Red cell distribution width: A predictor of the severity of hypertriglyceridemia-induced acute pancreatitis

BACKGROUND

Compared with patients with other causes of acute pancreatitis, those with hypertriglyceridemia-induced acute pancreatitis (HTG-AP) are more likely to develop persistent organ failure (POF). Therefore, recognizing the individuals at risk of developing POF early in the HTG-AP process is a vital for improving outcomes. Bedside index for severity in acute pancreatitis (BISAP), a simple parameter that is obtained 24 h after admission, is an ideal index to predict HTG-AP severity; however, the suboptimal sensitivity limits its clinical application. Hence, current clinical scoring systems and biochemical parameters are not sufficient for predicting HTG-AP severity.

AIM

To elucidate the early predictive value of red cell distribution width (RDW) for POF in HTG-AP.

METHODS

In total, 102 patients with HTG-AP were retrospectively enrolled. Demographic and clinical data, including RDW, were collected from all patients on admission.

RESULTS

Based on the Revised Atlanta Classification, 37 (33%) of 102 patients with HTG-AP were diagnosed with POF. On admission, RDW was significantly higher in patients with HTG-AP and POF than in those without POF (14.4% vs 12.5%, P < 0.001). The receiver operating characteristic curve demonstrated a good discriminative power of RDW for POF with a cutoff of 13.1%, where the area under the curve (AUC), sensitivity, and specificity were 0.85, 82.4%, and 77.9%, respectively. When the RDW was ≥ 13.1% and one point was added to the original BISAP to obtain a new BISAP score, we achieved a higher AUC, sensitivity, and specificity of 0.89, 91.2%, and 67.6%, respectively.

CONCLUSION

RDW is a promising predictor of POF in patients with HTG-AP, and the addition of RDW can promote the sensitivity of BISAP.

Dynamic nomogram for persistent organ failure in acute biliary pancreatitis: Development and validation in a retrospective study

BACKGROUND

Persistent organ failure (POF) increases the risk of death in patients with acute biliary pancreatitis (ABP). Currently, there is no early risk assessment tool for POF in patients with ABP.

AIMS

To establish and validate a dynamic nomogram for predicting the risk of POF in ABP.

METHODS

This was a retrospective study of 792 patients with ABP, with 595 cases in the development group and 197 cases in the validation group. Least absolute shrinkage and selection operator regression screened the predictors of POF, and logistic regression established the model (P < 0.05). A dynamic nomogram showed the model. We evaluated the model's discrimination, calibration, and clinical effectiveness; used the bootstrap method for internal validation; and conducted external validation in the validation group.

RESULTS

Neutrophils, haematocrit, serum calcium, and blood urea nitrogen were predictors of POF in ABP. In the development group and validation group, the areas under the receiver operating characteristic curves (AUROCs) were 0.875 and 0.854, respectively, and the Hosmer-Lemeshow test (P > 0.05) and calibration curve showed good consistency between the actual and prediction probability. Decision curve analysis showed that the dynamic nomogram has excellent clinical value.

CONCLUSION

This dynamic nomogram helps with the early identification and screening of high-risk patients with POF in ABP.

Growth differentiation factor 15 is an early predictor for persistent organ failure and mortality in acute pancreatitis

OBJECTIVES

Early prediction of persistent organ failure (POF) is crucial for patients with acute pancreatitis (AP). Growth differentiation factor 15 (GDF15), also known as macrophage inhibitory cytokine 1 (MIC-1), is associated with inflammatory responses. We investigated changes in plasma GDF15 and assessed its predictive value in AP.

METHODS

The study included 290 consecutive patients with AP admitted within 36 h after symptoms onset. Clinical data obtained during hospitalization were collected. Plasma GDF15 levels were determined using enzyme-linked immunosorbent assays. The predictive value of GDF15 for POF was analyzed.

RESULTS

There were 105 mild, 111 moderately severe, and 74 severe AP patients. Plasma GDF15 peak level were measured on admission, and significantly declined on the 3rd and 7th day. Admission GDF15 predicted POF and mortality with areas under the curve (AUC) of 0.847 (95% confidence interval [CI] 0.798-0.895) and 0.934 (95% CI 0.887-0.980), respectively. Admission GDF15, Bedside Index of Severity in Acute Pancreatitis, and hematocrit were independent factors for POF by univariate and multivariate logistic regression, and the nomogram built on these variables showed good performance (optimism-corrected c-statistic = 0.921). The combined predictive model increased the POF accuracy with an AUC 0.925 (95% CI 0.894-0.956), a net reclassification improvement of 0.3024 (95% CI: 0.1482-0.4565, P < 0.001), and an integrated discrimination index of 0.11 (95% CI 0.0497-0.1703; P < 0.001).

CONCLUSIONS

Plasma GDF15 measured within 48 h of symptom onset could help predict POF and mortality in AP patients.

Early versus delayed intervention in necrotizing acute pancreatitis complicated by persistent organ failure

BACKGROUND

Current guidelines for the treatment of patients with necrotizing acute pancreatitis (NAP) recommend that invasive intervention for pancreatic necrosis should be deferred to 4 or more weeks from disease onset to allow necrotic collections becoming "walled-off". However, for patients showing signs of clinical deterioration, especially those with persistent organ failure (POF), it is controversial whether this delayed approach should always be adopted. In this study, we aimed to assess the impact of differently timed intervention on clinical outcomes in a group of NAP patients complicated by POF.

METHODS

All NAP patients admitted to our hospital from January 2013 to December 2017 were screened for potential inclusion. They were divided into two groups based on the timing of initial intervention (within 4 weeks and beyond 4 weeks). All the data were extracted from a prospectively collected database.

RESULTS

Overall, 131 patients were included for analysis. Among them, 100 (76.3%) patients were intervened within 4 weeks and 31 (23.7%) underwent delayed interventions. As for organ failure prior to intervention, the incidences of respiratory failure, renal failure and cardiovascular failure were not significantly different between the two groups (P > 0.05). The mortality was not significantly different between the two groups (35.0% vs. 32.3%, P = 0.83). The incidences of new-onset multiple organ failure (8.0% vs. 6.5%, P = 1.00), gastrointestinal fistula (29.0% vs. 12.9%, P = 0.10) and bleeding (35.0% vs. 35.5%, P = 1.00), and length of ICU (30.0 vs. 22.0 days, P = 0.61) and hospital stay (42.5 vs. 40.0 days, P = 0.96) were comparable between the two groups.

CONCLUSION

Intervention within 4 weeks did not worsen the clinical outcomes in NAP patients complicated by POF.

Stress Hyperglycemia Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND/AIMS

Stress hyperglycemia is common in critical illness but it has not been clearly studied in patients with acute pancreatitis (AP). This study aimed to investigate the specific blood glucose (BG) level that defines stress hyperglycemia and to determine the impact of stress hyperglycemia on clinical outcomes in AP patients.

METHODS

AP patients admitted ≤ 48 h after abdominal pain onset were retrospectively analyzed. Patients were stratified by pre-existing diabetes and stress hyperglycemia was defined using stratified BG levels for non-diabetes and diabetes with clinical outcomes compared.

RESULTS

There were 967 non-diabetic and 114 diabetic (10.5%) patients met the inclusion criteria and the clinical outcomes between these two groups were not significantly different. In non-diabetes, the cut-off BG level of ≥ 180 mg/dl was selected to define stress hyperglycemia with an 8.8-fold higher odds ratio for persistent organ failure (POF) (95% CI 5.4-14.3; P < 0.001). For diabetes, ≥ 300 mg/dl was selected with a 7.5-fold higher odds ratio for POF (95% CI 1.7-34.3; P = 0.009). In multivariable logistic regression, stress hyperglycemia was independently associated with POF, acute necrotic collection, major infection and mortality. The combination of BG and systemic inflammatory response syndrome (SIRS) score in predicting POF was better than SIRS or Glasgow score alone.

CONCLUSIONS

This study identifies a cut-off BG level of ≥ 180 mg/dl and ≥ 300 mg/dl was optimal to define stress hyperglycemia for non-diabetic and diabetic AP patients, respectively. There was a significant relationship between stress hyperglycemia and adverse clinical outcomes.

Heparin-Binding Protein Levels at Admission and Within 24 h Are Associated with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND

Identification of patients at risk for persistent organ failure (POF) early in the course of acute pancreatitis (AP) is critical for early intervention. Heparin-binding protein (HBP) levels are closely related to inflammation. Therefore, we investigated the relationship between HBP levels and POF in patients with AP.

METHODS

This observational cohort study analyzed 66 patients with AP and 14 healthy volunteers between June 2019 and December 2019. Baseline characteristics, laboratory data, and severity scores of patients with different degrees of AP were compared. Levels of HBP were measured by ELISA. Serum HBP levels were analyzed using receiver operating characteristic curves to identify POF in AP.

RESULTS

Concentrations of serum HBP in healthy volunteers, MAP, MSAP, and SAP groups were 3.9 (range: 3.4-5) ng/ml, 5.2 (3.9-6.8) ng/ml, 5.9 (4.6-7.7) ng/ml, and 11 (8.0-13.8) ng/ml, respectively. The level of HBP in SAP patients was significantly elevated compared to the other groups (P < 0.01). HBP levels ≥ 7 ng/ml showed a specificity of 74%, a sensitivity of 90%, and an AUC of 0.82 for predicting POF.

CONCLUSIONS

HBP levels in patients with POF were significantly elevated. HBP is a useful marker for predicting severe AP.

A single center randomized double blind controlled trial of pentoxifylline in acute pancreatitis: Challenges and opportunities

OBJECTIVES

Despite substantial morbidity and mortality associated with acute pancreatitis (AP), only one small randomized controlled drug trial (RCT) is available in the past few decades from the United States. Hence, we conducted a single-center, double-blind, placebo-controlled RCT of pentoxifylline in AP.

METHODS

A total of 9 doses of oral pentoxifylline 400 mg or placebo tablet, three times daily, was administered within 72 h of diagnosis, using randomization blocks by pharmacy. Primary outcome was a composite outcome including any of the following: death, peripancreatic and/or pancreatic necrosis, infected pancreatic necrosis, persistent organ failure, persistent systemic inflammatory response syndrome, hospital stay longer than 4 days, need for intensive care, and need for intervention for necrosis.

RESULTS

Between July 7, 2015, and April 4, 2017, we identified 685 patients with AP, 233 met eligibility criteria and 176 were approached for the study. Of these, 91 (51.7%) declined and finally 45 in pentoxifylline group and 38 in placebo group (83 total) were compared. There were no significant differences in primary outcome (27 [60.0%] vs 15 [39.5%]; P = .06). Pentoxifylline group was not associated with any benefit, but withlonger stay (42% vs. 21%; P = .04) and higher readmission rates (16 %vs 3%; P = .047).

CONCLUSIONS

We could not demonstrate superiority of pentoxifylline over placebo. Smaller sample size and inclusion of all types of severity might be the reasons for lack of efficacy. The challenges observed in the present study indicate that, in order to conduct a successful drug trial in AP, a multi center collaboration is essential.

Early on-demand drainage versus standard management among acute necrotizing pancreatitis patients complicated by persistent organ failure: The protocol for an open-label multi-center randomized controlled trial

INTRODUCTION/AIM

Pancreatic necrosis occurs in a quarter of patients with acute pancreatitis, many of whom form an acute necrotic collection (ANC). The current standard treatment is to defer percutaneous catheter drainage (PCD) until the latter becomes "walled off," which takes approximately four weeks. The majority of patients that develop persistent organ failure (POF), the primary determinant of mortality, do so within four weeks. To defer PCD until after four weeks may result in a worse outcome because of a missed opportunity to treat early infection and thereby reduce the severity and/or duration of POF. This study is aimed to compare the clinical outcome of the current standard approach with early on-demand PCD in acute necrotizing pancreatitis (ANP) patients with ANC and POF.

METHODS/DESIGN

This is an open-label, multi-center, parallel, randomized, controlled trial. All patients with ANP who develop POF during the first week of onset will be screened for eligibility. In total, 120 study subjects will be randomized to either early on-demand PCD or standard care. Patients assigned to the former will receive PCD when they show signs of decompensation like new-onset OF, aggravation of pre-existent OF, and persistent OF for more than a week. The primary composite endpoint is major complication and/or death. Patients will be followed until discharge or death with an additional follow-up 90 days after randomization.

DISCUSSION

This study challenges the standard 4-week delay before PCD and will answer the question whether early on-demand PCD is associated with a lower incidence of major complications and/or death.

Early Rapid Fluid Therapy Is Associated with Increased Rate of Noninvasive Positive-Pressure Ventilation in Hemoconcentrated Patients with Severe Acute Pancreatitis

BACKGROUND/AIMS

Hematocrit is a widely used biomarker to guide early fluid therapy for patients with acute pancreatitis (AP), but there is controversy over whether early rapid fluid therapy (ERFT) should be used in hemoconcentrated patients. This study investigated the association of hematocrit and ERFT with clinical outcomes of patients with AP.

METHODS

Data from prospectively maintained AP database and retrospectively collected fluid management details were stratified according to actual severity defined by revised Atlanta classification. Hemoconcentration and "early" were defined as hematocrit > 44% and the first 6 h of general ward admission, respectively, and "rapid" fluid rate was defined as ≥ 3 ml/kg/h. Patients were allocated into 4 groups for comparisons: group A, hematocrit ≤ 44% and fluid rate < 3 ml/kg/h; group B, hematocrit ≤ 44% and fluid rate ≥ 3 ml/kg/h; group C, hematocrit > 44% and fluid rate < 3 ml/kg/h; and group D, hematocrit > 44% and fluid rate ≥ 3 ml/kg/h. Primary outcome was rate of noninvasive positive-pressure ventilation (NPPV).

RESULTS

A total of 912 consecutive AP patients were analyzed. ERFT has no impact on clinical outcomes of hemoconcentrated, non-severe or all non-hemoconcentrated AP patients. In hemoconcentrated patients with severe AP (SAP), ERFT was accompanied with increased risk of NPPV (odds ratio 5.96, 95% CI 1.57-22.6). Multivariate regression analyses confirmed ERFT and hemoconcentration were significantly and independently associated with persistent organ failure and mortality in patients with SAP.

CONCLUSIONS

ERFT is associated with increased rate of NPPV in hemoconcentrated patients with SAP.

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.

Clinical utility of fibrin-related biomarkers in human acute pancreatitis

AIM

To investigate whether the four fibrin-related markers (FRMs) fibrin monomer (FM), D-dimer (D-D), fibrinogen (FIB), and fibrin degradation products (FDP) reflect the extent of coagulation activation in vivo and to assess the predictive value of the FRMs in determining persistent organ failure (POF) and pancreatic necrosis (PN) in acute pancreatitis (AP) patients.

METHODS

One hundred and fifty-two AP patients were included in this prospective observational study. The final outcome was disease severity assessed by presence of POF and PN. The levels of the four FRMs were measured on days 1, 2, 3, and 7 after admission. ROC curves were used to compare the sensitivity, specificity, PPV, and NPV of FM, D-D, and FDP in predicting POF and PN with those of regular biochemical markers C-reaction protein (CRP) and lactate dehydrogenase (LDH).

RESULTS

Of the 152 patients included, 32 had POF and 44 had PN. There was no significant difference in serum FM levels between AP with POF and AP without POF at the first week after admission. Patients with PN had significantly higher FM than those without PN on day 1 (P = 0.043), day 2 (P = 0.008), day 3 (P = 0.001), and day 7 (P = 0.002) after admission. D-D was significantly higher in patients with POF than in those without on day 1 (P = 0.001), day 2 (P = 0.004), day 3 (P = 0.000), and day 7 (P = 0.002). Patients with PN had significantly higher D-D on day 1 (P = 0.023), day 2 (P = 0.045), day 3 (P = 0.000), and day 7 (P = 0.000) after admission. FDP was significantly higher in patients with POF than in those without on day 1 (P = 0.000), day 2 (P = 0.000), day 3 (P = 0.000), and day 7 (P = 0.000). Patients with PN had signficantly higher FDP on day 2 (P = 0.021), day 3 (P = 0.000), and day 7 (P = 0.000) after admission. FIB did not differ significantly between AP patients with POF and those without, or between AP patients with PN and those without. ROC analysis revealed that D-D (AUC = 0.693) and FDP (AUC = 0.711) were superior to CRP (AUC = 0.615) and LDH (AUC = 0.672) in predicting POF on day 1 of hospital admission, and D-D (AUC = 0.832) and FDP (AUC = 0.814) were superior than LDH (AUC = 0.639) and CRP (AUC = 0.706) in predicting PN on day 3 of hospital admission.

CONCLUSION

Plasma FRMs in AP patients increase significantly on the first week after admission. FDP and D-D correlate with disease severity of AP and can be considered as a potentially useful tool for the early diagnosis of AP with POF and PN.

Early prediction of persistent organ failure by serum apolipoprotein A-I and high-density lipoprotein cholesterol in patients with acute pancreatitis

BACKGROUND

Early identification of acute pancreatitis (AP) patients at high-risk of developing persistent organ failure (persistent OF) is a vital clinical goal. This research intends to assess the ability of apolipoprotein A-I (APO A-I) and high-density lipoprotein cholesterol (HDL-C) to predict persistent OF.

METHODS

Between January 2011 and September 2016, a total of 102 adult AP patients with organ failure, local complications or deterioration of former comorbidities disease during hospitalization were included in this study retrospectively. Serum lipids were tested and computed the correlation with clinical outcomes or scoring systems. The AUCs to predict persistent OF were also calculated and compared with each other.

RESULTS

Serum APO A-I and HDL-C levels were negatively associated with scoring systems. Meanwhile, serum lipids were negatively correlated with poor clinical outcomes. The AUCs of APO A-I, HDL-C, the combination of APO A-I and BISAP, or the combination of APO A-I and MCTSI to predict persistent OF among Moderately severe acute pancreatitis (MSAP) and Severe acute pancreatitis (SAP) patients were 0.886, 0.811, 0.912, and 0.900 or among those with organ failure were 0.915, 0.859, 0.933, and 0.933, respectively.

CONCLUSIONS

The concentrations of APO A-I, HDL-C, and the combinations of APO A-I and scoring systems have high predictive value to predict persistent OF.

Early diagnosis of pancreatic necrosis based on perfusion CT to predict the severity of acute pancreatitis

BACKGROUND

Perfusion CT can diagnose pancreatic necrosis in early stage of severe acute pancreatitis, accurately. However, no study to date has examined whether early diagnosis of pancreatic necrosis is useful in predicting persistent organ failure (POF).

METHODS

We performed a multi-center prospective observational cohort study to investigate whether perfusion CT can predict the development of POF in the early stage of AP, based on early diagnosis of the development of pancreatic necrosis (PN). From 2009 to 2012, we examined patients showing potential early signs of severe AP (n = 78) on admission. Diagnoses for the development of PN were made prospectively by on-site physicians on the admission based on perfusion CT (diagnosis 1). Blinded retrospective reviews were performed by radiologists A and B, having 8 and 13 years of experience as radiologists (diagnosis 2 and 3), respectively. Positive diagnosis for the development of PN were assumed equivalent to positive predictions for the development of POF. We then calculated the area under the curve (AUC) of the receiver operating characteristic for POF predictions.

RESULTS

Fourteen (17.9%) and 23 patients (29.5%) developed PN and POF, respectively. For diagnoses 1, 2, and 3, AUCs for POF predictions were 74, 68, and 73, respectively.

CONCLUSIONS

Perfusion CT diagnoses pancreatic necrosis and on that basis predicts the development of POF; http://www.umin.ac.jp/ctr/index-j.htm,UMIN000001926 .

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

PURPOSE

Elevated serum lactate dehydrogenase (LDH) has been reported in a serious of clinical diseases. However, the relationship between LDH and the incidence of persistent organ failure (POF) in acute pancreatitis (AP) has not been characterized.

MATERIALS AND METHODS

A total of 105 patients with AP who presented within 72h from symptom onset between 2014 and 2015 were included in this retrospective study. Demographic parameters and laboratory data on admission were compared between patients with and without POF. Multivariable logistic regression analyses were utilized to evaluate the prognostic value of LDH for predicting POF.

RESULTS

21 patients were diagnosed with POF. Compared to non-POF, patients with POF showed a significantly higher value of serum LDH on admission (741.57±331.72 vs. 296.08±135.73U/L, P<0.001). After multivariate logistic analysis, LDH remained an independent risk factor for POF (Hazard ratio 4.38, 95%CI: 1.42-13.47; P=0.010). A LDH value of 647U/L predicted POF with an area under the curve (AUC) of 0.876, a sensitivity with 76.2% and specificity with 98.8%, respectively.

CONCLUSIONS

Our results indicate that serum LDH on admission is independently associated with POF in AP and may serve as a potential prognostic factor.

Serum albumin, a good indicator of persistent organ failure in acute pancreatitis

BACKGROUND

To evaluate the predictive value of serum albumin (ALB) for persistent organ failure (POF) in acute pancreatitis (AP).

METHODS

We selected 158 patients with AP in this retrospective study from Jan.1st, 2015 to Dec.31st, 2015. Forty-six patients were diagnosed with POF. All the values of laboratory parameters were measured upon admission to hospital. And 48 h after admission, we examined serum albumin of each patient again, called 'ALB2'. Uni-and multi-variate logistic regression were used to evaluate the impact of ALB to predict POF.

RESULTS

The median age of the whole population was 48 years and 53.8% were male. The admission-time albumin of AP patients with POF was distinctly lower than patients without POF (28.9 (25.3-33.1) g/L vs. 38.5 (34.0-40.1) g/L, p < 0.001). In uni-variate analysis, WBC, PT, GLU, LDH, ALB, ALB2, BUN, Ca, HDL-C and Ranson were significantly associated with POF. After multivariate regression, ALB remained an independent prognostic factor for POF in AP (OR: 0.748, 95%CI: 0.645-0.868; p < 0.05). The AUC for ALB is 0.873 (0.808, 0.938), even larger than that for Ranson, 0.845 (0.634, 0.913).

CONCLUSIONS

We identified serum albumin predictive to persistent organ failure in acute pancreatitis.

Can mean platelet volume play a role in evaluating the severity of acute pancreatitis?

AIM

To investigate serum mean platelet volume (MPV) levels in acute pancreatitis (AP) patients and assess whether MPV effectively predicts the disease severity of AP.

METHODS

We included 117 consecutive patients with AP as the AP group and 34 consecutive patients with colorectal polyps (before endoscopic treatment) as the control group. Complete blood counts, liver function, platelet indices (MPV), coagulation parameters, lactate dehydrogenase (LDH) and C-reactive protein (CRP) were measured on days 1, 2, 3 and 7 after admission. Receiver operating characteristic curves were used to compare the sensitivity and specificity of MPV, white blood cell (WBC), LDH and CRP in predicting AP severity. The Modified Glasgow Prognostic Score (mGPS) and the 2012 revised Atlanta criteria were used to evaluate disease severity in AP.

RESULTS

MPV levels were significantly lower in the AP group than in the control group on day 1 (P = 0.000), day 2 (P = 0.029) and day 3 (P = 0.001) after admission. In addition, MPV values were lower on day 1 after admission than on day 2 (P = 0.012), day 3 (P = 0.000) and day 7 (P = 0.002) in all AP patients. Based on the mGPS, 78 patients (66.7%) were diagnosed with mild and 39 patients (33.3%) with severe AP. There was no significant difference in mean MPV levels between patients diagnosed with mild and severe AP based on the mGPS (P = 0.424). According to the 2012 revised Atlanta criteria, there were 98 patients (83.8%) without persistent organ failure (OF) [non-severe acute pancreatitis (non-SAP) group] and 19 patients (16.2%) with persistent OF (SAP group). MPV levels were significantly lower in the SAP group than in the non-SAP group on day 1 after admission (P = 0.002). On day 1 after admission using a cut-off value of 6.65 fL, the overall accuracy of MPV for predicting SAP according to the 2012 revised Atlanta criteria (AUC = 0.716) had a sensitivity of 91.8% and a specificity of 47.4% and was superior to the accuracy of the traditional markers WBC (AUC = 0.700) and LDH (AUC = 0.697).

CONCLUSION

MPV can be used at no additional cost as a useful, non-invasive biomarker that distinguishes AP with persistent OF from AP without persistent OF on day 1 of hospital admission.

Serum calcium as an indicator of persistent organ failure in acute pancreatitis

AIM

Decreased level of serum calcium was commonly seen in critical illness. Hypocalcemia was significantly more frequent in patients with severe form of acute pancreatitis (AP), and a negative correlation was observed between endotoxemia and serum calcium in AP. AP patients with persistent organ failure (POF) show an extremely high mortality. The association underlying calcium and POF in AP has not been characterized.

METHODS

We conducted a retrospective cohort study of adult patients who presented within 72hours from symptom onset of AP at our center between January 2014 and May 2015. Demographic parameters on admission, organ failure assessment, laboratory data and in-hospital mortality were compared between patients with and without POF. Uni-and multi-variate logistic regression analyses were utilized to evaluated the predictive ability of serum calcium.

RESULTS

A total of 128 consecutive AP patients, including 29 with POF, were included. Compared to patients without POF, patients with POF showed a significantly lower value of serum calcium on admission (2.11±0.46 vs. 1.55±0.36mmol/L, P<0.001). After multivariate logistic analysis, serum calcium remained an independent risk factor for POF (Hazard ratio 0.21, 95% confident interval: 0.08-0.58; P=0.002). A calcium value of 1.97mmol/L predicted POF with an area under the curve (AUC) of 0.888, a sensitivity with 89.7% and specificity with 74.8%, respectively.

CONCLUSION

Our results indicate that serum calcium on admission is independently associated with POF in AP and may serve as a potential prognostic factor.

Early Prediction of Persistent Organ Failure by Serum Angiopoietin-2 in Patients with Acute Pancreatitis

BACKGROUND

Biomarkers for the early prediction of the severity of acute pancreatitis (AP) are urgently needed for clinical management of the disease. Angiopoietin-2 (Ang-2), one of the autocrine peptides that reduce endothelial permeability, has been found to be associated with various diseases, including inflammatory disorders.

AIMS

This study aimed to determine whether serum Ang-2 could serve as a noninvasive biomarker for the early prediction of persistent organ failure (POF) in acute pancreatitis.

METHODS

A total of 120 AP patients were prospectively enrolled at Jinling Hospital. Serum samples were collected on admission. Clinical and laboratory data were recorded. Ang-2 levels were measured by enzyme-linked immunosorbent assay.

RESULTS

A total of 37 patients developed POF and were classified as having severe AP (SAP). Ang-2 was significantly higher on admission in patients who developed POF than in those who did not (p < 0.001 for all). Furthermore, receiver operating characteristic (ROC) curve analysis revealed that Ang-2 could distinguish patients who developed POF from mild AP (MAP, area under ROC curve [AUC] = 0.88, 95 % CI 0.78-0.94) and moderately severe AP patients (MSAP, AUC = 0.74, 95 % CI 0.63-0.83). In addition, multivariate logistic regression showed that increased Ang-2 was an independent predictor of developing POF between subgroups with MSAP and SAP (OR 7.2, 95 % CI 2.7-19.4) and among all AP patients (OR 12.1, 95 % CI 4.8-30.3).

CONCLUSIONS

Elevated serum Ang-2 levels on admission may be a promising biomarker for the prediction of POF in AP.

Predictors of severe and critical acute pancreatitis: a systematic review

BACKGROUND

Persistent organ failure and infected pancreatic necrosis are major determinants of mortality in acute pancreatitis, but there is a gap in the literature assessing the best available predictors of these two determinants. The purpose of this review was to investigate the utility of predictors of persistent organ failure and infected pancreatic necrosis in patients with acute pancreatitis, both alone and in combination.

METHODS

We performed a systematic search of the literature in 3 databases for prospective studies evaluating predictors of persistent organ failure, infected pancreatic necrosis, or both, with strict eligibility criteria.

RESULTS

The best predictors of persistent organ failure were the Japanese Severity Score and Bedside Index of Severity in Acute Pancreatitis when the evaluation was performed within 48h of admission, and blood urea nitrogen and Japanese Severity Score after 48h of admission. Systemic Inflammation Response Syndrome was a poor predictor of persistent organ failure. The best predictor of infected pancreatic necrosis was procalcitonin.

CONCLUSIONS

Based on the best available data, it is justifiable to use blood urea nitrogen for prediction of persistent organ failure after 48h of admission and procalcitonin for prediction of infected pancreatic necrosis in patients with confirmed pancreatic necrosis. There is no predictor of persistent organ failure that can be justifiably used in clinical practice within 48h of admission.

Could rising BUN predict the future development of infected pancreatic necrosis?

BACKGROUND

Infected (peri)pancreatic necrosis (IPN) in acute pancreatitis (AP) is associated with organ failure (OF) and high mortality. There are no established early markers of primary IPN. This study aimed to assess the association of simple parameters with primary IPN in AP.

METHODS

We retrospectively studied 281 patients with AP admitted to Mayo Clinic hospitals and identified those with microbiologically confirmed infections in (peri)pancreatic necrosis and collections. We defined primary IPN as infection of (peri)pancreatic necrotic tissue that developed before interventions. We recorded admission hematocrit, BMI, BUN, serum creatinine, SIRS score and development of persistent organ failure within 48 h of admission; and performed serial SIRS and BUN calculations for at least 48 h. We used univariate and multivariable analysis to assess associations and expressed results as odds ratio (OR)[95% CI].

RESULTS

27 (9.6%) patients developed IPN, of which 21 (77.7%) had primary IPN. 38.1% had Gram positive, 9.5% Gram negative and 52.3% mixed bacterial infections. Five (23.8%) of the patients with IPN had fungal infection. On univariate analysis, SIRS ≥ 2 at admission, rise in BUN by 5 mg/dL within 48 h of admission, persistence of SIRS for 48 h and development of persistent OF within 48 h of disease had significant association with development of primary IPN with OR (95% CI) of 4.12 (1.53-11.15), 10.25 (3.95-26.61), 1.19 (1.69-10.39) and 7.62 (2.58-21.25) [2-tailed p = 0.004, <0.0001, 0.002 and <0.0001] respectively. On multivariable analysis, only rise in BUN by 5 mg/dL within 48 h of admission was associated with primary IPN (p = 0.007).

CONCLUSIONS

Rising BUN within 48 h of admission can be used to predict development of primary IPN in AP.