Direct Bilirubin Is More Valuable than Total Bilirubin for Predicting Prognosis in Patients with Liver Cirrhosis

Han Ah Lee, Joon Young Jung, Young-Sun Lee, Young Kul Jung, Ji Hoon Kim, Hyonggin An, Hyung Joon Yim, Yoon Tae Jeen, Jong Eun Yeon, Kwan Soo Byun, Soon Ho Um, Yeon Seok Seo, Han Ah Lee, Joon Young Jung, Young-Sun Lee, Young Kul Jung, Ji Hoon Kim, Hyonggin An, Hyung Joon Yim, Yoon Tae Jeen, Jong Eun Yeon, Kwan Soo Byun, Soon Ho Um, Yeon Seok Seo

Abstract

Background/aims: Most prognostic prediction models for patients with liver cirrhosis include serum total bilirubin (TB) level as a component. This study investigated prognostic performance of serum direct bilirubin (DB) and developed new DB level-based prediction models for cirrhosis.

Methods: A total of 983 hospitalized patients with liver cirrhosis were included. DB-Model for End-Stage Liver Disease (MELD) score was calculated using MELD score formula, with serum DB level replacing TB level.

Results: Mean age of study population was 56.1 years. Alcoholic liver disease was the most frequent underlying condition (471 patients, 47.9%). Within 6 months, 144 patients (14.6%) died or received liver transplantation due to severe liver dysfunction. The area under the receiver operating characteristic curve (AUROC) for prediction of 6-month mortality with DB level was significantly higher than that with TB level (p<0.001). The AUROC of DB-MELD score for prediction of 6-month mortality was significantly higher than that of MELD score (p<0.001). Patients were randomly divided into training (n=492) and validation (n=491) cohorts. A new prognostic prediction model, "Direct Bilirubin, INR, and Creatinine" (DiBIC) score, was developed based on the most significant predictors of 6-month mortality. In training set, AUROC of DiBIC score for prediction of 6-month mortality was 0.892, which was significantly higher than that of the MELD score (0.875, p=0.017), but not different from that of DB-MELD score (0.886, p=0.272). Similar results were observed in validation set.

Conclusions: New prognostic models, DB-MELD and DiBIC scores, have good prognostic performance in liver cirrhosis patients, outperforming other currently available models.

Keywords: Direct bilirubin; Liver cirrhosis; Prediction model; Prognosis.

Conflict of interest statement

CONFLICTS OF INTEREST

No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1
Fig. 1
Flowchart of the patient population.
Fig. 2
Fig. 2
The receiver operating characteristic curves for the prediction of 6-month mortality with (A) total bilirubin and direct bilirubin; (B) the MELD and DB-MELD scores in patients with cirrhosis. MELD, Model for End-Stage Liver Disease; DB, direct bilirubin.
Fig. 3
Fig. 3
The receiver operating characteristic curves for the prediction of 6-month mortality with the MELD and DB-MELD scores in the training set (A) and the validation set (B). MELD, Model for End-Stage Liver Disease; DB, direct bilirubin; INR, international normalized ratio; DiBIC, Direct Bilirubin, INR, and Creatinine.

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