Nomogram for the prediction of infected pancreatic necrosis in moderately severe and severe acute pancreatitis

Abstract

Objectives: As a serious complication of moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP), infected pancreatic necrosis (IPN) can lead to a prolonged course of interventional therapy. Most predictive models designed to identify such patients are complex or lack validation. The aim of this study was to develop a predictive model for the early detection of IPN in MSAP and SAP.

Methods: A total of 594 patients with MSAP or SAP were included in the study. To reduce dimensionality, least absolute shrinkage and selection operator regression analysis was used to screen potential predictive variables, a nomogram was then constructed using logistic regression analysis. The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the discrimination, accuracy, and clinical efficacy of the model. External data were also obtained to further validate the constructed model.

Results: There were 476, 118, and 82 patients in the training, internal validation, and external validation cohorts, respectively. Platelet count, hematocrit, albumin/globulin, severity of acute pancreatitis, and modified computed tomography severity index score were independent factors for predicting IPN in MSAP and SAP. The area under the ROC curves were 0.923, 0.940, and 0.817, respectively, in the three groups. There was a good consistency between the actual probabilities and the predicted probabilities. DCA revealed excellent clinical utility.

Conclusion: The constructed nomogram is a simple and feasible model that has good clinical predictive value and efficacy in clinical decision-making for IPN in MSAP and SAP.

Keywords

infected pancreatic necrosis / moderately severe acute pancreatitis / nomogram / prediction model / severe acute pancreatitis

References

[1] Roberts SE, Morrison-Rees S, John A, Williams JG, Brown TH, Samuel DG. The incidence and aetiology of acute pancreatitis across Europe. Pancreatology. 2017;17(2):155-165.

[2] Wolbrink DRJ, Kolwijck E, Ten Oever J, Horvath KD, Bouwense SAW, Schouten JA. Management of infected pancreatic necrosis in the intensive care unit: a narrative review. Clin Microbiol Infect. 2020;26(1):18-25.

[3] Bruno MJ; Dutch Pancreatitis Study Group. Improving the outcome of acute pancreatitis. Dig Dis. 2016;34(5):540-545.

[4] Trikudanathan G, Wolbrink DRJ, van Santvoort HC, Mallery S, Freeman M, Besselink MG. Current concepts in severe acute and necrotizing pancreatitis: an evidence-based approach. Gastroenterology. 2019;156(7):1994-2007.e3.

[5] van Brunschot S, van Grinsven J, van Santvoort HC, et al; Dutch Pancreatitis Study Group. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet. 2018;391(10115):51-58.

[6] Bakker OJ, van Santvoort HC, Besselink MG, van der Harst E, Hofker HS, Gooszen HG; Dutch Pancreatitis Study Group. Prevention, detection, and management of infected necrosis in severe acute pancreatitis. Curr Gastroenterol Rep. 2009;11(2):104-110.

[7] Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13(10):818-829.

[8] Ong Y, Shelat VG. Ranson score to stratify severity in acute pancreatitis remains valid – Old is gold. Expert Rev Gastroenterol Hepatol. 2021;15(8):865-877.

[9] Papachristou GI, Muddana V, Yadav D, et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol. 2010;105(2):435-441.

[10] Banks PA, Bollen TL, Dervenis C, et al; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis—2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-111.

[11] Van Calster B, Wynants L, Verbeek JFM, et al. Reporting and interpreting decision curve analysis: a guide for investigators. Eur Urol. 2018;74(6):796-804.

[12] Bugiantella W, Rondelli F, Boni M, et al. Necrotizing pancreatitis: a review of the interventions. Int J Surg. 2016;28(Suppl 1):S163-S171.

[13] Lankisch PG, Apte M, Banks PA. Acute pancreatitis. Lancet. 2015;386(9988):85-96.

[14] Petrov MS, Shanbhag S, Chakraborty M, Phillips ARJ, Windsor JA. Organ failure and infection of pancreatic necrosis as determinants of mortality in patients with acute pancreatitis. Gastroenterology. 2010;139(3):813-820.

[15] Koutroumpakis E, Wu BU, Bakker OJ, et al. Admission hematocrit and rise in blood urea nitrogen at 24 h outperform other laboratory markers in predicting persistent organ failure and pancreatic necrosis in acute pancreatitis: a post hoc analysis of three large prospective databases. Am J Gastroenterol. 2015;110(12):1707-1716.

[16] Gomercic C, Gelsi E, Van Gysel D, et al. Assessment of D-dimers for the early prediction of complications in acute pancreatitis. Pancreas. 2016;45(7):980-985.

[17] Brown A, Orav J, Banks PA. Hemoconcentration is an early marker for organ failure and necrotizing pancreatitis. Pancreas. 2000;20(4):367-372.

[18] Lankisch PG, Mahlke R, Blum T, et al. Hemoconcentration: an early marker of severe and/or necrotizing pancreatitis? A critical appraisal. Am J Gastroenterol. 2001;96(7):2081-2085.

[19] Semple JW, Italiano JE, Freedman J. Platelets and the immune continuum. Nat Rev Immunol. 2011;11(4):264-274.

[20] Cox D, Kerrigan SW, Watson SP. Platelets and the innate immune system: mechanisms of bacterial-induced platelet activation. J Thromb Haemost. 2011;9(6):1097-1107.

[21] Scherlinger M, Richez C, Tsokos GC, Boilard E, Blanco P. The role of platelets in immune-mediated inflammatory diseases. Nat Rev Immunol. 2023;23(8):495-510.

[22] Cuthbertson CM, Christophi C. Disturbances of the microcirculation in acute pancreatitis. Br J Surg. 2006;93(5):518-530.

[23] Ammori BJ. Role of the gut in the course of severe acute pancreatitis. Pancreas. 2003;26(2):122-129.

[24] Glaubitz J, Wilden A, Frost F, et al. Activated regulatory T-cells promote duodenal bacterial translocation into necrotic areas in severe acute pancreatitis. Gut. 2023;72(7):1355-1369.

[25] Rau BM, Bothe A, Kron M, Beger HG. Role of early multisystem organ failure as major risk factor for pancreatic infections and death in severe acute pancreatitis. Clin Gastroenterol Hepatol. 2006;4(8):1053-1061.

[26] Santaolalla A, Sollie S, Rislan A, et al. Association between serum markers of the humoral immune system and inflammation in the Swedish AMORIS study. BMC Immunol. 2021;22(1):61.

[27] Wang YY, Li CY, Wang WY, et al. Serum albumin to globulin ratio is associated with the presence and severity of inflammatory bowel disease. J Inflamm Res. 2022;15:1907-1920.

[28] Soeters PB, Wolfe RR, Shenkin A. Hypoalbuminemia: pathogenesis and clinical significance. JPEN J Parenter Enteral Nutr. 2019;43(2):181-193.

[29] Hoffman LK, Ghias MH, Cohen SR, Lowes MA. Polyclonal hyperglobulinaemia and elevated acute-phase reactants in hidradenitis suppurativa. Br J Dermatol. 2018;178(2):e134-e135.

[30] Balthazar EJ, Robinson DL, Megibow AJ, Ranson JH. Acute pancreatitis: value of CT in establishing prognosis. Radiology. 1990;174(2):331-336.

[31] Mortele KJ, Wiesner W, Intriere L, et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patient outcome. AJR Am J Roentgenol. 2004;183(5):1261-1265.

[32] Dalal AD, Dalal YD, Rana DA. Modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome: a prospective observational study from a tertiary care teaching hospital, India. Ann Afr Med. 2023;22(3):340-346.

[33] Bateman RM, Sharpe MD, Jagger JE, et al. 36th International Symposium on Intensive Care and Emergency Medicine: Brussels, Belgium. 15–18 March 2016. Crit Care. 2016;20(Suppl 2):94.

[34] Banday IA, Gattoo I, Khan AM, Javeed J, Gupta G, Latief M. Modified computed tomography severity index for evaluation of acute pancreatitis and its correlation with clinical outcome: a tertiary care hospital based observational study. J Clin Diagn Res. 2015;9(8):TC01–TC05.

[35] Li G, Li S, Cao LX, et al. Nomogram development and validation for predicting minimally invasive step-up approach failure in infected necrotizing pancreatitis patients: a retrospective cohort study. Int J Surg. 2023;109(6):1677-1687.

RIGHTS & PERMISSIONS

2024 The Authors. Journal of Digestive Diseases published by Chinese Medical Association Shanghai Branch, Chinese Society of Gastroenterology, Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine and John Wiley & Sons Australia, Ltd.