Retrospective Cohort Study
Copyright ©The Author(s) 2015. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 21, 2015; 21(27): 8373-8381
Published online Jul 21, 2015. doi: 10.3748/wjg.v21.i27.8373
Score model for predicting acute-on-chronic liver failure risk in chronic hepatitis B
Fang-Yuan Gao, Yao Liu, Xiao-Shu Li, Xie-Qiong Ye, Le Sun, Ming-Fan Geng, Rui Wang, Hui-Min Liu, Xiao-Bing Zhou, Li-Li Gu, Yan-Min Liu, Gang Wan, Xian-Bo Wang
Fang-Yuan Gao, Yao Liu, Xiao-Shu Li, Xie-Qiong Ye, Le Sun, Ming-Fan Geng, Rui Wang, Hui-Min Liu, Xiao-Bing Zhou, Li-Li Gu, Yan-Min Liu, Xian-Bo Wang, Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
Gang Wan, Statistics Section, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China
Author contributions: Wang XB and Gao FY conceived of and designed the study; Gao FY, Liu Y, Li XS, Ye XQ, Sun L, Geng MF, Wang R, Liu HM, Zhou XB, Gu LL, Liu YM and Wan G contributed to the acquisition and analysis of data; Gao FY and Liu Y drafted the manuscript; all authors participated in interpretation of the findings; Wang XB revised the manuscript; all authors have read and approved the final version of the manuscript.
Supported by Grants from National Natural Science Foundation of China, No. 81273743, No. 81473641; and 215 Program, No. 2013-2-11.
Conflict-of-interest statement: The authors declare that they have no conflicts interest in this study.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at wangxianbo638@163.com.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Xian-Bo Wang, Professor, Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China. wangxianbo638@163.com
Telephone: +86-10-84322301 Fax: +86-10-84322301
Received: February 5, 2015
Peer-review started: February 6, 2015
First decision: March 10, 2015
Revised: March 25, 2015
Accepted: May 4, 2015
Article in press: May 4, 2015
Published online: July 21, 2015
Processing time: 166 Days and 21.2 Hours
Abstract

AIM: To establish a clinical scoring model to predict risk of acute-on-chronic liver failure (ACLF) in chronic hepatitis B (CHB) patients.

METHODS: This was a retrospective study of 1457 patients hospitalized for CHB between October 2008 and October 2013 at the Beijing Ditan Hospital, Capital Medical University, China. The patients were divided into two groups: severe acute exacerbation (SAE) group (n = 382) and non-SAE group (n = 1075). The SAE group was classified as the high-risk group based on the higher incidence of ACLF in this group than in the non-SAE group (13.6% vs 0.4%). Two-thirds of SAE patients were randomly assigned to risk-model derivation and the other one-third to model validation. Univariate risk factors associated with the outcome were entered into a multivariate logistic regression model for screening independent risk factors. Each variable was assigned an integer value based on the regression coefficients, and the final score was the sum of these values in the derivation set. Model discrimination and calibration were assessed using area under the receiver operating characteristic curve and the Hosmer-Lemeshow test.

RESULTS: The risk prediction scoring model included the following four factors: age ≥ 40 years, total bilirubin ≥ 171 μmol/L, prothrombin activity 40%-60%, and hepatitis B virus DNA > 107 copies/mL. The sum risk score ranged from 0 to 7; 0-3 identified patients with lower risk of ACLF, whereas 4-7 identified patients with higher risk. The Kaplan-Meier analysis showed the cumulative risk for ACLF and ACLF-related death in the two risk groups (0-3 and 4-7 scores) of the primary cohort over 56 d, and log-rank test revealed a significant difference (2.0% vs 33.8% and 0.8% vs 9.4%, respectively; both P < 0.0001). In the derivation and validation data sets, the model had good discrimination (C index = 0.857, 95% confidence interval: 0.800-0.913 and C index = 0.889, 95% confidence interval: 0.820-0.957, respectively) and calibration demonstrated by the Hosmer-Lemeshow test (χ2 = 4.516, P = 0.808 and χ2 = 1.959, P = 0.923, respectively).

CONCLUSION: Using the scoring model, clinicians can easily identify patients (total score ≥ 4) at high risk of ACLF and ACLF-related death early during SAE.

Keywords: Acute-on-chronic liver failure; Chronic hepatitis B; Prediction model; Risk score; Severe acute exacerbation

Core tip: Acute-on-chronic liver failure (ACLF) is a severe life-threatening clinical syndrome characterized by liver failure and associated with an extremely high mortality if liver transplantation or artificial liver support is not available. Early diagnosis might allow for effective patient risk stratification and more appropriate medical care. However, previous studies on severe acute exacerbation of ACLF have focused on the clinical outcomes, and global uniform standards and correlation studies for predicting ACLF occurrence are lacking. We developed a clinical scoring model to predict the risk of ACLF early in patients with chronic hepatitis B.