Over the last several decades, acute pancreatitis (AP) has emerged as one of the most common reasons for hospitalization in individuals with gastrointestinal conditions [
The most lethal complication of AP is persistent organ failure (POF) in early phases of the disease. Thus, it is very important to effectively predict POF during the initial stages of AP and to determine whether patients may need to be timely transferred to the intensive care unit (ICU) for treatments including adequate initial fluid resuscitation. Many previous studies have reported that a series of available scoring systems, including the Acute Physiology, Chronic Health Evaluation II (APACHE-II) score, Ranson score, modified Glasgow/Imrie score, systemic inflammatory response syndrome (SIRS) criteria, Bedside Index for the Severity in Acute Pancreatitis (BISAP) score, and Harmless Acute Pancreatitis Score (HAPS), can be used for the prediction of POF in clinical practice. Notably, the main limitation of these scoring systems is that these are difficult to widely practice during clinical management. Furthermore, Mounzer et al. have found that all of these clinical scoring systems are moderately accurate in predicting POF and that the accuracy of various predictive scoring systems is comparable [
Given that the accuracy of various predictive scoring systems is similar, current research is exploring simple, accurate, inexpensive, and repeatable methods to predict the severity of AP. Over the last two decades, a number of studies have reported that the serum levels of biochemical markers (blood urea nitrogen (BUN), creatinine, glucose, and hematocrit) within 24-48 h of admission are closely associated with the severity of AP [
The aims of the present study were (1) to compare the early serum levels of BUN, creatinine, glucose, and hematocrit and APACHE-II score for the prediction of POF in AP and (2) to determine whether the combination of a highly precise scoring system with a simple laboratory parameter can significantly improve the accuracy of predicting POF in AP.
From January 1, 2005, and December 31, 2016, we performed a retrospective single-center observational study on 2090 patients within 24 h of their admission to our hospital. The study was approved by the ethics committee of The First Affiliated Hospital of Nanchang University (No. 2011001).
All data were obtained from an electronic medical database. The inclusion criteria were as follows: (1) patients diagnosed with AP at our hospital within 24 h of admission; (2) evaluation of serum levels of BUN, creatinine, glucose, and hematocrit and the APACHE-II score within 24 h of admission; and (3) available data on patient age and sex, AP etiology and severity, presence of complications, length of hospital stay, and mortality.
AP was diagnosed according to the 2012 version of the Atlanta Classification System and internationally accepted definitions based on the presence of at least two of the following three criteria [
Statistical analyses were performed using IBM SPSS software, version 20.0 (Statistical Package for the Social Sciences, Chicago, IL, USA). Sensitivity, specificity, positive predictive value, and negative predictive value were calculated for the serum levels of BUN, creatinine, glucose, and hematocrit and the APACHE-II score at admission. Predictive accuracy was measured by the area under the receiver operating characteristic (ROC) curve (AUC).
In total, 2090 (35%) patients out of 6024 patients were evaluated within 24 h of hospital admission. Demographic and clinical characteristics (age, sex, AP etiology, comorbidities, and mortality) were similar between patients grouped based on the time after admission (<24 h vs. >24 h) as shown in Table
Population baseline characteristics between AP patients within 24 h of admission vs. those over 24 h.
Variable | AP within 24 h | AP over 24 h | |
---|---|---|---|
Median age (years) (IQR) | 51 (40-63) | 51 (40-63) | 0.957 |
Sex, | <0.001 | ||
Male | 1207 (58) | 2025 (52) | |
Female | 883 (42) | 1909 (48) | |
Pancreatitis etiology, | |||
Biliary | 1173 (56) | 2466 (63) | <0.001 |
Alcoholism | 130 (6) | 248 (6) | 0.911 |
Hypertriglyceridemia | 531 (25) | 656 (17) | <0.001 |
Idiopathic | 185 (9) | 398 (10) | 0.114 |
Comorbidities, | |||
Posthypertriglyceridemia | 195 (9) | 196 (5) | <0.001 |
Diabetes mellitus | 166 (8) | 253 (6) | 0.028 |
Pancreatic necrosis | 352 (17) | 834 (21) | <0.001 |
Severity classification, | |||
MAP | 970 (46) | 1701 (43) | 0.017 |
MSAP | 806 (39) | 1574 (40) | 0.275 |
SAP | 314 (15) | 659 (17) | 0.083 |
Hospital LOS (days) (IQR) | 8 (6-12) | 9 (6-13) | 0.001 |
Mortality (%) | 1.0 | 1.4 | <0.001 |
AP, acute pancreatitis;
The median age of the 2090 patients evaluated within 24 h of hospital admission was 51 years (interquartile range 40-63 years), and 58% of the patients were male. Classification of patients according to AP etiology revealed that 1173 (56%) AP cases were of biliary correlation, 130 (6%) were associated with alcohol abuse, 531 (25) were associated with hypertriglyceridemia, and 185 (9%) cases were idiopathic.
Table
Admission serum BUN, creatinine, glucose, and hematocrit levels and APACHE-II score as markers for persistent organ failure.
Laboratory markers | Persistent organ failure | Sensitivity (%) | Specificity (%) | Positive predictive value (%) | Negative predictive value (%) | AUC | |
---|---|---|---|---|---|---|---|
Yes | No | ||||||
BUN | |||||||
≥20 | 120 | 270 | 38 | 85 | 31 | 89 | 62 |
<20 | 194 | 1506 | |||||
Creatinine | |||||||
≥1.8 | 55 | 37 | 18 | 98 | 60 | 87 | 58 |
<1.8 | 259 | 1739 | |||||
Glucose | |||||||
≥7.1 | 233 | 845 | 74 | 52 | 22 | 92 | 63 |
<7.1 | 81 | 931 | |||||
Hematocrit | |||||||
≥44 | 140 | 475 | 45 | 73 | 23 | 88 | 59 |
<44 | 174 | 1301 | |||||
APACHE-II | |||||||
≥8 | 173 | 366 | 55 | 79 | 32 | 91 | 67 |
<8 | 141 | 1410 |
As shown in Tables
Admission serum BUN level vs. the outcome of persistent organ failure by etiology of acute pancreatitis.
BUN | Persistent organ failure | Sensitivity (%) | Specificity (%) | Positive predictive value (%) | Negative predictive value (%) | AUC | |
---|---|---|---|---|---|---|---|
Yes | No | ||||||
Biliary | |||||||
≥20 | 66 | 172 | 39 | 83 | 28 | 89 | 61 |
<20 | 102 | 832 | |||||
Alcoholic | |||||||
≥20 | 11 | 8 | 58 | 92 | 58 | 92 | 75 |
<20 | 8 | 96 | |||||
Hypertriglyceridemia | |||||||
≥20 | 23 | 31 | 30 | 88 | 43 | 81 | 59 |
<20 | 54 | 232 | |||||
Idiopathic | |||||||
≥20 | 3 | 27 | 20 | 83 | 10 | 92 | 52 |
<20 | 12 | 134 |
Admission serum creatinine level vs. the outcome of persistent organ failure by etiology of acute pancreatitis.
Creatinine | Persistent organ failure | Sensitivity (%) | Specificity (%) | Positive predictive value (%) | Negative predictive value (%) | AUC | |
---|---|---|---|---|---|---|---|
Yes | No | ||||||
Biliary | |||||||
≥1.8 | 23 | 15 | 14 | 98 | 61 | 87 | 56 |
<1.8 | 145 | 989 | |||||
Alcoholic | |||||||
≥1.8 | 7 | 1 | 37 | 99 | 88 | 90 | 68 |
<1.8 | 12 | 103 | |||||
Hypertriglyceridemia | |||||||
≥1.8 | 16 | 8 | 21 | 97 | 67 | 81 | 59 |
<1.8 | 61 | 255 | |||||
Idiopathic | |||||||
≥1.8 | 1 | 8 | 7 | 95 | 11 | 92 | 51 |
<1.8 | 14 | 153 |
Admission serum glucose level vs. the outcome of persistent organ failure by etiology of acute pancreatitis.
Glucose | Persistent organ failure | Sensitivity (%) | Specificity (%) | Positive predictive value (%) | Negative predictive value (%) | AUC | |
---|---|---|---|---|---|---|---|
Yes | No | ||||||
Biliary | |||||||
≥7.1 | 118 | 441 | 70 | 56 | 21 | 92 | 63 |
<7.1 | 50 | 563 | |||||
Alcoholic | |||||||
≥7.1 | 15 | 50 | 79 | 52 | 23 | 93 | 65 |
<7.1 | 4 | 54 | |||||
Hypertriglyceridemia | |||||||
≥7.1 | 67 | 181 | 87 | 31 | 27 | 89 | 59 |
<7.1 | 10 | 82 | |||||
Idiopathic | |||||||
≥7.1 | 12 | 69 | 80 | 57 | 15 | 97 | 69 |
<7.1 | 3 | 92 |
Admission hematocrit level vs. the outcome of persistent organ failure by etiology of acute pancreatitis.
HCT | Persistent organ failure | Sensitivity (%) | Specificity (%) | Positive predictive value (%) | Negative predictive value (%) | AUC | |
---|---|---|---|---|---|---|---|
Yes | No | ||||||
Biliary | |||||||
≥44 | 71 | 197 | 42 | 80 | 26 | 89 | 61 |
<44 | 97 | 807 | |||||
Alcoholic | |||||||
≥44 | 12 | 47 | 63 | 54 | 20 | 89 | 59 |
<44 | 7 | 57 | |||||
Hypertriglyceridemia | |||||||
≥44 | 38 | 124 | 49 | 47 | 23 | 78 | 51 |
<44 | 39 | 139 | |||||
Idiopathic | |||||||
≥44 | 6 | 49 | 40 | 70 | 11 | 93 | 55 |
<44 | 9 | 112 |
Admission APACHE-II score vs. the outcome of persistent organ failure by etiology of acute pancreatitis.
APACHE-II | Persistent organ failure | Sensitivity (%) | Specificity (%) | Positive predictive value (%) | Negative predictive value (%) | AUC | |
---|---|---|---|---|---|---|---|
Yes | No | ||||||
Biliary | |||||||
≥8 | 100 | 254 | 60 | 75 | 28 | 92 | 67 |
<8 | 68 | 750 | |||||
Alcoholic | |||||||
≥8 | 10 | 13 | 53 | 87 | 43 | 91 | 70 |
<8 | 9 | 91 | |||||
Hypertriglyceridemia | |||||||
≥8 | 38 | 43 | 49 | 84 | 47 | 85 | 67 |
<8 | 39 | 220 | |||||
Idiopathic | |||||||
≥8 | 7 | 26 | 47 | 84 | 21 | 94 | 65 |
<8 | 8 | 135 |
Koutroumpakis et al. constructed an early prediction classification tree based on hematocrit
Classification tree predicting persistent organ failure and pancreatic necrosis based on hematocrit (HCT)
Classification tree predicting persistent organ failure and pancreatic necrosis based on
We performed a retrospective single-center study on a large sample to assess the accuracy of POF prediction based on early laboratory parameters. Our data indicated that single laboratory indices do not have high accuracy for predicting POF in AP. The data in Table
Previous studies have reported that early changes in serum creatinine levels in AP are useful indicators of disease severity and mortality [
The relationship between the severity of AP and BUN levels has been extensively studied in recent years. Wu et al. have demonstrated BUN level as the most accurate predictor of mortality among indicators including calcium, hemoglobin, creatinine, and glucose levels [
Furthermore, many studies have reported close associations of elevated hematocrit levels within 24 h of admission with organ failure and necrotizing pancreatitis [
The association between glucose level and the severity of AP has also been previously reported. A study evaluated 170 patients with AP, and ROC analysis showed significant associations of glucose levels at admission with local complications (
Other scoring systems may also be helpful in predicting organ failure. Based on current evidence, the APACHE-II score has the following advantages in predicting organ failure. First, APACHE-II
The above studies have highlighted promising strategies for predicting the severity of AP. However, our study revealed that laboratory parameters are only moderately accurate in predicting POF with modest AUCs and that their efficacy is not as high as reported in the previous articles [
Based on above results, until a better approach has been identified, serum creatinine levels and APACHE-II scores obtained within 24 h of admission can help clinicians to predict the occurrence of POF and to decide on early management strategies. Early and vigorous fluid resuscitation maintains microcirculation, which may improve the prognosis of patients with SAP. Some recently published studies have proposed that early vigorous fluid resuscitation might prevent pancreatic necrosis and reduce the incidence of SIRS and organ failure at the 72 h timepoint, and it might even decrease in-hospital mortality [
In addition, an important finding of our study is that there is a very low likelihood of developing POF in AP patients who have a serum creatinine
This study has several limitations. First, all the data were retrospectively analyzed. Second, we included patients within 24 h of disease onset and excluded patients with more than 24 h of onset, which may have led to selection bias. Third, serum creatinine levels and APACHE-II scores were not recorded in our hospital database for all patients within 24 h of admission, and thus, unexpected biases may have arisen. To increase the reliability of our results and to reduce these potential biases, we need even larger samples. The present study provides preliminary data for the design of future randomized controlled trials for predicting POF during the initial stages of AP.
In conclusion, the combination of APACHE-II score ≥ 8 and serum creatinine
Blood urea nitrogen
Persistent organ failure
Acute pancreatitis
Receiver operating characteristic
Mild acute pancreatitis
Severe acute pancreatitis
Intensive care unit
Acute physiology, chronic health evaluation II
Systemic inflammatory response syndrome
Bedside index for the severity in acute pancreatitis
Harmless acute pancreatitis score
Moderately severe AP
Computed tomography.
All data generated or analyzed during this study are included in this published article.
The study was approved by the ethics committee of The First Affiliated Hospital of Nanchang University (No. 2011001).
Jianhua Wan and Wenqing Shu are co-first authors.
The authors declare no conflict of interest.
Jianhua Wan and Wenqing Shu conceived the study. Jianhua Wan, Wenhua He, Yin Zhu, Liang Xia, and Nonghua Lu participated in study design. Yin Zhu, Yong Zhu, Hao Zeng, and Pi Liu collected the data. Jianhua Wan and Wenhua He performed statistical analyses. Jianhua Wan and Wenqing Shu drafted the manuscript. Liang Xia and Nonghua Lu edited and checked the manuscript. All of the authors have read and approved the final manuscript.
The study design and data collection for this meta-analysis were funded by the National Natural Science Foundation of China (Nos. 81460130 and 81760121), the Science and Technology Plan Grant (No. 20165092) from the Health Department of Jiangxi Province, China, and the Science and Technology Plan Grant (Key project) (No. GJJ160024) from the Education Department of Jiangxi Province, China.