Early changes in serum creatinine level and estimated glomerular filtration rate predict pancreatic necrosis and mortality in acute pancreatitis: Creatinine and eGFR in acute pancreatitis

Development and Validation of a Nomogram for Predicting the Severity of the First Episode of Hyperlipidemic Acute Pancreatitis

Purpose

Early detection of hyperlipidemic acute pancreatitis (HLAP) with exacerbation tendency is crucial for clinical decision-making and improving prognosis. The aim of this study was to establish a reliable model for the early prediction of HLAP severity.

Patients and Methods

A total of 225 patients with first-episode HLAP who were admitted to Fujian Medical University Union Hospital from June 2012 to June 2023 were included. Patients were divided into mild acute pancreatitis (MAP) or moderate-severe acute pancreatitis and severe acute pancreatitis (MSAP+SAP) groups. Independent predictors for progression to MSAP or SAP were identified through univariate analysis and least absolute shrinkage and selection operator regression. A nomogram was established through multivariate logistic regression analysis to predict this progression. The calibration, receiver operating characteristic(ROC), and clinical decision curves were employed to evaluate the model's consistency, differentiation, and clinical applicability. Clinical data of 93 patients with first-episode HLAP who were admitted to the First Affiliated Hospital of Fujian Medical University from October 2015 to October 2022 were collected for external validation.

Results

White blood cell count, lactate dehydrogenase, albumin, serum creatinine, serum calcium, D-Dimer were identified as independent predictors for progression to MSAP or SAP in patients with HLAP and used to establish a predictive nomogram. The internally verified Harrell consistency index (C-index) was 0.908 (95% CI 0.867-0.948) and the externally verified C-index was 0.950 (95% CI 0.910-0.990). The calibration, ROC, and clinical decision curves showed this nomogram's good predictive ability.

Conclusion

We have established a nomogram that can help identify HLAP patients who are likely to develop MSAP or SAP at an early stage, with high discrimination and accuracy.

Prediction of Admission to Intensive Care Unit and 1-Year Mortality After Acute Pancreatitis With Walled-Off Pancreatic Necrosis: A Retrospective, Single-Center Cohort Study

BACKGROUND AND AIMS

Pancreatic walled-off necrosis (WON) carries significant mortality and morbidity risks, often necessitating intensive care unit (ICU) admission. This retrospective study aimed to evaluate whether routine biochemical parameters at the time of the index endoscopic procedure could predict ICU admission and 1-year mortality following endoscopic treatment of WON.

MATERIALS AND METHODS

We retrospectively identified 201 consecutive patients who underwent endoscopic drainage for WON between January 1, 2010, and December 31, 2020. Associations between routine biochemical blood tests and outcomes were assessed using logistic regression models.

RESULTS

Within 1 year of the index endoscopy, 31 patients (15.4%) died, and 40 (19.9%) were admitted to the ICU due to sepsis. Preoperative electrolyte disturbances were more prevalent among ICU-admitted patients and nonsurvivors. Hyperkalemia, hypoalbuminemia, and elevated urea were significant predictors of 1-year mortality, while hypernatremia, elevated serum creatinine, and hypoalbuminemia predicted ICU admission. Predictive models exhibited good discriminative ability, with an AUC of 0.84 (95% CI,0,75-0.93) for 1-year mortality and 0.86 (95%CI, 0.79-0.92) for ICU admission.

CONCLUSIONS

Preoperative imbalances in routine blood tests effectively predict adverse outcomes in endoscopically treated WON patients.

Severe Acute Pancreatitis Prediction: A Model Derived From a Prospective Registry Cohort

Background Severe acute pancreatitis (SAP) has a mortality rate as high as 40%. Early identification of SAP is required to appropriately triage and direct initial therapies. The purpose of this study was to develop a prognostic model that identifies patients at risk for developing SAP of patients managed according to a guideline-based standardized early medical management (EMM) protocol. Methods This single-center study included all patients diagnosed with acute pancreatitis (AP) and managed with the EMM protocol Methodist Acute Pancreatitis Protocol (MAPP) between April 2017 and September 2022. Classification and regression tree (CART®; Professional Extended Edition, version 8.0; Salford Systems, San Diego, CA), univariate, and logistic regression analyses were performed to develop a scoring system for AP severity prediction. The accuracy of the scoring system was measured by the area under the receiver operating characteristic curve. Results A total of 516 patients with mild (n=436) or moderately severe and severe (n=80) AP were analyzed. CART analysis identified the cutoff values: creatinine (CR) (1.15 mg/dL), white blood cells (WBC) (10.5 × 109/L), procalcitonin (PCT) (0.155 ng/mL), and systemic inflammatory response system (SIRS). The prediction model was built with a multivariable logistic regression analysis, which identified CR, WBC, PCT, and SIRS as the main predictors of severity. When CR and only one other predictor value (WBC, PCT, or SIRS) met thresholds, then the probability of predicting SAP was >30%. The probability of predicting SAP was 72% (95%CI: 0.59-0.82) if all four of the main predictors were greater than the cutoff values. Conclusions Baseline laboratory cutoff values were identified and a logistic regression-based prognostic model was developed to identify patients treated with a standardized EMM who were at risk for SAP.

Association of estimated glomerular filtration rate and all-cause mortality in acute pancreatitis: a retrospective analysis

BACKGROUND

Our primary objective was to explore the association between estimated glomerular filtration rate (eGFR) and all-cause mortality in acute pancreatitis (AP) admission to intensive care units.

METHODS

This study is a retrospective cohort analysis based on the Medical Information Mart for Intensive Care III database. The eGFR was calculated based on Chronic Kidney Disease Epidemiology Collaboration equation. Cox models with restricted cubic spline functions were used to evaluated the association of eGFR with all-cause mortality.

RESULTS

The mean eGFR was 65.93 ± 38.56 ml/min/1.73 m² in 493 eligible patients. 28-day mortality was 11.97% (59/ 493), which decreased by 15% with every 10 ml/min/1.73 m² increase in eGFR. The adjusted hazard ratio (95% confidence interval) was 0.85 (0.76-0.96). A non-linear association was proved between eGFR and all-cause mortality. When eGFR < 57 ml/min/1.73 m², there was a negative correlation between eGFR and 28-day mortality, hazard ratio (95% CI) was 0.97 (0.95, 0.99). The eGFR was also negatively correlated with in-hospital and in-ICU mortality. Subgroup analysis confirmed that the association between eGFR and 28-day mortality in different characteristics was stable.

CONCLUSIONS

The eGFR was negatively correlated with all-cause mortality in AP when eGFR is less than the threshold inflection point.

Early reduction of estimated Glomerular Filtration Rate (eGFR) predicts poor outcome in acutely ill hospitalized COVID-19 patients firstly admitted to medical regular wards (eGFR-COV19 study)

Background

Methods

Results

Conclusions

Diagnosis and Treatment of Acute Pancreatitis

The pancreas is a glandular organ that is responsible for the proper functioning of the digestive and endocrine systems, and therefore, it affects the condition of the entire body. Consequently, it is important to effectively diagnose and treat diseases of this organ. According to clinicians, pancreatitis—a common disease affecting the pancreas—is one of the most complicated and demanding diseases of the abdomen. The classification of pancreatitis is based on clinical, morphologic, and histologic criteria. Medical doctors distinguish, inter alia, acute pancreatitis (AP), the most common causes of which are gallstone migration and alcohol abuse. Effective diagnostic methods and the correct assessment of the severity of acute pancreatitis determine the selection of an appropriate treatment strategy and the prediction of the clinical course of the disease, thus preventing life-threatening complications and organ dysfunction or failure. This review collects and organizes recommendations and guidelines for the management of patients suffering from acute pancreatitis.

Usefulness of Random Forest Algorithm in Predicting Severe Acute Pancreatitis

BACKGROUND AND AIMS

This study aimed to develop an interpretable random forest model for predicting severe acute pancreatitis (SAP).

METHODS

Clinical and laboratory data of 648 patients with acute pancreatitis were retrospectively reviewed and randomly assigned to the training set and test set in a 3:1 ratio. Univariate analysis was used to select candidate predictors for the SAP. Random forest (RF) and logistic regression (LR) models were developed on the training sample. The prediction models were then applied to the test sample. The performance of the risk models was measured by calculating the area under the receiver operating characteristic (ROC) curves (AUC) and area under precision recall curve. We provide visualized interpretation by using local interpretable model-agnostic explanations (LIME).

RESULTS

The LR model was developed to predict SAP as the following function: -1.10-0.13×albumin (g/L) + 0.016 × serum creatinine (μmol/L) + 0.14 × glucose (mmol/L) + 1.63 × pleural effusion (0/1)(No/Yes). The coefficients of this formula were utilized to build a nomogram. The RF model consists of 16 variables identified by univariate analysis. It was developed and validated by a tenfold cross-validation on the training sample. Variables importance analysis suggested that blood urea nitrogen, serum creatinine, albumin, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, calcium, and glucose were the most important seven predictors of SAP. The AUCs of RF model in tenfold cross-validation of the training set and the test set was 0.89 and 0.96, respectively. Both the area under precision recall curve and the diagnostic accuracy of the RF model were higher than that of both the LR model and the BISAP score. LIME plots were used to explain individualized prediction of the RF model.

CONCLUSIONS

An interpretable RF model exhibited the highest discriminatory performance in predicting SAP. Interpretation with LIME plots could be useful for individualized prediction in a clinical setting. A nomogram consisting of albumin, serum creatinine, glucose, and pleural effusion was useful for prediction of SAP.

Accurate prediction of acute pancreatitis severity based on genome-wide cell free DNA methylation profiles

Background

Patients with severe acute pancreatitis (SAP) have a high mortality, thus early diagnosis and interventions are critical for improving survival. However, conventional tests are limited in acute pancreatitis (AP) stratification. We aimed to assess AP severity by integrating the informative clinical measurements with cell free DNA (cfDNA) methylation markers.

Methods

One hundred and seventy-five blood samples were collected from 61 AP patients at multiple time points, plus 24 samples from healthy individuals. Genome-wide cfDNA methylation profiles of all samples were characterized with reduced representative bisulfite sequencing. Clinical blood tests covering 93 biomarkers were performed on AP patients within 24 h. SAP predication models were built based on cfDNA methylation and conventional blood biomarkers separately and in combination.

Results

We identified 565 and 59 cfDNA methylation markers informative for acute pancreatitis and its severity. These markers were used to develop prediction models for AP and SAP with area under the receiver operating characteristic of 0.92 and 0.81, respectively. Twelve blood biomarkers were systematically screened for a predictor of SAP with a sensitivity of 87.5% for SAP, and a specificity of 100% in mild acute pancreatitis, significantly higher than existing blood tests. An expanded model integrating 12 conventional blood biomarkers with 59 cfDNA methylation markers further improved the SAP prediction sensitivity to 92.2%.

Conclusions

These findings have demonstrated that accurate prediction of SAP by the integration of conventional and novel blood molecular markers, paving the way for early and effective SAP intervention through a non-invasive rapid diagnostic test.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13148-021-01217-z.

Nomogram for the prediction of in-hospital incidence of acute respiratory distress syndrome in patients with acute pancreatitis

OBJECTIVE

Acute respiratory distress syndrome (ARDS) associated with high mortality is the common complication in acute pancreatitis (AP). The aim of this study was to formulate and validate an individualized predictive nomogram for in-hospital incidence of ARDS in Patients with AP.

METHOD

From January 2017 to December 2018, 779 individuals with AP were involved in this study. They were randomly distributed into primary cohort (n=560) and validation cohort (n=219). Based on the primary cohort, risk factors were identified by logistic regression model and a nomogram was performed. The nomogram was validated in the primary and validation cohort by the bootstrap validation method. The calibration curve was applied to evaluate the consistency between the nomogram and the ideal observation.

RESULTS

There were 728 patients in the non-ARDS group and 51 in the ARDS group, with an incidence of about 6.55%. Five independent factors including white blood cell counts (WBC), prothrombin time (PT), albumin (ALB), serum creatinine (SCR) and triglyceride (TG) were associated with in-hospital incidence of ARDS in Patients with AP. A nomogram was constructed based on the five independent factors with primary cohort of AUC=0.821 and validation cohort of AUC=0.823. Calibration curve analysis indicated that the predicted probability was in accordance with the observed probability in both primary and validation cohorts.

CONCLUSIONS

The study developed an intuitive nomogram with easily available laboratory parameters for the prediction of in-hospital incidence of ARDS in patients with AP. The incidence of ARDS for an individual patient can be fast and conveniently evaluated by our nomogram.

Initial Renal Function (eGFR) Is a Prognostic Marker of Severe Acute Pancreatitis: A Cohort-Analysis of 1,224 Prospectively Collected Cases

Background: Acute pancreatitis (AP) is a life-threatening disease. We aimed to explore the prognostic relevance of renal function based on estimated glomerular filtration rate (eGFR). Methods: A prospective registry of AP patients was established by the Hungarian Pancreatic Study Group. Data of 1,224 consecutive patients were collected between 2012 and 2017. Patients were divided into 3 groups according to their eGFR measured within 24 h of hospitalization: normal renal function: >90 mL/min, mild to moderate renal functional impairment: 30-90 mL/min and severe renal dysfunction: <30 mL/min. Associations of eGFR with outcome (survival, length of hospitalization, AP severity, blood glucose), inflammatory markers (erythrocyte sedimentation rate, white blood cell count), anemia and organ failure (heart, kidney, liver) were analyzed. Results: Death, longer hospitalization and severe AP, but not the cause of AP, were significantly associated with lower eGFR. The inflammatory markers (CRP, WBC count) but not anemia (Hb, Htk) were closely associated with severe renal dysfunction. Renal function was associated with heart and renal failure but not with other complications of AP such as respiratory failure, local pancreatic complications, diabetes or peptic ulcer. eGFR was not associated with liver damage (ALAT, γ-GT) or liver function (serum bilirubin) although biliary complications, alcohol and metabolic syndrome were the most common etiologies of AP. Conclusions: Our study suggests a useful prognostic value of initial eGFR in AP patients. Even mild eGFR reduction predicted mortality, severity of AP and the length of hospitalization. Thus, precise evaluation of renal function should be considered for assessing AP severity and outcome.

Factors Associated with Fluid Sequestration in Patients with Acute Pancreatitis: A Prospective Study in Tertiary Centre Hospital in Nepal

Background

Acute pancreatitis (AP) is associated with extensive fluid sequestration. The aim of this study was to determine association of fluid sequestration at 48 hours after hospital admission (FS⁴⁸) in AP patients with demographics, clinical parameters, and outcomes of AP.

Methods

A prospective observational study was carried out on all adult patients with AP admitted to Tribhuvan University Teaching Hospital, Nepal, from January to September 2017. FS⁴⁸ was calculated as the difference between fluid input and output in the first 48 hours of admission. The Kruskal-Wallis test with post hoc Dunn's test examined the difference in FS⁴⁸ between mild AP, moderately severe AP, and severe AP. Linear regression analysis was used to evaluate association between FS⁴⁸ with patients' characteristics and outcomes of AP. Outcomes of AP assessed included pancreatic necrosis, persistent organ failure, length of stay, and in-hospital mortality.

Results

Eighty patients (median age 44 years; 57% male) with a median FS⁴⁸ of 1610 mL were evaluated. The median FS⁴⁸ for mild AP, moderately severe AP, and severe AP were 1,180 mL, 2,380 mL, and 3,500 mL, respectively. There was a significant difference in pairwise comparisons between mild AP and moderately severe AP, along with mild AP and severe AP. Younger age, other etiology, and higher creatinine were independently associated with increased FS⁴⁸. Increased FS⁴⁸ was significantly associated with pancreatic necrosis, persistent organ failure, and in-hospital mortality.

Conclusions

In our study population, younger age and higher creatinine were predictors of increased FS⁴⁸. Increased FS⁴⁸ was associated with poorer outcomes of AP.

The challenge of prognostic markers in acute pancreatitis: internist's point of view

Acute pancreatitis, the most frequent hospitalization reason in internal medicine ward among gastrointestinal diseases, is burdened by high mortality rate. The disease manifests mainly in a mild form, but about 20-30% patients have a severe progress that requires intensive care. Patients presenting with acute pancreatitis should be clinically evaluated for organ failure signs and symptoms. Stratifying patients in the first days from symptoms onset is essential to determine therapy and care setting. The aim of our study is to evaluate prognostic factors for acute pancreatitis patients, hospitalized in internal medicine wards, and moreover, understanding the role of various prognostic scores validated in intensive care setting in predicting in-hospital mortality and/or admission to intensive care unit. We conducted a retrospective study enrolling all patients with diagnosis of acute pancreatitis admitted took an internal medicine ward between January 2013 and May 2019. Adverse outcome was considered in-hospital mortality and/or admission to intensive care unit. In total, 146 patients (137 with positive outcome and 9 with adverse outcome) were enrolled. The median age was (67.89 ± 16.44), with a slight prevalence of male (55.1%) compared to female (44.9%). C protein reactive (p = 0.02), creatinine (p = 0.01), sodium (p = 0.05), and troponin I (p = 0.013) after 48 h were significantly increased in patients with adverse outcome. In our study, progression in SOFA score independently increases the probability of adverse outcome in patients hospitalized with acute pancreatitis. SOFA score > 5 is highly predictive of in-hospital mortality (O.R. 32.00; C.I. 6.73-152.5; p = 0.001) compared to other scores. The use of an easy tool, validated in intensive care setting such as SOFA score, might help to better stratify the risk of in-hospital mortality and/or clinical worsening in patients hospitalized with acute pancreatitis in internal medicine ward.

Prognostic value of the creatinine-albumin ratio in acute pancreatitis debridement

Background

Increases in the levels of serum C-reactive protein (CRP) and creatinine (Cr) and decreases in those of albumin (Alb) are commonly observed in acute pancreatitis (AP). We aimed to evaluate the efficacy of the Cr/Alb and CRP/Alb ratios in the prediction of surgical treatment effect in AP patients.

Methods

This study retrospectively analyzed clinical data obtained from 140 AP patients who underwent debridement from January 2008 to November 2018 in Shanghai Ruijin Hospital. The Cr/Alb and CRP/Alb ratios at admission and before surgery were assessed in the analysis of clinical statistics, prediction of prognoses, and logistic regression analysis.

Results

The admission Cr/Alb had the best predictive value of the four ratios. This value was significantly higher in patients with re-operation and those who died (P < 0.05) and was correlated with the Acute Physiology and Chronic Health Evaluation (APACHE II) score, admission CRP/Alb, preoperative Cr/Alb, and post-operative complications. The admission Cr/Alb could predict the risk of AP-related re-operation and mortality with sensitivities, specificities and areas under the curve of 86.3%, 61.7% and 0.824, and 73.4%, 81.3% and 0.794, respectively. At a cut-off value of 3.43, admission Cr/Alb values were indicative of a worse clinical state, including impaired laboratory test values, APACHE II scores, rates of post-operative complications and re-operation, and mortality (P < 0.05). In the logistic regression analysis, admission Cr/Alb values were independently related to the APACHE II score, post-operative renal failure, and mortality.

Conclusion

Cr/Alb is a novel but promising, easy-to-measure, reproducible, non-invasive prognostic score for the prediction of the effect of debridement in AP patients.

Acute pancreatitis and the weekend effect: does weekend admission affect patient outcome?

Introduction

When a patient is admitted to a hospital for acute pancreatitis (AP), the day of the week on which the admission occurs may influence the outcome of care. The link between reduced weekend staffing practices and outcomes for patients hospitalised for AP, however, has been inadequately studied.

Aim

To evaluate the relationship between weekend admission and AP outcome.

Material and methods

One hundred and twenty-six patients were prospectively included, assessed according to the revised Atlanta criteria, and observed until discharge or death. Weekend and weekday admissions were compared in terms of severity, aetiology, length of hospital stay, and in-hospital mortality.

Results

Patients were divided into two groups according to the timing of admission (weekday, n = 99, 78.6%; or weekend, n = 27, 21.4%). AP was considered severe in 33 (26.2%) patients, moderately severe AP in 37 (29.4%) patients, and mild in 56 (44.4%) patients. No significant differences were found with regard to the distribution of AP severity between the two groups. The impact of weekend admission was not significant for aetiology or for the length of hospital stay (median of 9 vs. 10 days). In-hospital mortality rates were not significantly different for weekday and weekend admissions.

Conclusions

Patients admitted for hospitalisation during a weekend received the same level and quality of care at the facility under study as AP patients admitted during the week. Additionally, the rate of favourable outcomes for patients admitted during the weekend was found to be similar to the outcomes of patients admitted on a weekday.

Recent Advances in Diagnosis and Severity Assessment of Acute Pancreatitis

The incidence and prevalence of acute pancreatitis (AP) is increasing over time. The diagnosis of acute pancreatitis is established by revised Atlanta criteria (2012). Multiple criteria and scoring systems have been used for assessment of severity of AP. Majority of acute pancreatitis cases (80%) are mild, the challenge remains in early diagnosis, severity assessment and treatment of severe AP and its complications. Assessment of severity of AP is important part of management because line of treatment depends on aetiology and severity of acute pancreatitis. In this article a comprehensive review of recent advances in diagnosis and severity assessment of acute pancreatitis has been described.

[Harmless acute pancreatitis score on admission can accurately predict mild acute pancreatitis]

OBJECTIVE

To evaluate the efficacy of harmless acute pancreatitis score (HAPS) on admission for predicting mild acute pancreatitis (MAP).

METHODS

We prospectively collected the data from consecutive AP patients admitted to West China Hospital between January, 2016 and August, 2017, and HAPS scores were calculated on admission. The clinical outcomes of the patients with harmless AP (HAPS>2) and those with non-harmless AP (HAPS≤2) were compared. MAP was defined based on the severity classification of 2012 Revised Atlanta guidelines. The area under the curve (AUC) of the receiver- operator characteristic curve (ROC), specificity, sensitivity, positive predictive value (PPV) and negative predictive value (NPV) of HAPS on admission for predicting MAP were analyzed.

RESULTS

Of the 703 patients with AP analyzed, 182 were predicted to have harmless AP and 521 to have non- harmless AP, and the patients in the latter group had significantly worse clinical outcomes (P < 0.001). The total number of patients with MAP was 359 in the study. The specificity, the sensitivity, the PPV and NPV of HAPS on admission for predicting MAP was 97.7% (95% CI: 95.4-99.0), 48.2% (95% CI: 42.9-53.3), 95.6% (95% CI: 91.5- 98.1) and 64.1% (95% CI: 59.8- 68.2), respectively, and the AUC was 0.749 (95% CI: 0.72- 0.78).

CONCLUSIONS

HAPS score on admission can accurately predict MAP.

Serum Creatinine Level and APACHE-II Score within 24 h of Admission Are Effective for Predicting Persistent Organ Failure in Acute Pancreatitis

Aim

The present study was aimed at comparing serum markers and APACHE-II score to predict persistent organ failure (POF) in early acute pancreatitis (AP).

Methods

In this retrospective study, data from 6024 patients with AP were included within 24 h of their admission. Serum levels of urea nitrogen (BUN), creatinine, glucose, and hematocrit and APACHE-II score were analyzed for patients with AP. We employed the area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, and specificity analyses to evaluate the accuracy of the studied laboratory parameters and APACHE-II score.

Results

Our study included 2090 (35%) patients out of 6024 patients who were evaluated within 24 h of hospital admission. For predicting POF, serum creatinine level ≥ 1.8 mg/dl had the highest specificity (98%). The second classification tree has shown that when the serum creatinine level > 1.8 and APACHE − II ≥ 8 within 24 h were combined, the rates of predicted persistent organ failure achieved 66.7%.

Conclusions

In this large, hospital-based retrospective study, we demonstrated that an APACHE-II score ≥ 8 and a serum creatinine level ≥ 1.8 mg/dl within 24 h of admission can positively predict POF in AP and that serum creatinine levels < 1.8 mg/dl within 24 h of admission can be useful for negatively predicting POF in AP.

Evaluation of Early Prognostic Factors of Mortality in Patients with Acute Pancreatitis: A Retrospective Study

Early and accurate assessment of severity in acute pancreatitis (AP) is of great importance to provide effective disease management and prevent mortality. In this study, we aim to evaluate early indicators that predict the mortality of AP. We retrospectively analyzed 24-hour clinical characteristics and laboratory data in 166 AP patients recruited between January 2014 and November 2015 in Baotou Central Hospital. In total, 18 patients did not survive the disease. Multivariate logistic regression showed that red cell distribution (RDW) (OR = 2.965, P = 0.001) and creatinine (OR = 1.025, P = 0.005) were early independent risk factors of AP mortality while albumin (OR = 0.920, P = 0.032) levels reduced AP mortality. The corresponding optimal cut-off values were 14.45, 125.5, and 34.95, respectively. The positive predictive values of the AP mortality were 80.1%, 54.5%, and 69.5%. In combined measurement, the area under the curve of RDW, creatinine, and albumin was 0.964 (95% CI: 0.924 to 1.000, P < 0.001). RDW ≥ 14.45%, creatinine ≥ 125.5 μmol/l, and albumin ≤ 34.95 g/l indicated a good predictive value for mortality in AP patients with a sensitivity of 100% and specificity of 64.2%. RDW, creatinine, and albumin may serve as early indicators for AP mortality which warrants further clinical investigation.

Immature granulocytes predict severe acute pancreatitis independently of systemic inflammatory response syndrome

Introduction

Early prediction of severity of acute pancreatitis (AP) by a simple parameter that positively correlates with the activation stage of the immune system would be very helpful because it could influence the management and improve the outcome. Tumor necrosis factor α (TNF-α) and interleukin-1 (IL-1) play a critical role in the pathogenesis systemic inflammatory response syndrome (SIRS) and severity of AP. One of the effects of IL-1 and TNF-α is an increase in the number of immature granulocytes (IGs) in the peripheral blood.

Aim

To assess whether the IGs% in plasma could be an independent marker of AP severity.

Material and methods

A cohort of 77 patients with AP were prospectively enrolled in the study. The IGs were measured from whole blood samples obtained from the first day of hospitalization using an automated analyser.

Results

We observed 44 (57%) patients with mild AP, 21 (27%) patients with moderate severe AP (SAP) and 12 (16%) patients with SAP. The cut-off value of IGs was 0.6%. The IGs > 0.6% had a sensitivity, specificity, and positive and negative predictive value of 100%, 96%, 85.7%, and 100%, respectively (area under the curve (AUC) = 0.98). On admission, SIRS was present in 25 (32%) patients. We found that in patients who fulfilled at least two criteria for SIRS, SAP could be predicted with 75% sensitivity and 75.4% specificity, positive predictive value 36%, negative predictive value 94.2%.

Conclusions

The IGs% as a routinely obtained marker appears to be a promising, independent biomarker and a better predictor of early prognosis in SAP than SIRS and white blood cell.

High-Density Lipoprotein Cholesterol, Blood Urea Nitrogen, and Serum Creatinine Can Predict Severe Acute Pancreatitis

BACKGROUND AND AIMS

Early prediction of disease severity of acute pancreatitis (AP) would be helpful for triaging patients to the appropriate level of care and intervention. The aim of the study was to develop a model able to predict Severe Acute Pancreatitis (SAP).

METHODS

A total of 647 patients with AP were enrolled. The demographic data, hematocrit, High-Density Lipoprotein Cholesterol (HDL-C) determinant at time of admission, Blood Urea Nitrogen (BUN), and serum creatinine (Scr) determinant at time of admission and 24 hrs after hospitalization were collected and analyzed statistically.

RESULTS

Multivariate logistic regression indicated that HDL-C at admission and BUN and Scr at 24 hours (hrs) were independently associated with SAP. A logistic regression function (LR model) was developed to predict SAP as follows: -2.25-0.06 HDL-C (mg/dl) at admission + 0.06 BUN (mg/dl) at 24 hours + 0.66 Scr (mg/dl) at 24 hours. The optimism-corrected c-index for LR model was 0.832 after bootstrap validation. The area under the receiver operating characteristic curve for LR model for the prediction of SAP was 0.84.

CONCLUSIONS

The LR model consists of HDL-C at admission and BUN and Scr at 24 hours, representing an additional tool to stratify patients at risk of SAP.

Endothelial markers are associated with pancreatic necrosis and overall prognosis in acute pancreatitis: A preliminary cohort study

BACKGROUND

Endothelial injury is believed to play an important role in the evolution of pancreatic microcirculatory dysfunction and pancreatic necrosis (PN) in patients with acute pancreatitis (AP). The aim of this study was to investigate the role of three endothelial markers (von Willebrand factor, vWF; E-selectin; endothelial protein C receptor, EPCR) in the early phase of AP, especially the relationship between endothelial markers and PN.

METHODS

From March 2015 to March 2016, 57 AP patients admitted within 72 h of symptom onset in our hospital were included for this study. Blood samples were taken on admission and the clinical characteristics and outcomes of these patients were recorded. The levels of vWF, E-selectin and EPCR were measured using ELISA for analysis and compared with other severity markers of AP.

RESULTS

All the three markers were significantly different in healthy control, mild, moderate and severe AP patients. Moreover, the endothelial markers, especially vWF, also showed significant difference in patients with different extent of PN, as well as those with or without MODS. Additionally, the levels of endothelial markers correlated well with other commonly used markers of AP severity.

CONCLUSION

Elevated endothelium-related mediators (vWF, E-selectin and EPCR) appear to participate in the development of PN and may be a potential indicator of overall prognosis. Our results may help clinicians better understand the pathophysiological process of the development of PN.

Soluble urokinase-type plasminogen activator receptor (suPAR) in patients with acute pancreatitis (AP) - Progress in prediction of AP severity

BACKGROUND

Soluble urokinase-type plasminogen activator receptor (suPAR) is a glycoprotein secreted during inflammation and infections. Moreover, increased levels of suPAR are observed after hypoxia and ischaemia. The aim of the study was to assess whether suPAR could represent a useful marker of acute pancreatitis (AP) severity.

PATIENTS AND METHODS

We have observed a cohort of 126 prospectively enrolled patients. Based on the presence of persistent organ failure (more than 48 h) and local complications (diagnosis of moderate AP [MSAP]), patients were classified into three groups: mild AP (MAP), moderate and severe AP (SAP). The blood samples were taken on admission for detecting suPAR concentrations.

RESULTS

AP was considered severe in 33 patients (26.2%), MSAP was found in 37 patients (29.4%), and MAP was found in 56 patients (44,4%). The AUC for SAP predicted by suPAR was 0.993. The calculated cut-off point for prognosis SAP is 4.75 ng/mL. The BISAP score of ≥3 for detection of SAP had sensitivity and specificity of 94.6% and 63.6%, respectively. The AUC for severity predicted by BISAP amounted to 0.916. Additionally, suPAR turned out to be a good predictor of fatal AP: for the cut-off point 7.05 ng/mL, the AUC was 0.917. The AUC for death prediction in AP patients based on the BISAP score ≥3 was 0.894.

CONCLUSIONS

suPAR concentration is a promising new diagnostic and prognostic indicator in SAP obtainable in the early stage of disease. Larger studies are recommended to evaluate this role further.

Association of Matrix Metalloproteinases -7, -8 and -9 and TIMP -1 with Disease Severity in Acute Pancreatitis. A Cohort Study

Objectives

Several biomarkers for early detection of severe acute pancreatitis (SAP) have been presented. Matrix metalloproteinases (MMP) and their tissue inhibitors (TIMP) are released early in inflammation. We aimed to assess levels of MMP-7, -8, -9 and TIMP-1 in acute pancreatitis (AP) and explore their ability to detect disease severity. Our second aim was to find an association between MMPs, TIMP and creatinine.

Methods

We collected plasma samples for MMP-7, -8, -9 and TIMP-1 analyses from 176 patients presenting within 96 h from onset of acute pancreatitis (AP) symptoms. We used samples from 32 control subjects as comparison. The revised Atlanta Classification was utilised to assess severity of disease. Receiver operating characteristic curve analysis and Spearman´s Rho-test were utilised for statistical calculations.

Results

Compared with controls, patients showed higher levels of all studied markers. MMP-8 was higher in moderately severe AP than in mild AP (p = 0.005) and MMP-8, -9 and TIMP-1 were higher in severe than in mild AP (p<0.001, p = 0.005 and p = 0.019). MMP-8 detected SAP with an AUC of 0.939 [95% CI 0.894–0.984], LR+ 9.03 [5.30–15.39]. MMP-8, -9 and TIMP-1 failed to discern moderately severe AP from SAP. MMP-7 was not different between patient groups. MMP-7 and TIMP-1 correlated weakly with creatinine (Rho = 0.221 and 0.243). MMP-8 might be a useful biomarker in early detection of SAP.

Fluid resuscitation in acute pancreatitis: Normal saline or lactated Ringer's solution?

AIM: To investigate whether administration of Ringer’s solution (RL) could have an impact on the outcome of acute pancreatitis (AP).

METHODS: We conducted a retrospective study on 103 patients [68 men and 35 women, mean age 51.2 years (range, 19-92 years)] hospitalized between 2011 and 2012. All patients admitted to the Department of Gastroenterology of the Central Clinical Hospital of the Ministry of Interior (Poland) with a diagnosis of AP who had disease onset within 48 h of presentation were included in this study. Based on the presence of persistent organ failure (longer than 48 h) as a criterion for the diagnosis of severe AP (SAP) and the presence of local complications [diagnosis of moderately severe AP (MSAP)], patients were classified into 3 groups: mild AP (MAP), MSAP and SAP. Data were compared between the groups in terms of severity (using the revised Atlanta criteria) and outcome. Patients were stratified into 2 groups based on the type of fluid resuscitation: the 1-RL group who underwent standard fluid resuscitation with a RL 1000 mL solution or the 2-NS group who underwent standard fluid resuscitation with 1000 mL normal saline (NS). All patients from both groups received an additional 5% glucose solution (1000-1500 mL) and a multi-electrolyte solution (500-1000 mL).

RESULTS: We observed 64 (62.1%) patients with MAP, 26 (25.24%) patients with MSAP and 13 (12.62%) patients with SAP. No significant difference in the distribution of AP severity between the two groups was found. In the 1-RL group, we identified 22 (55.5%) MAP, 10 (25.5%) MSAP and 8 (20.0%) SAP patients, compared with 42 (66.7%) MAP, 16 (24.4%) MSAP and 5 (7.9%) SAP cases in the 2-NS group (P = 0.187). The volumes of fluid administered during the initial 72-h period of hospitalization were similar among the patients from both the 1-RL and 2-NS groups (mean 3400 mL vs 3000 mL, respectively). No significant differences between the 1-RL and 2-NS groups were found in confirmed pancreatic necrosis [10 patients (25%) vs 12 patients (19%), respectively, P = 0.637]. There were no statistically significant differences between the 1-RL and 2-NS groups in the percentage of patients who required enteral nutrition (23 patients vs 17 patients, respectively, P = 0.534). Logistic regression analysis confirmed these findings (OR = 1.344, 95%CI: 0.595-3.035, P = 0.477). There were no significant differences between the 1-RL and 2-NS groups in mortality and the duration of hospital stay (median of 9 d for both groups, P = 0.776).

CONCLUSION: Our study failed to find any evidence that the administration of RL in the first days of AP leads to improved clinical outcomes.

Urinary neutrophil gelatinase-associated lipocalin as an early predictor of disease severity and mortality in acute pancreatitis

OBJECTIVES

In reference to our earlier publication, laboratory tests that reflect severe intravascular volume depletion can be used for predicting the severity of acute pancreatitis (AP). The aim of the study was to assess whether urinary level of neutrophil gelatinase-associated lipocalin (NGAL) could represent a useful marker of AP severity.

METHODS

We observed a cohort of 104 prospectively enrolled patients. The patients were classified into 3 groups: mild AP, moderately severe AP, and severe AP. Urine samples were collected on admission (NGAL-as) and during the first 24 hours (NGAL-first day) for examination of urinary level of NGAL concentrations from the first day.

RESULTS

Acute pancreatitis was considered severe in 16 (15%) patients, moderately severe in 25 (24%) patients, and mild in 63 (61%) patients.There were statistically significant trends for an increase in severity (P = 0.04, P = 0.003) and mortality (P < 0.031, P = 0.01) with raising NGAL-as and NGAL-first day concentrations, respectively. The areas under the curve for severity predicted by NGAL-as and NGAL-first day were 0.75 and 0.93, respectively. The areas under the curve for mortality prediction by NGAL-as and NGAL-first day were 0.980 and 0.92, respectively.

CONCLUSIONS

The urinary level of NGAL is a promising new diagnostic and prognostic factor for severe AP in an early stage of the disease.

Early phase of acute pancreatitis: Assessment and management

Acute pancreatitis (AP) is a potentially life-threatening disease with a wide spectrum of severity. The overall mortality of AP is approximately 5%. According to the revised Atlanta classification system, AP can be classified as mild, moderate, or severe. Severe AP often takes a clinical course with two phases, an early and a late phase, which should both be considered separately. In this review article, we first discuss general aspects of AP, including incidence, pathophysiology, etiology, and grading of severity, then focus on the assessment of patients with suspected AP, including diagnosis and risk stratification, followed by the management of AP during the early phase, with special emphasis on fluid therapy, pain management, nutrition, and antibiotic prophylaxis.