Heterogeneity Analysis Of Clinical Features Of Moderately Severe Acute Pancreatitis Based On The Atlanta Classification

ObjectiveRecent studies have found that the clinical outcomes of moderately severe acute pancreatitis(MSAP)are different among different subgroups.In addition,most previous studies have focused on the predictors of severe acute pancreatitis(SAP),while MS AP account for a relatively large proportion of acute pancreatitis(AP)and have high incidence.So far,there are few studies on predicting MSAP.The objective of this study was to further subdivide MSAP,evaluate the heterogeneity of MSAP subgroups,and analyze the predictive value of common scoring systems and laboratory indicators for MSAP.MethodsA retrospective analysis was performed for patients with AP who were admitted to Northern Jiangsu People’s Hospital from January 1,2016 to December 31,2020.According to the inclusion and exclusion criteria,total of 1335 AP patients were finally included,including 674 patients with mild acute pancreatitis(MAP),595 patients with MSAP and 66 patients with SAP.Among them,MSAP patients were divided into four groups according to local complications and transient organ failure(TOF),including single acute peripancreatic fluid collection(APFC)without TOF group,multiple APFC without TOF group,other local complications other than APFC without TOF group,and TOF group.The baseline data and the severity of AP among the four subgroups were compared.Meanwhile,the severity of the disease was compared between the single APFC group and the MAP group and between the TOF group and the SAP group.Logistic regression analysis was employed to explore the influencing factors associated with MSAP and TOF,and to compare the odds ratio(OR)of each independent risk factor.Receiver operating characteristic(ROC)curves were used to compare the area under the curve(AUC)of predicting MSAP and TOF by common scoring systems(acute physiology and chronic health evaluation Ⅱ(APACHE Ⅱ),bedside index for severity in AP(BISAP),Glasgow)and laboratory indicators(Ca2+,lactate dehydrogenase(LDH),glucose(GLU),C-reactive protein(CRP),procalcitonin(PCT),blood urea nitrogen(BUN)),and to determine the efficiency,sensitivity and specificity of each index.Results1.Baseline characteristics in different subgroups of MSAP:A total of 1335 patients diagnosed with AP were included in this study.Among them,595 patients with MSAP were divided into four subgroups for comparison of baseline data according to local complications and TOF.The results showed that patients in the TOF group were older than in the other three groups(P<0.05),while there were no significant differences in gender,BMI,etiology,past history,drinking history and smoking history in the four subgroups(P>0.05).APFC was the most common local complication in MSAP patients and TOF group,and acute necrotic collection(ANC)was the most common complication in the other local complications group.2.Severity of disease in different subgroups of MSAP:In terms of scoring systems,there were statistically significant differences among the four subgroups(P<0.05).The proportions of APACHE Ⅱ≥8,Glasgow≥3 and BISAP≥3 in the TOF group were much higher than in the other three groups,while the proportions of these three systems were the lowest in the single APFC group.In terms of laboratory indicators,there were significant differences in the levels of Ca2+,LDH,PCT and BUN among the four subgroups(P<0.05).The level of Ca2+in the single APFC group was the highest,while the levels of LDH,PCT and BUN were the lowest.In terms of clinical outcomes,the length of hospital stays and hospitalization costs in the single APFC group were also lower than in the other three groups,however,those were highest in the TOF group(P<0.05).One patient in the other local complications group was admitted to ICU for 4 days,while three patients in the TOF group were admitted to ICU for 3,5,and 7 days,respectively.The ICU admission rate in the TOF group was significantly higher than in the multiple APFC group(P<0.05).The mortality among all four subgroups was 0.3.The severity of disease in single APFC patients versus MAP patients:There were no statistically significant differences in scoring systems(APACHE Ⅱ≥8,Glasgow≥3,BISAP≥3)and laboratory indicators(LDH,GLU,PCT,BUN)between the single APFC patients and MAP patients(P>0.05)and no patients were admitted to ICU or died in both groups.Compared with the MAP group,the level of Ca2+ was significantly lower,the level of CRP,length of hospitalization and hospitalization costs were significantly higher in the single APFC group(P<0.05).4.The severity of disease in TOF patients versus SAP patients:The incidence OF(respiratory failure,renal failure),the proportion of the scoring system(Glasgow≥3),the levels of laboratory indicators(LDH,GLU,BUN),and the clinical outcomes(hospitalization cost,ICU occupancy rate,the length of ICU stays)in the TOF group were significantly lower than in the SAP group(P<0.05).The level of Ca2+in the TOF group was significantly higher than in the SAP group(P<0.05).In addition,the incidence of local complications in the TOF group was lower than that in the SAP group,but there was no significant statistical difference(P>0.05).5.Influencing factors of MSAP and TOF:Age>60 years,gender,hypertension,coronary heart disease,diabetes,alcoholism,smoker,AP recurrence≥2 times,TG≥5.65mmol/L and positive systemic inflammatory response syndrome(SIRS)were included in the logistic regression model as independent variables.The dependent variable was whether MSAP or TOF occurred.Multivariate logistic regression analysis showed that TG≥5.65mmol/L(OR=1.408，95%CI 1.076-1.844)and positive SIRS(OR=2.238,95%CI 1.633-3.067)were independent risk factors for MSAP patients,and positive SIRS seemed to be more dangerous.Age>60 years(OR=4.467,95%CI 2.182-9.145)and positive SIRS(OR=5.021,95%CI 2.622-9.616)were independent risk factors for TOF patients.Moreover,positive SIRS seemed to be more dangerous.6.Predictors of MSAP and TOF:Common scoring systems and laboratory indicators were statistically significant in predicting the occurrence of MSAP(P<0.001).CRP had the highest efficiency(AUC=0.692,P<0.001)for the prediction of MSAP,and the sensitivity and specificity were 62.25%and 68.68%,respectively.All the other indicators except GLU had statistical significance in predicting the occurrence of TOF(P<0.05).BISAP had the highest efficiency for the prediction of TOF(AUC=0.792,P<0.001),and the sensitivity and specificity were 61.90%and 83.79%,respectively.Conclusions1.MSAP patients with only single APFC without TOF showed significantly milder and tended to be MAP.On the contrary,MSAP patients with TOF showed relatively more severe.2.TG≥5.65mmol/L and positive SIRS were independent risk factors for MSAP patients.Age>60 years and positive SIRS were independent risk factors for TOF patients.3.For the prediction of MSAP,the efficiency of common scoring systems and laboratory indicators was low.For the prediction of TOF,BISAP had the highest efficiency and was a good predictor.