Early Changes in Blood Urea Nitrogen Predict Mortality in Acute Pancreatitis

doi:10.1053/j.gastro.2009.03.056

Gastroenterology

Volume 137, Issue 1, July 2009, Pages 129-135

https://doi.org/10.1053/j.gastro.2009.03.056 Get rights and content

Background & Aims

Routine laboratory tests that reflect intravascular volume status can play an important role in the early assessment of acute pancreatitis (AP). The objective of this study was to evaluate accuracy of serial blood urea nitrogen (BUN) versus serial hemoglobin (Hgb) measurement for prediction of in-hospital mortality in AP.

Methods

We performed an observational cohort study on data from 69 US hospitals from January 2003 to December 2006. Repeated measures analysis was used to examine the relationship between early trends in BUN and Hgb with respect to mortality. Multivariate logistic regression was used to evaluate the impact of admission BUN, change in BUN, admission Hgb, and change in Hgb on mortality. Time-specific receiver operating characteristic curves and multivariable logistic regression compared accuracy of BUN, Hgb, and additional routine laboratory tests.

Results

BUN levels were persistently higher among nonsurvivors than survivors during the first 48 hours of hospitalization (F–test; P < .0001). No such relationship existed for Hgb (F–test; P = .33). For every 5-mg/dl increase in BUN during the first 24 hours, the age- and gender-adjusted odds ratio for mortality increased by 2.2 (95% confidence limits, 1.8, 2.7). Of the 6 routine laboratory tests examined, BUN yielded the highest area under the concentration–time curve (AUC) for predicting mortality at admission (AUC = 0.79), 24 hours (AUC = 0.89), and 48 hours (AUC = 0.90). Combining admission BUN and change in BUN at 24 hours produced an AUC of 0.91 for mortality.

Conclusion

In a large, hospital-based cohort study, we identified serial BUN measurement as the most valuable single routine laboratory test for predicting mortality in AP.

Section snippets

Setting and Patient Data

The present study was approved by the Brigham and Women's Institutional Review Board. We obtained patient data from the Cardinal Health Clinical Outcomes Research Database (Cardinal Health, Marlborough, MA). This dataset has supported public reporting of hospital performance in Pennsylvania and elsewhere for 20 years. Details of the data collection and abstraction process for the Cardinal database have been previously described.16, 17, 18 The database contains information on patient

Results

We identified a total of 13,384 AP cases by ICD-9-CM code (577.0). There were 5819 AP cases with ≥3 BUN and Hgb measurements within 48 hours of admission. Table 1 shows the patient demographics, admission laboratory data, and outcomes of the overall AP population and study cohort. There were no meaningful differences in demographic or admission laboratory data between the study cohort and overall population. However, length of stay (median, 6.7 vs 4 days; t test; P < .0001), frequency of

Discussion

In a large, hospital-based, observational cohort study, we have compared the accuracy of serial BUN versus serial Hgb measurement for prediction of mortality in AP. First, we demonstrated that mean BUN levels were persistently elevated among nonsurvivors versus survivors of AP during the first 48 hours of hospitalization. Second, an elevated admission BUN and a rise in BUN within the first 24 hours of hospitalization were both independently associated with increased mortality after controlling

Acknowledgements

The authors acknowledge the contributions of Linda Hyde and Karen Derby of Cardinal Health for their assistance with data management. We also thank Rie Maurer, MS, from the Division of Gastroenterology and General Clinical Research Center at Brigham and Women's Hospital for statistical consultation. We further thank Dr Tianxi Cai, PhD, from the Harvard School of Public Health for assistance with initial study design.

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: This work was developed as part of the Laboratory Evaluation of Acute Pancreatitis (LEAP) study.

: Conflicts of interest The authors disclose no conflicts.

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Clinical—Liver, Pancreas, and Biliary TractEarly Changes in Blood Urea Nitrogen Predict Mortality in Acute Pancreatitis

Background & Aims

Methods

Results

Conclusion

Section snippets

Setting and Patient Data

Results

Discussion

Acknowledgements

Pancreatology

Am J Gastroenterol

Pancreatology

Am J Gastroenterol

Pancreatology

Pancreatology

Clin Lab Med

Lancet

Practice guidelines in acute pancreatitis

Am J Gastroenterol

The Pancreatitis Outcome Prediction (POP) Score: a new prognostic index for patients with severe acute pancreatitis

Crit Care Med

UK guidelines for the management of acute pancreatitis

Gut

IAP guidelines in acute pancreatitis

Dig Surg

JPN Guidelines for the management of acute pancreatitis: medical management of acute pancreatitis

J Hepatobiliary Pancreat Surg

Acute pancreatitis: bench to the bedside

Gastroenterology

Pancreatic microcirculatory changes in experimental pancreatitis of graded severity in the rat

Surgery

Microcirculatory function and tissue damage is improved after therapeutic injection of bovine hemoglobin in severe acute rodent pancreatitis

Pancreas

Volume assessment in patients with necrotizing pancreatitis: a comparison of intrathoracic blood volume index, central venous pressure, and hematocrit, and their correlation to cardiac index and extravascular lung water index

Crit Care Med

Applying Ockham's razor to pancreatitis prognostication: a four-variable predictive model

Ann Surg

The early prediction of mortality in acute pancreatitis: a large population-based study

Gut

Clinical—Liver, Pancreas, and Biliary Tract
Early Changes in Blood Urea Nitrogen Predict Mortality in Acute Pancreatitis