Akash Deep

Anil Dhawan

Chulananda Goonasekera

Claire Elizabeth Matthews

DA Sass

MH Zweig

NP Shanmugam

RH Squires Jr

S Bansal

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Matthews et al. Critical Care 2014, 18:665http://ccforum.com/content/18/6/665LETTERValidity of pediatric index of mortality 2 (PIM2)score in pediatric acute liver failureClaire Elizabeth Matthews1, Chulananda Goonasekera2, Anil Dhawan2 and Akash Deep2*IntroductionPediatric acute liver failure (PALF) is an aggressive clinicalsyndrome in which a previously healthy child rapidly loseshepatic function and can become critically ill within days[1,2]. The mortality rate has been reported as high as 70%without a liver transplant, which is the only curativetreatment to date [3]. However, when the current criterionof an international normalized ratio of more than 4 forlisting for transplantation is used, 10% who are listedspontaneously recover and another 10% die while waitingto be listed [4]. This has serious implications for scarcedonor organs and the risk of subjecting a child tounnecessary transplantation, surgical complications, andlifelong immunosuppression. The underlying challenge isto identify early enough those with PALF for whomchances of survival without a transplant are null, so thatthese can be super-urgently listed. As such, early mortalityprediction is as important as the criteria for listing fortransplantation.The goal of the present study was to investigate theprognostic accuracy of the commonly used mortalityprediction score known as pediatric index of mortality 2(PIM2). PIM2 uses 10 variables on admission to thepediatric intensive care unit (PICU) to assess risk ofmortality and in the UK is used as a measure of thequality of service. All children who were admitted to thePICU at King’s College Hospital between 2003 and 2013and who had PALF as defined by the PALF study group[1] were entered into a database which records routinelycollected data that included daily clinical, biochemical,and treatment variables. We compared PIM2 scores onadmission to 28-day survival with or without transplantation.As this was a retrospective analysis of routinely collectedanonymized data, ethical approval or informed consentwas not required. This study has been registered as aservice evaluation project at King’s College Hospital.* Correspondence: akash.deep@nhs.net2King’s College Hospital, Denmark Hill, London SE5 9RS, UKFull list of author information is available at the end of the article© 2014 Matthews et al.; licensee BioMed CentCommons Attribution License (http://creativecreproduction in any medium, provided the orDedication waiver (http://creativecommons.orunless otherwise stated.FindingsOne hundred and three children (55 males; medianage 2 years, age range 0 to 19 years) were included.Forty-three received a liver transplant; of these, fivedied (mortality of 11.6%). Of the 60 who were nottransplanted, 20 died (mortality of 33.3%). A receiveroperating characteristic (ROC) curve was developedby using the study population and their outcomes. Anarea under the curve (AUC) of more than 0.75 wasconsidered clinically useful [5]. The AUC in transplantedchildren was 0.346 (95% confidence interval (CI) 0.000 to0.671), suggesting that PIM2 is of absolutely no value inpredicting mortality in transplanted children. In thenon-transplanted group, the AUC of ROC was 0.712(95% CI 0.561 to 0.864), which was not sensitive or specificenough to minimize the risk of wrong categorization fortransplantation.Thus, we conclude that PIM2 is not fit for use inPALF as it neither predicts mortality nor identifieschildren in need of liver transplantation. It may alsobias the quality assessment of PICUs in liver centers.As such, the quest for a better predictive score inPALF continues.AbbreviationsAUC: Area under the curve; CI: Confidence interval; PALF: Pediatric acute liverfailure; PICU: Pediatric intensive care unit; PIM2: Pediatric index of mortality 2;ROC: Receiver operating characteristic.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsCEM carried out the data collection, interpreted the results, and drafted themanuscript. CG analyzed the data and performed the statistical analysis. ADhrevised the manuscript critically for intellectual content. ADe participated inthe design of the study and helped to draft the manuscript. All authors readand approved the final manuscript.AcknowledgmentsThe authors appreciate the help and support provided by all staff, PICU,King’s College Hospital, London.ral Ltd. This is an Open Access article distributed under the terms of the Creativeommons.org/licenses/by/4.0), which permits unrestricted use, distribution, andiginal work is properly credited. The Creative Commons Public Domaing/publicdomain/zero/1.0/) applies to the data made available in this article,Matthews et al. Critical Care 2014, 18:665 Page 2 of 2http://ccforum.com/content/18/6/665Author details1St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, UK. 2King’sCollege Hospital, Denmark Hill, London SE5 9RS, UK.References1. Squires RH Jr, Shneider BL, Bucuvalas J, Alonso E, Sokol RJ, Narkewicz MR,Dhawan A, Rosenthal P, Rodriguez-Baez N, Murray KF, Horslen S, Martin MG,Lopez MJ, Soriano H, McGuire BM, Jonas MM, Yazigi N, Shepherd RW,Schwarz K, Lobritto S, Thomas DW, Lavine JE, Karpen S, Ng V, Kelly D,Simonds N, Hynan LS: Acute liver failure in children: the first 348 patientsin the pediatric acute liver failure study group. J Pediatr 2006, 148:652–658.2. Sass DA, Shakil AO: Fulminant hepatic failure. Liver Transpl 2005,11:594–605.3. Bansal S, Dhawan A: Acute liver failure. Indian J Pediatr 2006, 73:931–934.4. Shanmugam NP, Dhawan A: Selection criteria for liver transplantation inpaediatric acute liver failure: the saga continues. Pediatr Transplant2011, 15:5–6.5. Zweig MH, Campbell G: Receiver-operating characteristic (ROC) plots:a fundamental evaluation tool in clinical medicine. Clin Chem 1993,39:561–577.doi:10.1186/s13054-014-0665-zCite this article as: Matthews et al.: Validity of pediatric index ofmortality 2 (PIM2) score in pediatric acute liver failure. Critical Care2014 18:665.

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Validity of pediatric index of mortality 2 (PIM2) score in pediatric acute liver failure

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Validity of pediatric index of mortality 2 (PIM2) score in pediatric acute liver failure

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