAP is likely to be more severe than BAP or PAP. Greater emphasis should be placed on determining aetiology on admission.

Evaluation of 880 patients diagnosed with acute pancreatitis according to the Revised Atlanta Classification: A single-center experience

OBJECTIVE The Revised Atlanta Classification (RAC) is increasingly used in the evaluation of patients diagnosed with acute pancreatitis (AP). In our study, we aimed to evaluate the etiology, disease severity, and mortality rates of patients diagnosed with AP in our center in the previous 6 years. METHODS Patients diagnosed with AP between 2013 and 2018 were evaluated. AP etiology, demographic data, disease severity, and mortality rates according to the RAC were evaluated. RESULTS A total of 880 patients were included in the study. Five hundred and eighteen (59%) patients were female and 362 (41%) were male. Regarding the etiology, 474 (53.9%) patients had biliary AP (BAP), 71 (8.1%) had hyperlipidemic AP (HAP), and 44 (5%) had alcoholic AP (AAP). According to the RAC, 561 (63.7%) patients were considered to be in the mild AP group (MAP), 268 (30.5%) in the moderately severe AP (MSAP), and 51 (5.8%) in the severe AP (SAP). The mortality rate was 4.8% in the MSAP group and 49% in the SAP group. Mortality was 2.3 times in patients over 65 years old and 3.7 times higher in patients with ischemic heart disease. CONCLUSIONS In our country, BAP is still the main etiology of acute pancreatitis. Over the years, we have seen a decrease in BAP and idiopathic AP cases, while there was an increase in HAP cases due to factors such as lifestyle changes and fatty nutrition. We found that mortality was associated with disease severity, advanced age (> 65 y), hypertension, and ischemic heart disease regardless of the etiology.

The early predictive value of routine laboratory tests on the severity of acute pancreatitis patients in pregnancy: a retrospective study

Acute pancreatitis in pregnancy (APIP) varies in severity from a self-limiting mild condition to a severe life-threatening condition, and its severity is significantly correlated with higher risks of maternal and foetal death. This study evaluated the early predictive value of routine laboratory tests on the severity of APIP patients. We enrolled 100 patients with APIP in West China Hospital. Initial routine laboratory tests, including the biochemistry and hematologic tests were collected within 48 hours after the onset of APIP. For predicting SAP in AP, LDH had the highest specificity of 0.879. RDW was a suitable predictive marker as it had the sensitivity of 0.882. Lower levels of triglycerides (<4.72 mmol/L) predicted mild AP of APIP, with an area under the curve (AUC) of 0.724, and a negative predictive value of 0.80. Furthermore, a risk score was calculated based on white blood cells, neutrophils, RDW, LMR and LDH, as an independent marker (adjusted odds ratio = 3.013, 95% CI 1.893 to 4.797, P < 0.001), with the highest AUC of 0.906, a sensitivity of 0.875 and a specificity of 0.828. In conclusion, the risk score we recommended was the powerful marker to aid in the early prediction of the severity of APIP patients.

The prognostic value of immature granulocyte in patients with acute pancreatitis

BACKGROUND

Acute pancreatitis is the inflammation of the pancreas. It can range from mild forms to life-threatening severe cases. There is not yet a marker that can detect severe cases in the early period. Early diagnosis and treatment of this disease has critical importance for prognosis. In this study, we aimed to investigate the percentage of immature granulocyte (IG %) in patients with acute pancreatitis in order to predict the severity of the disease and in-hospital mortality.

METHOD

This study was carried out retrospectively in academic emergency department (ED), faculty of medicine between 01.01.2017 and 30.06.2019. The patients were divided into three groups as mild, moderate and severe. In addition, the patients were divided into two groups: those discharged from the hospital and those who died in the hospital. IG % and other laboratory parameters of the patients were recorded in the study form. The primary outcome for this study is the value of IG% in predicting severity in AP patients. A receiver operating characteristic (ROC) curve analysis was performed.

RESULTS

A total of 218 patients (107 male) were included in the study. The mean age of the patients was 56.9 ± 18.3 years. It was found that IG% levels were higher in patients with severe pancreatitis (p = .018). In the ROC analysis that was done to determine the severity of the disease, the cut-off value of IG% was found as >1.1. As such case, specificity was %38.89, sensitivity was 95.00%, positive predictive value (PPV) was 41.18% and negative predictive value (NPV) was found as 94.53% (Area Under Curve (AUC) = 0.698). In ROC analysis that was performed to determine in-hospital mortality, the cut-off value of IG level was found as >1.8, sensitivity was 50.00%, specificity was 97.12%, PPV was 45.45% and NPV was found as 97.58% (AUC = 0.708). CONCLUSıONS: This study shows that higher IG% levels may correlate with higher disease severity and in-hospital mortality in patients with acute pancreatitis.

A decision support system for the prediction of mortality in patients with acute kidney injury admitted in intensive care unit

Intensive care unit (ICU) is a very special unit of a hospital, where healthcare professionals provide treatment and, later, close follow-up to the patients. It is crucial to estimate mortality in ICU patients from many viewpoints. The purpose of this study is to classify the status of patients with acute kidney injury (AKI) in ICU as early mortality, late mortality, and survival by the application of Classification and Regression Trees (CART) algorithm to the patients' attributes such as blood urea nitrogen, creatinine, serum and urine neutrophil gelatinase-associated lipocalin (NGAL), alkaline phosphatase, lactate dehydrogenase (LDH), gamma-glutamyl transferase, laboratory electrolytes, blood gas, mean arterial pressure, central venous pressure and demographic details of patients. This study was conducted 50 patients with AKI who were followed up in the ICU. The study also aims to determine the significance of relationship between the attributes used in the prediction of mortality in CART and patients' status by employing the Kruskal-Wallis H test. The classification accuracy, sensitivity, and specificity of CART for the tested attributes for the prediction of early mortality, late mortality, and survival of patients were 90.00%, 83.33%, and 91.67%, respectively. The values of both urine NGAL and LDH on day 7 showed a considerable difference according to the patients' status after being examined by the Kruskal-Wallis H test.

Prognostic value of lactate dehydrogenase for in-hospital mortality in severe and critically ill patients with COVID-19

Background: Lactate dehydrogenase (LDH) has been proved to be a prognostic factor for the severity and poor outcomes of coronavirus disease 2019 (COVID-19). In most studies, patients with various levels of COVID-19 severity were pooled and analyzed which may prevent accurate evaluation of the relationship between LDH and disease progression and in-hospital death. In this study, we aimed to evaluate the association of LDH with in-hospital mortality in severe and critically ill patients with COVID-19. Methods: This single-center retrospective study enrolled 119 patients. Survival curves were plotted using Kaplan-Meier method and compared by log-rank test. Multivariate Cox regression models were used to determine the independent risk factors for in-hospital mortality. Receiver-operator curves (ROCs) were constructed to evaluate the predictive accuracy of LDH and other prognostic biomarkers. Results: Compared to the survival group, LDH levels in the dead group were significantly higher [559.5 (172, 7575) U/L vs 228 (117, 490) U/L, (P < 0.001)]. In Multivariate Cox regression, it remained an independent risk factor for in-hospital mortality (Hazard ratio 5.985, 95.0%CI: 1.498-23.905; P=0.011). A cutoff value of 353.5 U/L predicted the in-hospital mortality with a sensitivity of 94.4% and a specificity of 89.2% respectively. Conclusion: LDH is a favorable prognostic biomarker with high accuracy for predicting in-hospital mortality in severe and critically ill patients with COVID-19. This may direct physicians worldwide to effectively prioritize resources for patients at high risk of death and to implement more aggressive treatments at an earlier phase to save patients' lives.

Association of Serum Levels of Silent Information Regulator 1 with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND/AIMS

Early assessment is a key factor for adequate and comprehensive treatment of acute pancreatitis (AP). Silent information regulator 1 (SIRT1) plays an important role in inflammation. The aim was to explore the relationship between serum SIRT1 and persistent organ failure (POF) in patients with AP.

METHODS

Thirty-seven healthy controls (HCs) and 113 patients with AP were recruited for this study. All 113 patients whose blood samples were collected on the first morning after admission were within 48 h of the onset of AP symptoms. The concentration of serum SIRT1 protein was determined by enzyme-linked immunosorbent assay.

RESULTS

The serum SIRT1 protein levels were 1495.7 ± 185.9, 2098.3 ± 153.6, 2498.4 ± 198.2, and 3674.3 ± 170.8 pg/ml in the HCs, mild AP, moderately severe AP, and severe AP groups, respectively. Obvious differences were observed between HCs and patients with AP (P < 0.05). Significant increases were observed in SIRT1 concentrations in patients with POF compared with non-POF patients (P < 0.05). When the cut-off of the SIRT1 concentration was 4065.4 pg/ml, the serum SIRT1 concentration had an area under the curve (AUC) of the receiver operating characteristic curve of 0.825 (95% CI 0.744-0.906) for predicting POF, with a sensitivity of 61.4% and specificity of 92.8%. Combining serum SIRT1 and bedside index for severity acute pancreatitis (BISAP) achieved 0.931 (95% CI 0.882, 0.980) of AUC for the predication of POF.

CONCLUSIONS

High serum SIRT1 levels may serve as an early predictive marker for POF. Combining the serum SIRT1 concentration with BISAP increased the ability to predict outcomes.

Early predictors of hyperlipidemic acute pancreatitis

The present study aimed to investigate early risk factors for hyperlipidemic acute pancreatitis (HLAP) in order to open up novel routes for its prevention and treatment. Demographics, laboratory data obtained within 48 h, enhanced computed tomography (CT) imaging data and the modified CT severity index (MCTSI) for 111 patients with HLAP who were assessed at Ordos Central Hospital (Ordos, China) between January 2015 and October 2017 were retrospectively analyzed. Of these, 17 patients progressed to infectious pancreatic necrosis (IPN) and 14 patients progressed to organ failure (OF), the occurrence of which were the study outcomes. The patients were divided into pairs groups: IPN and non-IPN, as well as OF and non-OF, and differences between the groups were determined regarding various clinicopathological parameters. Furthermore, univariate and multivariate regression analyses were performed to identify parameters associated with the risk of progression to IPN or OP. On univariate analysis, the following parameters were deemed as being significantly associated with the risk of IPN: Serum calcium ions, C-reactive protein (CRP), extent of necrosis, procalcitonin (PTC) and the MCTSI. Furthermore, calcium ions, red cell distribution width (RDW), extent of necrosis and the MCTSI were significantly associated with the risk of OF on univariate analysis. Multivariate logistic regression analysis for these parameters then indicated that CRP (P=0.014), RDW (P=0.025) and the extent of necrosis (P=0.022) were significant and independent predictors of progression; thus, these are early risk factors for patients with HLAP. Receiver operating characteristic curves were generated to evaluate the predictive value of these factors, and the area under the curve for the three parameters was 0.863 [95% confidence interval (CI), 0.646-0.886], 0.727 (95% CI, 0.651-0.803) and 0.833 (95% CI, 0.739-0.936), respectively. Therefore, CRP, RDW and the extent of necrosis are early predictive indexes for the risk of progression in HLAP.

Targeting tumor-associated acidity in cancer immunotherapy

Checkpoint inhibitors, such as cytotoxic T-lymphocyte-associated protein-4 (CTLA-4) and programmed cell death-1 (PD-1) monoclonal antibodies have changed profoundly the treatment of melanoma, renal cell carcinoma, non-small cell lung cancer, Hodgkin lymphoma, and bladder cancer. Currently, they are tested in various tumor entities as monotherapy or in combination with chemotherapies or targeted therapies. However, only a subgroup of patients benefit from checkpoint blockade (combinations). This raises the question, which all mechanisms inhibit T cell function in the tumor environment, restricting the efficacy of these immunotherapeutic approaches. Serum activity of lactate dehydrogenase, likely reflecting the glycolytic activity of the tumor cells and thus acidity within the tumor microenvironment, turned out to be one of the strongest markers predicting response to checkpoint inhibition. In this review, we discuss the impact of tumor-associated acidity on the efficacy of T cell-mediated cancer immunotherapy and possible approaches to break this barrier.

Relation between polyphenols, malondialdehyde, antioxidant capacity, lactate dehydrogenase and toxic elements in human colostrum milk

The present study investigated the interrelationships between the concentration of total polyphenols (TP), malondialdehyde (MDA), total antioxidant capacity (TAC), lactate dehydrogenase activity (LDH) and content of toxic elements (Al, As, Cd, Ni, Pb) in human colostrum milk (n = 75), and further assessed their potential association with maternal lifestyle characteristics. As and Cd were always below detection limits while Al, Ni and Pb were found at the level of 89.7, 6.2 and 1.3 μg L^-1, respectively. Concentrations of TP and MDA, in the studied group were 46.91 ± 21.25 mg GAE L^-1 and 0.66 ± 0.27 nmol mL^-1, respectively, and were inversely correlated (Rs = -0.32; p < 0.01). TP and TAC increased significantly with maternal consumption of vegetables (Rs = 0.25 and Rs = 0.37, respectively; p < 0.05). Concentration of Al was positively correlated with MDA (Rs = 0.21; p < 0.01) and negatively with TP (Rs = -0.28; p < 0.01). Positive correlation was also found between Pb and MDA (Rs = 0.32; p < 0.01). No association with place of living (urban/rural), women's age and former smoking were found for any studied milk parameter. The results add to the general understanding of factors influencing redox balance in milk and potentially affecting its quality.

血清钙离子对急性胰腺炎持续性器官功能衰竭的预测价值

目的

探讨血清钙离子(serum calcium Ca²⁺)在急性胰腺炎(acute pancreatitis, AP)持续性器官功能衰竭(persistent organ failure, POF)中的临床意义.

方法

选取2012-01/2016-12温州市龙湾区第一人民医院及温州医科大学附属第二医院进行治疗的AP患者165例, 收集患者在症状发作72 h内的临床资料及实验室数据, 分为AP非持续性器官功能衰竭(non persistent organ failure, NO-POF)127例和POF 38例两组, 多因素Logistic回归分析用于评价血清Ca²⁺的预测能力, 采用工作特征曲线(receiver operator characteristic curve, ROC)分析计算血清Ca²⁺的截断值.

结果

经急性胰腺炎NO-POF 127例和POF 38例临床资料及实验室数据比较, 血清Ca²⁺ POF组明显低于NO-POF组, 差异有统计学意义(P<0.001); 多因素Logistic回归分析, 血清Ca²⁺是急性胰腺炎POF的独立危险因素(OR = 0.30, 95%CI: 0.12-0.76); ROC分析结果显示: 血清Ca²⁺预测急性胰腺炎POF的曲线下面积为0.764(95%CI: 0.27-0.58, P<0.001), 其最佳预测截点1.84 mmol/L, 预测POF的敏感性为75.4%, 特异性为72.5%.

结论

入院患者血清Ca²⁺与急性胰腺炎POF独立相关, 可作为一个潜在的预后因素.

Decreased high density lipoprotein cholesterol is an independent predictor for persistent organ failure, pancreatic necrosis and mortality in acute pancreatitis

High density lipoprotein cholesterol (HDL-C) has been reported as a significant indicator of systemic inflammation. The association underlying HDL-C and persistent organ failure (POF), pancreatic necrosis (PNec) and mortality in acute pancreatitis (AP) has not been evaluated. From 2007 to 2016, consecutive AP patients with admission lipid profiles assessment were included in this study. The association of HDL-C value and other lipids with outcomes was explored with Cox proportional regression models, which were adjusted for confounding factors. 1131 consecutive AP patients were clinically eligible. Overall, 17.9% of the patients developed with POF, 27.1% experienced PNec, and 6.7% died during hospitalization. Lower HDL-C median (<1.06 mmol/L) was identified as an independent prognostic factor of the outcomes. Moreover, there was a positive trend for the association across increasing HDL-C quartiles and POF, PNec and mortality after multivariable analysis (p values were <0.001, <0.001 and 0.043, respectively). The AUC of HDL-C for the outcomes were comparable to that of Ranson score for diagnosing POF (0.778 vs. 0.678; P < 0.001), PNec (0.734 vs. 0.701; P = 0.143) and mortality (0.768 vs. 0.745; P = 0.516). Decreased HDL-C value is an independent risk factor for the incidence of POF, PNec and in-hospital mortality in AP.