Accuracy of Conventional and Novel Scoring Systems in Predicting Severity and Outcomes in Acute Pancreatitis: A Retrospective Study

doi:10.21203/rs.3.rs-335639/v1

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Accuracy of Conventional and Novel Scoring Systems in Predicting Severity and Outcomes in Acute Pancreatitis: A Retrospective Study

https://doi.org/10.21203/rs.3.rs-335639/v1

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Backgroud: Recently there are several novel scoring systems to evaluate the severity and outcomes of acute pancreatitis. This study is to compare the effectiveness of novel and traditional scoring systems for predicting severity and outcomes in acute pancreatitis.

Methods: Patients between January 2003 and August 2020 were reviewed. Ranson score (RS), Glasgow score (GS), beside index of severity in acute pancreatitis (BISAP), pancreatic activity scoring system (PASS), and Chinese simple scoring system (CSSS) were determined within 48h after admission. Multivariate logistic regression was used for severity, mortality, and organ failure prediction. Optimum cutoffs were identified using ROC analysis.

Results: A total of 1848 patients were included. AUCs of RS, GS, BISAP, PASS, and CSSS for severity prediction were 0.861, 0.865, 0.829, 0.778, and 0.816, respectively. AUCs for mortality prediction were 0.693, 0.736, 0.789, 0.858, and 0.759. AUCs for ARDS prediction were 0.745, 0.784, 0.834, 0.936, and 0.820. AUCs for ARF prediction were 0.707, 0.734, 0.781, 0.868, and 0.816.

Conclusions: RS, and GS predict severity superior to mortality and organ failure while PASS predicts mortality and organ failure better. BISAP and CSSS shared steady capacity in severity and outcomes prediction.

Cardiac & Cardiovascular Systems

Endocrinology & Metabolism

Acute pancreatitis

severity

organ failure

mortality

scoring system

Acute pancreatitis (AP) is an inflammatory disease of the pancreas with a worldwide incidence varying from 33.2/100,000 to 45/100,000 in the general population[1-3]. Approximately 10%~20% of patients with AP have a severe clinical course, with significant morbidity and mortality due to local and systemic complications[3-6]. Acute respiratory distress syndrome (ARDS) and acute renal failure (ARF) are common complications of SAP, and result in worse outcomes[7-9]. Therefore, the early detection of ARDS and ARF in patients with AP is indispensable.

Many studies have compared biochemical markers and various scoring systems in the early stage to predict disease course and outcomes in AP[10-13]. Conventional scoring systems, including the Ranson score (RS), Glasgow score (GS), and acute physiology, chronic health Evaluation (APACHE) II score, and bedside index of severity in acute pancreatitis (BISAP) have been used to assess the severity of AP. However, these scores are complicated and require multiple difficult clinical parameters for risk stratification. Although biomarkers are easy to obtain, their ability in predicting outcomes varies[14-17]. Resenly, some novel scoring systems has been reported. A prospective cohort study[18] showed that Pancreatic activity scoring system (PASS) (Table 1), first reported by Southern California Pancreas Study Group in 2017[19], could forecast important clinical events at different points in AP course. Another new scoring system called Chinese simple scoring system (CSSS) (Table 2) was proposed in 2020 [20]. Both scores haven’t been widely used yet.

The present study aimed to specifically determine the accuracy of these traditional and newly scoring systems as well as biomarkers in predicting severity, mortality, and organ failure in patients with AP.

Study design and patient selection

A retrospective study was conducted. Records of patients with AP from January 2003 to July 2020 in our hospital were reviewed.

Patients were diagnosed with AP if they met at least two of the following three criteria: (1) abdominal pain consistent with AP, (2) serum lipase activity or amylase activity at least three times greater than the upper limit of normal, and (3) characteristic findings on abdominal imaging. Patients younger than 16 years, or known to have chronic pancreatitis, or without sufficient data were excluded from the study.

Definitions of severity and organ failure

Severity of AP was evaulated based on the reevised Atlanta classification[21]. Mild AP was defined as AP in the absence of organ failure and local/systemic complications. Severe AP was characterized by the presence of organ failure and/or local complications. Organ failure was defined according to the modified Marshall scoring system[22].

Biochemical markers, scoring systems, and their cutoffs

Biochemical markers measured within 48 h after admission were analysed. RS[23], GS[24], BISAP[25], PASS[19], and CSSS[20] were calculated for each patient within 48 h after admission. Scores were compared for their accuracy in the prediction of disease severity, mortality, and development of organ failure (ARDS and ARF).

Statistical analysis

SPSS v23.0 (IBM Corp., Armonk, NY) was used for statistical analyses. Continuous variables were displayed as mean ± standard deviation. The Student t-test was used for continuous variables. The chi-square test was used for categorical variables. Univariate and multivariate logistic regression analyses were carried out to identify risk factors. Potential risk factors with P < 0.05 in the univariate analyses were enrolled into the binary logistic backward stepwise regression analysis. The results are presented as odds ratios (OR) with 95% confidence intervals (CIs). ROC curves of the scores were used for the prediction of severe AP, mortality, ARDS, and ARF. Areas under the curve (AUCs) were used to evaluate the predictive accuracy of each scoring system. All optimum cutoffs were identified on the basis of highest sensitivity and specificity values generated from the ROC curves. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A P value of less than 0.05 was considered as statistical significance.

Baseline characteristics

Among 1848 patients enrolled, 1164 (62.99%) were mild AP and 684 (37.01%) were severe AP. Mean age of the patients was 48.22±16.21 years. Mean age of severe group was older than that of mild group (P<0.001). A male preponderance (68.19%) was found. ARF was more common in male gender than female gender (P<0.001). A higher BMI was observed in the severe group than that in the mild group (P<0.001). BMI of patients with ARDS/ARF were higher than those without ARDS/ARF (P<0.05) (Table 3).Gallstones (38.47%) were the most common cause of AP, followed by hypertriglyceridemia (16.72%) and alcohol consumption (10.77%). Alcohol-associated pancreatitis was more common in severe AP group, ARDS group, and ARF group (Table 3). Hyperlipidemia (14.88%) and type-2 diabetes mellitus (7.52%) were common comorbidities. Numbers of smoking and alcohol intake history were 541 (29.27%) and 591 (31.98%), respectively. Alcohol consumption was more common in patients with severe AP (P<0.001), ARDS (P=0.002), and ARF (P<0.001) (Table 3). Longer hospital stay was observed in patients with severe AP than in patients with mild AP (P<0.001). Mortality of severe AP group was much higher than that of mild group (P<0.001) (Table 3).

Biomarkers in Predicting Severity, Mortality, and Organ Failure

In the multivariate analysis, white blood cell count, serum albumin, LDH, calcium, glucose, and CRP predicted severity of AP. Their ORs for predicting severe AP were 5.429 (95% CI, 2.5-12), 2.551 (95% CI, 1.1-5.7), and 2.661 (95% CI, 1.3-5.3), respectively. Serum total bilirubin was taken as an independent factor for mortality prediction (OR, 1.013; 95% CI, 1.004-1.023). For predicting organ failure, body mass index, blood leukocyte, and serum calcium were independent variables for ARDS, while blood urea nitrogen and serum triglyceridemic were independent variables for ARF. However, among them only serum calcium showed a better OR value (Table 4).

Scoring Systems in Predicting Severity, Mortality, and Organ Failure

For severe AP prediction, ROC curve indicated an area under the curve (AUC) of 0.861 for RS, 0.865 for GS, 0.829 for BISAP, 0.778 for PASS, and 0.816 for CSSS, respectively. Cutoffs were as following: RS of at least 2, GS of at least 2, BISAP of at least 2, PASS of at least 90, and CSSS of at least 2 (Table 5, Fig.1A). For mortality prediction, AUCs of scoring systems were as following: 0.693 for RS, 0.0.736 for GS, 0.789 for BISAP, 0.858 for PASS, and 0.759 for CSSS. Cutoffs of scoring systems for mortality prediction were as followings: RS of at least 3, GS of at least 2, BISAP of at least 3, PASS of at least 190, and CSSS of at least 3 (Table 5, Fig.1B). For ARDS prediction, AUCs of scoring systems were as following: 0.745 for RS, 0.784 for GS, 0.834 for BISAP, 0.936 for PASS, and 0.820 for CSSS. Cutoffs of RS, GS, BISAP, and CSSS were all of at least 2, and cutoff of PASS was of at least 195 (Table 5, Fig.1C). For ARF prediction, AUCs of scoring systems were as following: 0.707 for RS, 0.734 for GS, 0.781 for BISAP, 0.868 for PASS, and 0.816 for CSSS. Cutoffs of RS, GS, BISAP, and CSSS were all of at least 3, and cutoff of PASS was of at least 65 (Table 5, Fig.1D).

In the present study, BMI was an independent factor of development of ARDS in AP, consistent with a meta-analysis, which demonstrated obesity as an important risk factor for the development of ARDS[26]. This probably due to higher levels of circulating neutrophil[27] and low grade of chronic inflammation triggered by obesity[28].

Our study revealed serum Ca²⁺ showed good ORs for severity and ARDS prediction. Abnormal regulation of Ca²⁺ signals act as a crucial trigger in pathogenesis of AP[29]. Study showed that hypocalcemia was an independent risk factor of severe AP and respiratory failure in AP[30]. According to the present study, WBC predicted development of severe AP and ARDS. Besides, serum albumin, glucose, LDH, and CRP are also predictive factors of severe AP. These biomarkers are common factors to predict severe AP. As for mortality prediction, multivariate analysis identified increase of serum total bilirubin was a risk factor. Although few studies reported certain relationship between total bilirubin and mortality in AP, some studies clarified that albumin-bilirubin (ALBI) score has high predictive capacity for in-hospital mortality or prognosis in patients with critical diseases such as acute upper gastrointestinal bleeding due to liver cirrhosis[31], post-operation of hepatic carcinoma[32, 33] and acute pancreatitis[34]. Moreover, our study showed that elevation of serum triglyceride was a risk factor of ARF in AP, which was consistent with the meta-analysis reported in 2018[35].

RS, GS, and BISAP showed high accuracy in predicting severity rather than outcomes of AP in the present study. RS and GS predicted the severity and three outcomes of AP equally well, which was probably due to similar parameters they shared. Though simple, they are not repeatable. According to our study, BISAP was inferior to both RS and GS in predicting severity, which was consistent with other prospective studies[36, 37]. For items in RS and GS cover more systems than those in BISAP. Nevertheless, BISAP was superior to RS and GS in predicting mortality in the present study. Hall et al also found that RS and GS were not good indicators of mortality in AP[38]. BISAP was also better at predicting ARDS and ARF than RS and GS, possibly because it is based on three important items that are related to the renal and respiratory systems, such as BUN, SIRS, and pleural effusion.

PASS was a system that assesses activity of AP at any time of hospitalization. It contents not only object items (organ failure and SIRS), but also subject items (abdominal pain, morphine usage and ability to tolerate solid diet). The repeatable items make it available at any time of hospitalization. A prospective study[18] demonstrated that an AUC of 0.71 for PASS with cutoff﹥140 in predicting severe AP on admission. We shared similar AUC of PASS for severe AP prediction. As our center rarely use morphine to release abdominal pain of patients with AP, so the cutoff for sverity prediction was only 90. In the present study, PASS scores predicted best in mortality and organ failure, especially for ARDS prediction. For PASS contents organ failure items. But the subject items (such as abdominal pain, morphine usage and ability to tolerate solid diet) make it inferior to other scores in severity prediction. So far, no more studies report the predictive ability of PASS in outcomes of AP.

Four biomarkers, heart rate, and pancreatic image are enrolled in CSSS. According to the present study, AUCs of CSSS for severity and mortality were 0.834 and 0.838, respectively. And cutoff points were 4 for severity and 6 for mortality. However, our study showed a smaller AUCs and smaller cutoff points cmparing to the original study[20]. This probably because sample size of out study was larger than that of the original study. In our study, CSSS showed nearly the same ability in predicting the four outcomes of AP and it shared nearly equel capacity with BISAP in predicting outcomes of AP, which indicates that CSSS is a promising scoring system. However, no more studies referring to CSSS are found. Hence, larger sample size and prospective studies are needed to verify the efficiency of this new score.

Comparison of both conventional and novel scoring systems, as well as biomarkers with a large number of Chinese populations in prediction of severity and outcomes in AP is the characteristics of the present study. Yet it is a study of retrospective and single center. Besides, there was diversity in the period between the onset of AP and admission. This probably resulted in heterogeneity in the timings of score calculations and biochemical marker measurements.

RS, and GS predict severity superior to mortality and organ failure while PASS predicts mortality and organ failure better. BISAP and CSSS shared steady capacity in severity and outcomes prediction. More prospective multicenter studies are needed to confirm the value of novel scoring systems in predicting the severity and outcomes of AP.

ARF: Acute renal failure; ARDS: Acute respiratory distress syndrome; RS: Ranson score; GS: Glasgow score; APACHE: Acute physiology and chronic health evaluation; BISAP: Bedside index of severity in acute pancreatitis; PASS: Pancreatic activity scoring system; CSSS: Chinese simple scoring system; AUC: Areas under the curve; ROC: Receiver operating characteristic; BMI: body-mass index; T2DM: type-2 diabetes mellitus; WBC: White blood cell count; BUN: Blood urea nitrogen; LDH: Lactate dehydrogenase; CRP: C-reactive protein; AST: Aspartate transaminase

Acknowledgements

None.

Authors’ contributions

QW and JW contributed in the conception of the work, designing the study, collecting biochemical data and revising the draft. MQ and GDT contributed in the conception of the work and designing the study. HYY contributed in the conception of the work and collecting the biochemical data. ZHL contributed in the conception of the work, conducting the study and revising the draft. All authors approved the final manuscript.

Funding

This study was supported by the National Natural Science Foundation of China (81970558) and the Natural Science Foundation of Guangxi Province (2018GXNSFBA281154).

Availability of data and materials

All data used in this study are available from the corresponding author.

Ethics approval and consent to participate

This study was approved by the Medical Ethics Committee of First Affiliated Hospital of Guangxi Medical University (No. 2020(KY-E-177).

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no Competing interests.

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Table 1. Pancreatic activity scoring system (PASS).

Parameter	weights
Organ failure	× 100 for each system
SIRS	× 25 for each criteria
Abdominal pain (0-10)	× 5
Morphine equivalent dose (mg)	× 5
Tolerating solid diet (yes=0, no=1)	× 40

SIRS: systemic inflammatory response syndrome; Organ failure definition: modified Marshall or SOFA score ≥ 2 pts any category

Table 2. Chinese simple scoring system (CSSS).

variables	0	1	2	3	4
Serum creatinine (μmol/L)	<100	﹥100
Blood glucose (mmol/L)	<12	﹥12
LDH (U/L)	<380	﹥380
CRP (mmol/L)	<65	﹥65
Heart rate (beats/min)	<100	﹥100
Extent of pancreatic necrosis	0	<30%	30%-50%	50%-70%	﹥70%

LDH: lactate dehydrogenase; CRP: C-reactive protein

Table 3. Univariate analysis of factors associated with severity, mortality, ARDS, and ARF in AP.

Characteristic	Severity				Mortality			ARDS			ARF
Characteristic	Mild (n = 1164)		Severe (n = 684)	P	Survivor (n = 1782)	Non-survivor (n = 66)	P	No (n =1735)	Yes (n = 113)	P	No (n = 1706)	Yes (n = 142)	P
Age, y	46.22 (15.40)		51.62 (16.99)	<0.001	48.07 (16.10)	52.09 (18.69)	0.048	48.12 (16.18)	49.79 (16.66)	0.288	48.12 (16.22)	49.41 (16.12)	0.363
Male gender, n (%)	783 (67.27)		477 (69.74)	0.271	1210 (67.90)	50 (75.76)	0.178	1175 (67.72)	85 (75.22)	0.097	1142 (66.94)	118 (83.10)	<0.001
BMI, kg/m²	23.43 (4.26)		24.73 (4.52)	<0.001	23.99 (4.45)	23.07 (2.92)	0.293	23.85 (4.39)	25.44 (4.44)	0.009	23.85 (4.33)	25.51 (5.16)	0.006
Comorbidities, n (%)
Hyperlipidemia	169 (14.52)		106 (15.50)	0.568	267 (14.98)	8 (12.12)	0.521	257 (14.81)	18 (15.93)	0.747	245 (14.36)	30 (21.13)	0.03
T2DM	85 (7.30)		54 (7.89)	0.641	134 (7.52)	5 (7.58)	0.986	130 (7.49)	9 (7.96)	0.854	135 (7.91)	4 (2.82)	0.013
Etiology, n (%)
Gallstones	467 (40.12)		244 (35.67)	0.058	697 (39.11)	14 (21.21)	0.003	681 (39.25)	30 (26.55)	0.007	679 (39.80)	32 (22.54)	<0.001
Alcoholic	101 (8.68)		98 (14.33)	<0.001	191 (10.72)	8 (12.12)	0.718	178 (10.26)	21 (18.58)	0.006	169 (9.91)	30 (21.13)	<0.001
Hypertriglyceridemia	186 (15.98)		123 (17.98)	0.265	301 (16.89)	11 (16.67)	0.308	288 (16.60)	21 (18.58)	0.584	278 (16.30)	31 (21.83)	0.089
Smoker, n (%)	337 (28.95)		204 (29.82)	0.691	525 (29.46)	16 (24.24)	0.36	505 (29.11)	36 (31.86)	0.533	490 (28.72)	51 (35.92)	0.07
Alcohol intake history, n (%)	334 (28.69)		257 (37.57)	<0.001	568 (31.87)	23 (34.85)	0.611	540 (31.12)	51 (45.13)	0.002	520 (30.48)	71 (50.00)	<0.001
Hospital stay, d	12.35 (8.18)		16.56 (11.95)	<0.001	14.01 (9.68)	10.08 (14.82)	0.042	13.53 (8.85)	19.38 (19.8)	0.003	13.58 (9.02)	17.52 (17.16)	0.009
Death, n (%)	6 (0.52)		60 (8.77)	<0.001	-	-	-	29 (1.67)	37 (32.74)	<0.001	26 (1.52)	40 (28.17)	<0.001
WBC (*109/L)	10.46 (4.96)		14.71 (6.37)	<0.001	11.94 (5.77)	14.58 (8.26)	0.012	11.84 (5.81)	14.89 (6.36)	<0.001	11.79 (5.58)	14.92 (8.28)	<0.001
Hemoglobin (g/L)	127.61 (21.99)		128.11 (30.90)	0.713	128.26 (24.63)	115.28 (43.57)	0.019	127.78 (24.37)	127.99 (40.63)	0.957	127.78 (23.77)	127.99 (42.19)	0.955
Hematocrit	0.46 (1.52)		0.41 (0.52)	0.408	0.45 (1.26)	0.33 (0.10)	0.452	0.45 (1.28)	0.39 (0.15)	0.632	0.45 (1.29)	0.40 (0.23)	0.652
BUN (mmol/L)	4.70 (4.51)		7.06 (6.74)	<0.001	5.35 (5.16)	12.37 (10.53)	<0.001	5.27 (5.01)	10.40 (9.88)	<0.001	4.93 (4.32)	13.50 (10.68)	<0.001
Creatinine (μmol/L)	77.41 (35.51)		109.02 (99.68)	<0.001	85.73 (60.61)	191.88 (159.04)	<0.001	84.88 (58.86)	156.95 (140.72)	<0.001	76.51 (28.59)	244.83 (163.11)	<0.001
Total bilirubin (μmol/L)	38.25 (67.41)		41.66 (52.51)	0.277	38.41 (59.80)	72.16 (107.79)	0.023	39.54 (62.76）	39.40 (53.76)	0.983	39.07 (60.74)	45.55 (79.37)	0.274
Albumin (g/L)	37.78 (7.16)		34.19 (7.33)	<0.001	36.69 (7.31)	28.97 (7.02)	<0.001	36.6.69 (7.36)	32.31 (7.32)	<0.001	36.76 (7.24)	32.04 (8.40)	<0.001
AST (IU/L)	68.94 (113.56)		104.17 (293.67)	0.004	76.66 (121.03)	244.29 (894.16)	0.145	82.42 (206.45)	76.95 (82.21)	0.794	76.34 (120.21)	158.44 (618.75)	0.151
Calcium (mmol/L)	2.20 (0.24)		2.00 (0.33)	<0.001	2.14 (0.27)	1.85 (0.63)	0.001	2.14 (0.27)	1.89 (0.48)	<0.001	2.14 (0.27)	1.90 (0.44)	<0.001
Blood glucose (mmol/L)	7.41 (3.84)		10.21 (5.37)	<0.001	8.25 (4.47)	13.33 (7.78)	0.003	8.20 (4.40)	11.54 (7.09)	0.001	8.12 (4.26)	12.59 (7.69)	<0.001
LDH (IU/L)	234.9 (104.21)	420.76 (235.22)		<0.001	305.78 (186.17)	476.00 (326.16)	0.003	298.31 (177.79)	493.86 (291.49)	<0.001	298.65 (176.75)	475.35 (300.05)	<0.001
Triglycerides (mmol/L)	2.89 (4.37)		4.5 (6.08)	<0.001	3.51 (5.12)	3.99 (6.52)	0.558	3.38 (5.00)	5.60 (6.88)	<0.006	3.27 (4.79)	6.7 (8.06)	<0.001
CRP (mg/L)	78.53 (58.34)		138.28 (60.29)	<0.001	109.77 (66.56)	128.77 (62.19)	0.036	106.83 (65.32)	143.21 (66.71)	<0.001	107.57 (66.88)	134.55 (58.07)	<0.001
Ranson score	0.67(0.77)		2.57 (1.37)	<0.001	1.34 (1.36)	2.41 (1.58)	<0.001	1.29 (1.33)	2.64 (1.46)	<0.001	1.29 (1.32)	2.45 (1.61)	<0.001
Glasgow score	0.48 (0.69)		2.24 (1.25)	<0.001	1.09 (1.23)	2.39 (1.53)	<0.001	1.05 (1.22)	2.45 (1.20)	<0.001	1.04 (1.20)	2.28 (1.21)	<0.001
BISAP	0.6 (0.72)		1.95 (1.1)	<0.001	1.05 (1.06)	2.42 (1.25)	<0.001	1.01 (1.04)	2.49 (1.00)	<0.001	1.00 (1.02)	2.27 (1.20)	<0.001
PASS	105.51 (52.27)		172.05 (81.08)	<0.001	125.56 (66.82)	253.64 (94.44)	<0.001	120.82 61.05）	273.19 (76.21)	<0.001	120.73 (61.42)	243.11 (91.49)	<0.001
CSSS	0.55 (0.78)		2.12 (1.50)	<0.001	1.08 (1.29)	2.62 (1.69)	<0.001	1.01 (1.22)	2.98 (1.65)	<0.001	0.99 (1.19)	2.89 (1.66)	<0.001

ARDS: acute respiratory distress syndrome; ARF: acute renal failure; AP: acute pancreatitis; BMI: body-mass index; T2DM: type-2 diabetes mellitus; WBC: white blood cell count; BUN: blood urea nitroge; CRP: C-reactive protein; AST: aspartate transaminase; LDH: lactate dehydrogenase; BISAP: bedside index of severity in acute pancreatitis; PASS: pancreatic activity scoring system; CSSS: Chinese simple scoring system. P<0.05 accepted as statistically significant

Table 4. Multivariate analysis of factors predicting severity, mortality, ARDS, and ARF in AP.

Characteristic	Severity		Mortality		ARDS		ARF
Characteristic	OR (95% CI)	P	OR (95% CI)	P	OR (95% CI)	P	OR (95% CI)	P
Age	0.994 (0.975-1.014)	0.575	1.023 (0.979-1.069)	0.308	-	-	-	-
Male gender	-	-	-	-	-	-	0.731 (0.101-5.295)	0.731
BMI, kg/m²	0.985 (0.919-1.055)	0.66	-	-	1.139 (1.022-1.271)	0.019	1.125 (0.996-1.269)	0.057
Etiology
Gallstones	1.256 (0.635-2.487)	0.512	0.255 (0.036-1.826)	0.174	1.794 (0.620-5.193)	0.281	0.974 (0.197-4.821)	0.974
Alcoholic	1.416 (0.526-3.808)	0.491	-	-	0.378 (0.074-1.923)	0.241	0.844 (0.153-4.649)	0.846
Hypertriglyceridemia							0.365 (0.065-2.036)	0.25
Smoker							0.996 (0.285-3.488)	0.995
Alcohol intake history	0.862 (0.467-1.590)	0.634	-	-	1.956 (0.657-5.827)	0.228	3.613 (0.810-16.122)	0.092
Comorbidities
Hyperlipidemia	-	-	-	-	-	-	1.501 (0.529-4.26)	0.446
T2DM	-	-	-	-	-	-	0.999 (0.363-2.749)	0.998
WBC (*10⁹/L)	1.110 (1.040-1.184)	0.002	0.946 (0.819-1.094)	0.456	1.135 (1.048-1.23)	0.002	0.946 (0.839-1.067)	0.368
Hemoglobin (g/L)	-	-	1.023 (0.994-1.052)	0.118	-	-	-	-
BUN (mmol/L)	1.124 (0.974-1.297)	0.109	1.013 (0.914-1.122)	0.808	0.99 (0.917-1.069)	0.802	1.243 (1.097-1.408)	0.001
Creatinine (μmol/L)	1.005 (0.996-1.015)	0.268	1.006 (0.999-1.013)	0.105	1.002 (0.996-1.009)	0.484	-	-
Total bilirubin (μmol/L)	-	-	1.013 (1.004-1.023)	0.007	-	-	-	-
Albumin (g/L)	0.940 (0.894-0.989)	0.016	0.948 (0.833-1.079)	0.418	1.035 (0.978-1.095)	0.234	0.939 (0.854-1.032)	0.191
AST (IU/L)	1.002 (0.999-1.006)	0.18	-	-	-	-	-	-
Calcium (mmol/L)	0.196 (0.065-0.592)	0.004	0.882 (0.089-8.692)	0.914	0.042 (0.006-0.303)	0.002	1.205 (0.313-4.639)	0.786
Blood glucose (mmol/L)	1.081 (1.016-1.150)	0.014	1.023 (0.916-1.143)	0.686	1.021 (0.938-1.112)	0.624	1.054 (0.956-1.162)	0.294
LDH (IU/L)	1.004 (1.002-1.006)	<0.001	1.003 (1.000-1.005)	0.061	1.000 (0.998-1.002)	0.785	1.000 (0.998-1.003)	0.781
Triglycerides (mmol/L)	1.022 (0.961-1.086)	0.486	-	-	0.943 (0.845-1.051)	0.287	1.119 (1.012-1.239)	0.029
CRP (mg/L)	1.007 (1.003-1.012)	0.002	0.999 (0.988-1.011)	0.844	1.002 (0.995-1.008)	0.409	1.000 (0.993-1.008)	0.926

ARDS: acute respiratory distress syndrome; ARF: acute renal failure; AP: acute pancreatitis; BMI: body-mass index; T2DM: type-2 diabetes mellitus; CRP: C-reactive protein; AST: aspartate transaminase; BUN: blood urea nitrogen; LDH: lactate dehydrogenase; BISAP: bedside index of severity in acute pancreatitis; PASS: pancreatic activity scoring system; CSSS: Chinese simple scoring system. P<0.05 accepted as statistically significant.

Table 5. Effectiveness of scoring systems for predicting severity, mortality, ARDS, and ARF in AP.

	Cutoff	AUC (95% CI)	Sensitivity (95% CI)	Specificity (95% CI)	PPV (95% CI)	NPV (95% CI)
Severity
Ranson score	≥2	0.861 (0.844-0.876)	0.741 (0.707-0.774)	0.864 (0.843-0.883)	0.762 (0.728-0.794)	0.850 (0.828-0.870)
Glasgow score	≥ 2	0.865 (0.849-0.881)	0.708 (0.672-0.742)	0.900 (0.882-0.917)	0.807 (0.773-0.838)	0.840 (0.818-0.860)
BISAP	≥ 2	0.829 (0.811-0.846)	0.649 (0.612-0.685)	0.869 (0.848-0.887)	0.744 (0.707-0.778)	0.808 (0.785-0.830)
PASS	≥ 90	0.778 (0.759-0.797)	0.889 (0.863-0.912)	0.545 (0.516-0.574)	0.534 (0.505-0.564)	0.893 (0.868-0.915)
CSSS	≥ 2	0.816 (0.797-0.833)	0.605 (0.568-0.642)	0.894 (0.876-0.910)	0.750 (0.712-0.786)	0.812 (0.791-0.832)
Mortality
Ranson score	≥3	0.693 (0.671-0.714)	0.515 (0.389-0.640)	0.976 (0.967-0.983)	0.500 (0.376-0.624)	0.978 (0.968-0.985)
Glasgow score	≥ 2	0.736 (0.715-0.756)	0.727 (0.604-0.830)	0.690 (0.668-0.712)	0.080 (0.060-0.105)	0.986 (0.977-0.991)
BISAP	≥ 3	0.789 (0.770-0.807)	0.606 (0.478-0.724)	0.882 (0.866-0.897)	0.160 (0.117-0.211)	0.984 (0.976-0.989)
PASS	≥ 190	0.858 (0.841-0.874)	0.788 (0.670-0.879)	0.809 (0.790-0.827)	0.133 (0.101-0.170)	0.990 (0.984-0.995)
CSSS	≥ 3	0.759 (0.738-0.778)	0.515 (0.389-0.640)	0.872 (0.856-0.887)	0.130 (0.092-0.177)	0.980 (0.972-0.986)
ARDS
Ranson score	≥2	0.745 (0.725-0.765)	0.761 (0.672-0.836)	0.666 (0.644-0.689)	0.129 (0.105-0.157)	0.977 (0.967-0.985)
Glasgow score	≥2	0.784 (0.764-0.802)	0.779 (0.691-0.851)	0.705 (0.683-0.726)	0.147 (0.119-0.178)	0.980 (0.971-0.987)
BISAP	≥2	0.834 (0.816-0.851)	0.823 (0.740-0.888)	0.710 (0.688-0.731)	0.156 (0.127-0.187)	0.984 (0.975-0.990)
PASS	≥ 195	0.936 (0.924-0.946)	0.903 (0.833-0.950)	0.860 (0.843-0.876)	0.296 (0.248-0.347)	0.993 (0.987-0.996)
CSSS	≥ 2	0.820 (0.802-0.838)	0.752 (0.662-0.829)	0.731 (0.709-0.752)	0.154 (0.125-0.187)	0.978 (0.969-0.986)
ARF
Ranson score	≥ 3	0.707 (0.686-0.728)	0.507 (0.422-0.592)	0.792 (0.772-0.811)	0.169 (0.134-0.208)	0.951 (0.938-0.961)
Glasgow score	≥ 3	0.734 (0.711-0.752)	0.542 (0.457-0.626)	0.857 (0.841-0.872)	0.213 (0.172-0.259)	0.963 (0.954-0.972)
BISAP	≥ 3	0.781 (0.761-0.800)	0.346 (0.283-0.413)	0.897 (0.882-0.911)	0.300 (0.244-0.361)	0.915 (0.901-0.928)
PASS	≥ 165	0.868 (0.852-0.883)	0.831 (0.759-0.889)	0.754 (0.733-0.774)	0.219 (0.185-0.257)	0.982 (0.973-0.988)
CSSS	≥ 3	0.816 (0.798-0.834)	0.578 (0.492-0.660)	0.895 (0.879-0.909)	0.313 (0.257-0.373)	0.962 (0.952-0.971)

ARDS: acute respiratory distress syndrome; ARF: acute renal failure; AP: acute pancreatitis; AUC: area under the curve; PPV: positive predictive value; NPV: negative predictive value; BUN: blood urea nitrogen; BISAP: bedside index of severity in acute pancreatitis; PASS: pancreatic activity scoring system; CSSS: Chinese simple scoring system.

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Accuracy of Conventional and Novel Scoring Systems in Predicting Severity and Outcomes in Acute Pancreatitis: A Retrospective Study

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