Retrospective Study
Copyright ©The Author(s) 2024. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Crit Care Med. Dec 9, 2024; 13(4): 98862
Published online Dec 9, 2024. doi: 10.5492/wjccm.v13.i4.98862
Predicting the risk of mortality in children with dengue-induced hepatitis admitted to the paediatric intensive care unit
Thanh Tat Nguyen, Phuong Thi-Mai Ngo, Luan Thanh Vo
Thanh Tat Nguyen, Department of Tuberculosis, Woolcock Institute of Medical Research, Ho Chi Minh 700000, Viet Nam
Thanh Tat Nguyen, Phuong Thi-Mai Ngo, Luan Thanh Vo, Department of Infectious Diseases, The Children’s Hospital 2, Ho Chi Minh 700000, Viet Nam
Co-corresponding authors: Thanh Tat Nguyen and Luan Thanh Vo.
Author contributions: Nguyen TT was responsible for formal analysis, methodology, and funding acquisition; Nguyen TT and Ngo TMP were responsible for writing original draft; Nguyen TT and Vo TL were responsible for conceptualization; Nguyen TT, Vo TL, and Ngo TMP were responsible for data curation, investigation, and critical revision of the final manuscript; all of the authors read and approved the final version of the manuscript to be published.
Institutional review board statement: This sub-study stemmed from the main research, which was approved by the Scientific Committee and Institutional Review Board of the Children’s Hospital 2, Ho Chi Minh City, Vietnam (approval No. 391/QD-BVND2, March 22, 2022).
Informed consent statement: We used a secondary dataset from primary research, which was considered to cause less than minimal risk to participants. Therefore, the need for ethical approval was waived. This study was performed in accordance with the principles of Good Clinical Practice and ethical guidelines of the Declaration of Helsinki.
Conflict-of-interest statement: All authors declare that there is no conflict of interest.
Data sharing statement: The original contributions of this study are included in the article and supplementary material. Further requests can be directed to the corresponding authors.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Thanh Tat Nguyen, MD, PhD, Academic Research, Senior Researcher, Department of Tuberculosis, Woolcock Institute of Medical Research, Pham Ngoc Thach Street, Ho Chi Minh 700000, Viet Nam. thanhhonor@gmail.com
Received: July 8, 2024
Revised: September 26, 2024
Accepted: October 20, 2024
Published online: December 9, 2024
Processing time: 115 Days and 7.9 Hours
Abstract
BACKGROUND

Dengue-associated acute liver failure (PALF) accounts for a high mortality rate in children admitted to the pediatric intensive care unit (PICU). To date, there is a lack of data on clinical algorithms for estimating the risk of mortality in pediatric patients with dengue-induced severe hepatitis (DISH).

AIM

To determine the prevalence of PALF and identify the predictors of mortality among patients with DISH.

METHODS

This single-institution retrospective study was performed at a tertiary pediatric hospital in Vietnam between 2013 and 2022. The primary outcome was in-hospital mortality in pediatric patients with DISH, which was defined as either aspartate aminotransferase > 350 IU/L or alanine aminotransferase > 400 IU/L. Prognostic models for estimating the risk of death among patients with DISH were developed using a predefined set of clinical covariables and hepatic biomarkers on PICU admission and during the first 72 hours of admission. Area under the curve, multivariable logistic regression, and multiple imputation using the chained equation for missing values were performed. Backward stepwise model selection based on the Akaike information criterion was employed. Bootstrapping, calibration slope, and Brier score were used to assess the final models.

RESULTS

A total of 459 children with DISH were included in the analysis. The median patient age was 7.7 years (interquartile range: 4.3-10.1 years). The prevalence of dengue-associated PALF in children with DISH was 18.3%. Thirty-nine DISH patients developing PALF (8.5%) died. Hepatic biomarkers, including the international normalized ratio (INR) ≥ 2.11 and total serum bilirubin (≥ 1.7 mg/dL), showed high predictive values for mortality (all P values < 0.001). Multivariable models showed the significant clinical predictors of death from dengue-induced PALF in patients with DISH, including reduced level of consciousness (pain and unresponsive levels on the Alert, Verbal, Pain, Unresponsive scale), high vasoactive-inotropic score (> 30), and elevated levels of blood lactate, INR, and serum bilirubin. The final prognostic model demonstrated high discrimination, Brier score, and an acceptable calibration slope.

CONCLUSION

The prevalence of PALF in children with DISH is 18.3%. We developed robust prognostic models to estimate the risk of death in hospitalized children with severe dengue-induced hepatitis.

Keywords: Dengue; Dengue-associated acute liver failure; Dengue-induced severe hepatitis; Dengue shock syndrome; Hepatic encephalopathy; Mortality

Core Tip: The prevalence of dengue-associated acute liver failure in children with dengue-induced severe hepatitis (DISH) was 18.3%. The in-hospital mortality rate was approximately 8.5% among DISH patients developing acute liver failure. Hepatic biomarkers, including international normalized ratio (INR) (≥ 2.11) and total serum bilirubin (≥ 1.7 mg/dL), showed high predictive values for mortality. The significant predictors of mortality in children with DISH were decreased level of consciousness (pain and unresponsive levels on the Alert, Verbal, Pain, Unresponsive scale), high vasoactive-inotropic score (> 30), elevated blood lactate and INR levels during the first 24 hours of pediatric intensive care unit admission, and rising serum bilirubin during the first 72 hours of admission.