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Risk assessment in sepsis: a new prognostication rule by APACHE II score and serum soluble urokinase plasminogen activator receptor

Evangelos J Giamarellos-Bourboulis1*, Anna Norrby-Teglund2, Vassiliki Mylona3, Athina Savva1, Iraklis Tsangaris4, Ioanna Dimopoulou4, Maria Mouktaroudi1, Maria Raftogiannis1, Marianna Georgitsi1, Anna Linnér2, George Adamis5, Anastasia Antonopoulou14, Efterpi Apostolidou6, Michael Chrisofos7, Chrisostomos Katsenos8, Ioannis Koutelidakis9, Katerina Kotzampassi10, George Koratzanis3, Marina Koupetori11, Ioannis Kritselis12, Korina Lymberopoulou3, Konstantinos Mandragos8, Androniki Marioli3, Jonas Sundén-Cullberg2, Anna Mega13, Athanassios Prekates14, Christina Routsi15, Charalambos Gogos16, Carl-Johan Treutiger2, Apostolos Armaganidis4 and George Dimopoulos4

Author Affiliations

1 4th Department of Internal Medicine, University of Athens, Medical School, 12462 Athens, Greece

2 Center for Infectious Medicine F59, Karolinska Institutet, 14186 Stockholm, Sweden

3 2nd Department of Internal Medicine, 'Sismanogleion' Athens Hospital, 15126 Athens Greece

4 2nd Department of Critical Care, University of Athens, Medical School, 12462 Athens, Greece

5 1st Department of Internal Medicine, 'G. Gennimatas' Athens Hospital, 115 27 Athens, Greece

6 Intensive Care Unit, Ptolemaida General Hospital, 50400, Ptolemaida, Greece

7 2nd Department of Urology, University of Athens, Medical School, 15126 Athens, Greece

8 Intensive Care Unit, 'Korgialeneion-Benakeion' Athens Hospital, 11526 Athens, Greece

9 2nd Department of Surgery, University of Thessaloniki, Medical School, 54635 Thessaloniki, Greece

10 1st Department of Propedeutic Surgery, University of Thessaloniki, Medical School, 54635 Thessaloniki, Greece

11 1st Department of Internal Medicine, 'Thriassio' Elefsina General Hospital, 19600 Magoula, Greece

12 Department of Surgery, Nafplion General Hospital, 21100 Nafplion, Greece

13 Intensive Care Unit, 'Laikon' Athens General Hospital, 11527 Athens, Greece

14 Intensive Care Unit, 'Tzaneion' Hospital of Piraeus, 18536 Piraeus, Greece

15 1st Department of Critical Care, University of Athens, Medical School, 10676 Athens, Greece

16 1st Department of Internal Medicine, University of Patras, Medical School, 26504 Rion, Greece

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Critical Care 2012, 16:R149  doi:10.1186/cc11463

Published: 8 August 2012

Abstract

Introduction

Early risk assessment is the mainstay of management of patients with sepsis. APACHE II is the gold standard prognostic stratification system. A prediction rule that aimed to improve prognostication by APACHE II with the application of serum suPAR (soluble urokinase plasminogen activator receptor) is developed.

Methods

A prospective study cohort enrolled 1914 patients with sepsis including 62.2% with sepsis and 37.8% with severe sepsis/septic shock. Serum suPAR was measured in samples drawn after diagnosis by an enzyme-immunoabsorbent assay; in 367 patients sequential measurements were performed. After ROC analysis and multivariate logistic regression analysis a prediction rule for risk was developed. The rule was validated in a double-blind fashion by an independent confirmation cohort of 196 sepsis patients, predominantly severe sepsis/septic shock patients, from Sweden.

Results

Serum suPAR remained stable within survivors and non-survivors for 10 days. Regression analysis showed that APACHE II ≥17 and suPAR ≥12 ng/ml were independently associated with unfavorable outcome. Four strata of risk were identified: i) APACHE II <17 and suPAR <12 ng/ml with mortality 5.5%; ii) APACHE II < 17 and suPAR ≥12 ng/ml with mortality 17.4%; iii) APACHE II ≥ 17 and suPAR <12 ng/ml with mortality 37.4%; and iv) APACHE II ≥17 and suPAR ≥12 ng/ml with mortality 51.7%. This prediction rule was confirmed by the Swedish cohort.

Conclusions

A novel prediction rule with four levels of risk in sepsis based on APACHE II score and serum suPAR is proposed. Prognostication by this rule is confirmed by an independent cohort.