Systematic review and meta-analysis of risk scores in prediction for the clinical outcomes in patients with acute variceal bleeding

Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding

STUDY OBJECTIVE

Early prognostic stratification could optimize the management of patients with upper gastrointestinal bleeding and reduce unnecessary hospitalizations. The aim of this study was to assess and compare the performance of existing prognostic scores in predicting therapeutic intervention and death.

METHODS

A systematic search of the literature identified existing prognostic scores. A multicenter retrospective cohort study included adult patients hospitalized for upper gastrointestinal bleeding from January 1, 2019, to December 31, 2020. The primary outcome was a composite including therapeutic intervention within 7 days (blood transfusion, endoscopic, surgical, or interventional radiology hemostasis) and/or 30-day death. Discrimination performance was estimated by the area under the curve (AUC). The ability to identify low-risk patients was analyzed using sensitivity and negative predictive value (NPV) for defined thresholds.

RESULTS

The systematic search identified 39 prognostic scores, 12 of which could be analyzed. Among the 990 patients included, therapeutic intervention and/or death occurred in 755 (76.4%) patients. Scores with the highest discriminative performance to predict the primary composite outcome were Glasgow-Blatchford score (GBS) (AUC 0.869 [0.842 to 0.895]), modified GBS (AUC 0.872 [0.847 to 0.898]) and modified GBS 2 (AUC 0.855 [0.827 to 0.884]). The best performance to identify low-risk patients was for GBS≤1 (sensitivity 0.99 [0.99 to 1.00], NPV 0.89 [0.75 to 0.97]) and modified GBS=0 (sensitivity 0.99 [0.98 to 1.00], NPV 0.84 [0.71 to 0.94]).

CONCLUSIONS

The GBS and the modified GBS are the 2 best performing scores because they achieve both key objectives: stratifying patients based on their risk of therapeutic intervention and/or death and identifying low-risk patients who may qualify for outpatient management.

An imaging-based machine learning model outperforms clinical risk scores for prognosis of cirrhotic variceal bleeding

OBJECTIVES

To develop and validate a machine learning model based on contrast-enhanced CT to predict the risk of occurrence of the composite clinical endpoint (hospital-based intervention or death) in cirrhotic patients with acute variceal bleeding (AVB).

METHODS

This retrospective study enrolled 330 cirrhotic patients with AVB between January 2017 and December 2020 from three clinical centers. Contrast-enhanced CT and clinical data were collected. Centers A and B were divided 7:3 into a training set and an internal test set, and center C served as a separate external test set. A well-trained deep learning model was applied to segment the liver and spleen. Then, we extracted 106 original features of the liver and spleen separately based on the Image Biomarker Standardization Initiative (IBSI). We constructed the Liver-Spleen (LS) model based on the selected radiomics features. The performance of LS model was evaluated by receiver operating characteristics and calibration curves. The clinical utility of models was analyzed using decision curve analyses (DCA).

RESULTS

The LS model demonstrated the best diagnostic performance in predicting the composite clinical endpoint of AVB in patients with cirrhosis, with an AUC of 0.782 (95% CI 0.650-0.882) and 0.789 (95% CI 0.674-0.878) in the internal test and external test groups, respectively. Calibration curves and DCA indicated the LS model had better performance than traditional clinical scores.

CONCLUSION

A novel machine learning model outperforms previously known clinical risk scores in assessing the prognosis of cirrhotic patients with AVB CLINICAL RELEVANCE STATEMENT: The Liver-Spleen model based on contrast-enhanced CT has proven to be a promising tool to predict the prognosis of cirrhotic patients with acute variceal bleeding, which can facilitate decision-making and personalized therapy in clinical practice.

KEY POINTS

• The Liver-Spleen machine learning model (LS model) showed good performance in assessing the clinical composite endpoint of cirrhotic patients with AVB (AUC ≥ 0.782, sensitivity ≥ 80%). • The LS model outperformed the clinical scores (AUC ≤ 0.730, sensitivity ≤ 70%) in both internal and external test cohorts.

Predicting the risk of variceal rehemorrhage in cirrhotic patients with portal vein thrombosis: A two-center retrospective study

OBJECTIVES

Although portal vein thrombosis (PVT) was thought to deteriorate portal hypertension and contribute to poor prognosis, risk stratification remains unclear. This study aimed to evaluate its effect on the risk of variceal rehemorrhage and to develop a competitive risk model in cirrhotic patients with PVT.

METHODS

Cirrhotic patients with and without PVT admitted for acute variceal hemorrhage were retrospectively included after matching (1:1) for age, gender and etiology of cirrhosis from two tertiary centers with 1-year follow-up. Those with PVT were subsequently divided into the training and validation cohorts. Cox regression analysis was performed to identify risk factors and develop a competitive risk model, of which the predictive performance and optimal decision threshold were evaluated by C-index, competitive risk curves, calibration curves and decision curve analysis.

RESULTS

Among 398 patients, PVT significantly increased the variceal rehemorrhage risk. Multivariate Cox regression analysis identified that the Child-Turcotte-Pugh score (P = 0.013), chronic PVT (P = 0.025), C-reactive protein (P < 0.001), and aspartate aminotransferase (P = 0.039) were independently associated with variceal rehemorrhage, which were incorporated into the competitive risk model, with high C-index (0.804 and 0.742 of the training and validation cohorts, respectively), risk stratification ability, and consistency. The optimal decision range of the threshold probability was 0.2-1.0.

CONCLUSION

We confirmed the adverse effect of PVT on variceal rehemorrhage and developed a competitive risk model for variceal rehemorrhage in cirrhotic patients with PVT, which might be conveniently used for clinical decision-making.

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Age, blood tests and comorbidities and AIMS65 risk scores outperform Glasgow-Blatchford and pre-endoscopic Rockall score in patients with upper gastrointestinal bleeding

BACKGROUND

Upper gastrointestinal (GI) bleeding is a life-threatening condition with high mortality rates.

AIM

To compare the performance of pre-endoscopic risk scores in predicting the following primary outcomes: In-hospital mortality, intervention (endoscopic or surgical) and length of admission (≥ 7 d).

METHODS

We performed a retrospective analysis of 363 patients presenting with upper GI bleeding from December 2020 to January 2021. We calculated and compared the area under the receiver operating characteristics curves (AUROCs) of Glasgow-Blatchford score (GBS), pre-endoscopic Rockall score (PERS), albumin, international normalized ratio, altered mental status, systolic blood pressure, age older than 65 (AIMS65) and age, blood tests and comorbidities (ABC), including their optimal cut-off in variceal and non-variceal upper GI bleeding cohorts. We subsequently analyzed through a logistic binary regression model, if addition of lactate increased the score performance.

RESULTS

All scores had discriminative ability in predicting in-hospital mortality irrespective of study group. AIMS65 score had the best performance in the variceal bleeding group (AUROC = 0.772; P < 0.001), and ABC score (AUROC = 0.775; P < 0.001) in the non-variceal bleeding group. However, ABC score, at a cut-off value of 5.5, was the best predictor (AUROC = 0.770, P = 0.001) of in-hospital mortality in both populations. PERS score was a good predictor for endoscopic treatment (AUC = 0.604; P = 0.046) in the variceal population, while GBS score, (AUROC = 0.722; P = 0.024), outperformed the other scores in predicting surgical intervention. Addition of lactate to AIMS65 score, increases by 5-fold the probability of in-hospital mortality (P < 0.05) and by 12-fold if added to GBS score (P < 0.003). No score proved to be a good predictor for length of admission.

CONCLUSION

ABC score is the most accurate in predicting in-hospital mortality in both mixed and non-variceal bleeding population. PERS and GBS should be used to determine need for endoscopic and surgical intervention, respectively. Lactate can be used as an additional tool to risk scores for predicting in-hospital mortality.

Value of Some Scoring Systems for the Prognosis of Rebleeding and In-Hospital Mortality in Liver Cirrhosis with Acute Variceal Bleeding

Background: Upper gastrointestinal (GI) hemorrhage, caused by acute esophageal variceal bleeding, is a common complication and a leading cause of death in patients with cirrhosis. Therefore, predicting the risk in order to employ an active management to prevent rebleeding and death is crucial. Currently, there are many prognostic scoring systems that have been proposed, but research is needed to find a valid score which can be applied in clinical practice in each country and population. Aims: To compare the value of ALBI (Albumin-Bilirubin), PALBI (Platelet Albumin-Bilirubin), AIMS65, model for end-stage liver disease (MELD), and Child–Pugh scores (CPS) approaches in predicting early rebleeding and in-hospital mortality of acute variceal bleeding in patients with cirrhosis. Subjects and methods: We performed a cross-sectional descriptive study on cirrhotic patients with acute variceal bleeding who were being treated at the Department of Gastroenterology, Intensive care unit—Military Hospital 103 and the Institute for Treatment of Digestive Diseases—108 Military Central Hospital from September 2020 to May 2022. We calculated ALBI, PALBI, AIMS65, MELD, Child–Pugh values and compared them with the rates of early rebleeding and in-hospital mortality. Then, determined and compared the prognostic value through an analysis of the area under the curve (AUC). Results: 222 patients with acute esophageal variceal bleeding were eligible for inclusion in the study. The rates of rebleeding and in-hospital mortality were 9.0% and 6.8%, respectively. Regarding the prognosis of early rebleeding, the ALBI and PALBI scores have good prognostic value (AUROC 0.74; 95% CI: 0.63–0.85 and AUROC 0.7; 95% CI: 0.59–0.81; p = 0.004, respectively), while the Child–Pugh, MELD, AIMS65 scores have little prognostic value, with AUROC < 0.70. Regarding prognosis of in-hospital mortality: the ALBI, PALBI, MELD and AIMS65 all have good value in predicting in-hospital mortality, with AUROC of 0.81 (95% CI: 0.68–0.93, respectively; p < 0.001); 0.8 (95% CI: 0.69–0.91; p <0.001); 0.83 (95% CI: 0.72–0.93; p < 0.001); and 0.82 (95% CI: 0.76–0.87, p < 0.001), respectively. While Child–Pugh score only has medium prognostic value, with AUROC 0.79 (95% CI: 0.66–0.92; p < 0.05). However, there was no significant difference between these prognostic scoring systems. Conclusion: the ALBI, PALBI, MELD and AIMS65 scores all had similar good value in predicting in-hospital mortality, but with early rebleeding prognosis, only ALBI and PALBI had good value. CPS does not show prognostic value like other scores, both in predicting early rebleeding and in-hospital mortality.

The Accuracy of Pre-Endoscopic Scores for Mortality Prediction in Patients with Upper GI Bleeding and No Endoscopy Performed

(1) Background: The assessment of mortality and rebleeding rate in upper gastrointestinal bleeding (UGIB) is essential, and several prognostic scores have been proposed. Some patients with UGIB did not undergo endoscopy, either because they refused the procedure, suffered from alcohol withdrawal symptoms or altered general status, or because the bleeding was severe enough to cause death before the endoscopy. The mortality risk in the subgroup of patients without endoscopy is poorly evaluated in the literature. (2) Methods: The purpose of the study was to identify the most useful scores for the assessment of in-hospital mortality in patients with UGIB with no endoscopy performed and no known etiology. A total of 198 patients with UGIB and no endoscopy performed were admitted between January 2017 and December 2021 and the accuracy of 12 prognostic scores and the Charlson comorbidity index for in-hospital mortality prediction were analyzed, as well as Child-Pugh Turcotte (CPT) and Meld scores in patients with cirrhosis. (3) Results: The mortality rate was 37.9%, higher than in variceal (21.9%, p < 0.0001) and non-variceal bleeding (7.4%, p < 0.0001). The most accurate scores by AUC were the International Bleeding score (INBS, 0.844), Glasgow Blatchford (0.783), MAP score (0.78), Iino (0.766), AIM65 and modified N-score (0.745 each), modified Glasgow-Blatchford (0.73), H3B2 and N-score (0.701); Rockall, Baylor, and T-score had an AUC below 0.7. MELD score was superior to CPT in patients with cirrhosis (AUC 0.811 versus 0.670). (4) Conclusions: The mortality rate in UGIB with no endoscopy was higher than in both variceal and non-variceal bleeding and was higher in the pandemic period but with no statistical significance (45.3% versus 32.14%, p = 0.0586), mainly because of positive cases. Only one case of rebleeding was noted; the hospitalization period was significantly shorter. The most accurate score was International Bleeding Score; the MELD score had a higher but moderate accuracy compared with CPT in patients with cirrhosis.

Development and validation of a practical prognostic nomogram for evaluating inpatient mortality of cirrhotic patients with acute variceal hemorrhage

INTRODUCTION AND OBJECTIVES

Cirrhotic patients with acute variceal hemorrhage (AVH) have high short-term mortality. Established prognostic scores are seldom applicable clinically, partially because they need external validation or contain subjective variables. We aimed to develop and validate a practical prognostic nomogram based on objective predictors to predict prognosis for cirrhotic patients with AVH.

PATIENTS AND METHODS

We enrolled 308 AVH patients with cirrhosis from our center as the derivation cohort to develop a new nomogram using logistic regression and validated it in cohorts of patients from Medical Information Mart for Intensive Care (MIMIC) III (n = 247) and IV (n = 302).

RESULTS

International normalized ratio (INR), albumin (ALB) and estimated glomerular filtration rate (eGFR) were identified as predictors for inpatient mortality and a nomogram was constructed based on them. The nomogram discriminated well in both derivation and MIMIC-III/-IV validation cohorts with the area under the receiver operating characteristic curves (AUROCs) of 0.846 and 0.859/0.833, respectively and showed a better agreement between expected and observed outcomes (Hosmer-Lemeshow tests, all comparisons, P > 0.05) than other scores in all cohorts. Our nomogram had the lowest Brier scores (0.082/0.114/0.119 in training/MIMIC-III/MIMIC-IV) and highest R² (0.367/0.393/0.346 in training/MIMIC-III/MIMIC-IV) compared to the recalibrated model for end-stage liver disease (MELD), MELD-hepatic encephalopathy (MELD-HE) and cirrhosis acute gastrointestinal bleeding (CAGIB) scores in all cohorts.

CONCLUSIONS

We developed a practical prognostic nomogram using easily verified indicators available in initial patient evaluation, which may serve as a reliable tool to accurately predict inpatient mortality for cirrhotic patients with AVH.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and liver cirrhosis]

Introduction

Liver cirrhosis is a progressive and chronic disease of the liver, of diverse etiology, which is frequently associated with glucose intolerance and in some cases concurs with type 2 diabetes (DM2). DM2 is associated with adverse outcomes in patients with cirrhosis, including a higher rate of hospitalizations, a higher prevalence of hepatocellular carcinoma, and an increased risk of mortality. Malnutrition is another frequent complication of cirrhosis, the prevalence of which increases with the degree of liver dysfunction, worsening the prognosis. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with liver cirrhosis.