Beyond SOFA Alone: Integrating Inflammatory Burden and Nutritional-Immune Reserve to Refine ICU Mortality Risk Stratification
Keywords:
critical illness, intensive care unit, SOFA score, C-reactive protein, Prognostic nutritional index, ICU mortality, prognostic biomarkersAbstract
Abstract.
Background and aim: Mortality in critically ill patients is influenced by organ dysfunction, systemic inflammation, and nutritional–immune status. This study aimed to compare the prognostic performance of the Prognostic Nutritional Index (PNI), albumin-derived neutrophil-to-lymphocyte ratio (Alb-dNLR) score, C-reactive protein (CRP), procalcitonin (PCT), and Sequential Organ Failure Assessment (SOFA) score for predicting ICU mortality and to evaluate whether inflammatory and nutritional–immune markers provide incremental prognostic value beyond SOFA alone.
Methods: This retrospective cohort study included 276 patients admitted to the ICU of Dr. Wahidin Sudirohusodo Hospital, Makassar, Indonesia. Prognostic performance was evaluated using Receiver operating characteristic (ROC) analysis, multivariable logistic regression, combined predictive models, calibration testing, and DeLong pairwise AUC comparison.
Results: ICU mortality occurred in 161 patients (58.3%). SOFA score demonstrated the highest discrimination (AUC 0.738), followed by CRP (0.670) and PNI (0.616). In multivariable analysis, SOFA (OR 1.446, P<0.001), CRP (OR 1.009, P<0.001), and PNI (OR 0.956, P=0.016) were independently associated with mortality. The SOFA+CRP model significantly improved discrimination over SOFA alone (ΔAUC 0.0489, P=0.0115). The multidomain SOFA+CRP+PNI model showed the highest AUC (0.793)
Conclusions: ICU mortality risk was better characterized through a multidomain approach integrating organ dysfunction, systemic inflammation, and nutritional–immune vulnerability. SOFA remained the core prognostic marker, CRP provided the clearest incremental value, and PNI offered complementary prognostic information. Prospective validation is required before clinical implementation.
Key words: critical illness; intensive care unit; SOFA score; C-reactive protein; prognostic nutritional index; ICU mortality; prognostic biomarkers
Running Title: Multidomain Prognosis in ICU Mortality
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