Chronic liver injury scores are superior prognostic indicators of outcomes in severe alcohol-related burns – Nature

Report on Prognostic Indicators in Severe Alcohol-Related Burns with Emphasis on Sustainable Development Goals (SDGs)

Abstract

This retrospective study conducted at a supraregional burn center in Northern Germany from 2007 to 2024 assessed the prognostic value of blood alcohol concentration (BAC) and non-invasive liver fibrosis scores in burn patients. Among 121 patients with large-surface burns, BAC showed no significant predictive value for mortality, whereas liver fibrosis markers such as the Fibrosis-4 (FIB-4) score and Aspartate Transaminase-to-Platelet Ratio Index (APRI) demonstrated strong prognostic accuracy. Multivariate analysis identified the Abbreviated Burn Severity Index (ABSI), serum albumin, and FIB-4 score as independent mortality predictors. The study recommends routine screening for chronic liver dysfunction in burn patients to improve risk stratification and outcomes, aligning with SDG 3: Good Health and Well-being.

Introduction

Alcohol consumption contributes to approximately 2.6 million deaths annually worldwide, impacting liver and cardiovascular health and increasing risks of cancer and behavioral disorders. Burn injuries affect around 8 million people yearly, with up to 40% presenting elevated BAC at admission. Both acute and chronic alcohol abuse impair immune response and healing, exacerbating burn outcomes. Chronic liver disease (CLD), including alcohol-related liver disease, is a significant global health concern affecting 1.5 billion people and is linked to increased surgical risk and mortality.

This study focuses on evaluating the impact of BAC and chronic liver injury (CLI) markers on burn outcomes, addressing a gap in current injury scoring systems that omit these factors. This approach supports SDG 3 by aiming to enhance healthcare quality and outcomes for vulnerable populations.

Methods

Study Design

1. Retrospective cross-sectional analysis of adult burn patients admitted with positive BAC.
2. Patients categorized into low (<100 mg/dL) and high (≥100 mg/dL) BAC groups.
3. Non-invasive liver fibrosis scores (FIB-4, APRI, NAFLD fibrosis score) calculated from admission laboratory data.
4. Propensity score matching performed to adjust for confounders such as burn size and depth.
5. Statistical analyses included logistic regression and receiver operating characteristic (ROC) curve assessments.

Ethical Considerations

The study was approved by the local ethics committee, with informed consent obtained, ensuring compliance with ethical standards and contributing to SDG 16: Peace, Justice, and Strong Institutions.

Results

Patient Demographics and Burn Characteristics

• 121 patients included; 77.9% male; mean age 44.4 years.
• Higher smoking prevalence and comorbidities in the high BAC group.
• Burn etiology predominantly flame exposure (77.7%).
• More severe burns (deep partial-thickness and full-thickness) observed in high BAC group.
• No significant differences in total body surface area burned or ABSI scores between BAC groups.

Admission Characteristics

• Admissions with low BAC peaked in summer months; high BAC admissions more frequent in autumn to spring.
• Most admissions occurred during night shifts, with no significant difference between groups.

Outcomes

• Mean hospital stay: 15.19 days; no significant difference between BAC groups.
• ICU admission required in 81.1% of patients; similar rates across BAC groups.
• Mortality rate was 14%, with no significant difference between BAC groups.
• Propensity score matching confirmed no independent association of BAC with mortality after adjustment.

Analysis Using Non-Invasive Laboratory Scores for Chronic Liver Injury (CLI)

• FIB-4 score showed highest predictive accuracy for mortality (AUC=0.781), followed by APRI (AUC=0.736).
• MELD and NAFLD fibrosis scores had limited predictive value.
• Serum ethanol concentration did not predict mortality effectively (AUC=0.547).
• Patients with intermediate to high FIB-4 risk were older, had more severe burns, comorbidities, and higher mortality (24.4% vs. 5.9%).
• Propensity score matching indicated clinically relevant mortality differences based on FIB-4 risk, supporting its prognostic utility.

Predictors of Mortality: Bivariate and Multivariate Analyses

• Significant mortality predictors included age, BMI, bilirubin, AST, FIB-4 score, mechanical ventilation, pneumonia, and wound infection.
• Multivariate analysis identified ABSI (OR=2.42), serum albumin (OR=0.29), and FIB-4 score (OR=1.50) as independent predictors.
• Combining FIB-4 with ABSI improved mortality prediction models, highlighting the importance of chronic liver dysfunction in burn prognosis.

Discussion

This study emphasizes that chronic liver injury markers, particularly the FIB-4 score, are superior to acute BAC levels in predicting mortality in severe alcohol-related burn patients. The findings advocate for integrating liver fibrosis assessment into burn severity scoring systems to enhance risk stratification and clinical decision-making, aligning with SDG 3 by promoting health and well-being.

Implications for Sustainable Development Goals

• SDG 3 (Good Health and Well-being): Early identification of high-risk burn patients through non-invasive liver fibrosis markers can improve treatment outcomes and reduce mortality.
• SDG 10 (Reduced Inequalities): Addressing alcohol-related health disparities by incorporating chronic liver disease screening in burn care.
• SDG 16 (Peace, Justice, and Strong Institutions): Ethical conduct and data privacy maintained throughout the study, ensuring responsible research practices.

Recommendations

1. Implement routine FIB-4 and APRI screening for burn patients, especially those with elevated BAC.
2. Revise burn severity scoring systems to include chronic liver dysfunction markers.
3. Develop targeted interventions for patients with chronic liver injury to improve long-term recovery.
4. Promote patient education and alcohol withdrawal management as part of rehabilitation programs.
5. Conduct multicenter prospective studies to validate findings and standardize liver function assessment protocols.

Limitations

• Single-center retrospective design limits generalizability.
• Potential selection bias due to non-standardized BAC testing.
• Small sample size may limit statistical power.
• Use of non-invasive liver fibrosis markers without invasive confirmation.

Conclusion

The study concludes that non-invasive liver fibrosis scores, particularly the FIB-4 score, provide valuable prognostic information in severe alcohol-related burn patients beyond acute alcohol intoxication. Incorporating these markers into clinical practice supports improved patient outcomes and aligns with global health objectives under the Sustainable Development Goals.

1. Sustainable Development Goals (SDGs) Addressed or Connected to the Issues Highlighted in the Article

1. SDG 3: Good Health and Well-being

   • The article focuses on health outcomes related to acute and chronic alcohol abuse, chronic liver injury, and burn injuries.
   • It addresses mortality, morbidity, and healthcare interventions in burn patients with alcohol-related complications.
   • It emphasizes improving prognostic tools and clinical management to enhance patient survival and recovery.

2. SDG 6: Clean Water and Sanitation (Indirectly)

   • While not directly discussed, prevention of infections in burn patients (wound infections, pneumonia) relates to sanitation and infection control.

3. SDG 10: Reduced Inequalities

   • The article highlights the burden of alcohol abuse and chronic liver disease among burn patients, a vulnerable population that may face health disparities.
   • Improving risk stratification and targeted interventions can reduce inequalities in health outcomes.

4. SDG 17: Partnerships for the Goals

   • The study calls for multicenter research and standardized protocols, implying collaboration and partnerships in health research.

2. Specific Targets Under Those SDGs Identified Based on the Article’s Content

1. SDG 3: Good Health and Well-being

   • Target 3.4: By 2030, reduce by one third premature mortality from non-communicable diseases through prevention and treatment and promote mental health and well-being.
   • Target 3.8: Achieve universal health coverage, including financial risk protection and access to quality essential health-care services.
   • Target 3.c: Substantially increase health financing and recruitment, development, training and retention of the health workforce in developing countries.

2. SDG 10: Reduced Inequalities

   • Target 10.2: Empower and promote the social, economic and political inclusion of all, irrespective of age, sex, disability, race, ethnicity, origin, religion or economic or other status.

3. SDG 17: Partnerships for the Goals

   • Target 17.6: Enhance North-South, South-South and triangular regional and international cooperation on and access to science, technology and innovation.
   • Target 17.18: Enhance capacity-building support to developing countries to increase significantly the availability of high-quality, timely and reliable data.

3. Indicators Mentioned or Implied in the Article to Measure Progress Towards the Identified Targets

1. Health Outcome Indicators (SDG 3)

   • Mortality rate among burn patients, particularly those with alcohol-related liver injury.
   • Length of hospital stay and ICU admission rates.
   • Incidence of postoperative complications such as wound infections and pneumonia.
   • Predictive accuracy (Area Under Curve – AUC) of non-invasive liver fibrosis scores (FIB-4, APRI) for mortality risk.
   • Prevalence of chronic liver disease and alcohol abuse in burn patients.

2. Health System and Service Indicators (SDG 3.8)

   • Integration of liver fibrosis markers into burn severity scoring systems for improved risk stratification.
   • Implementation of routine screening protocols for liver function in burn centers.

3. Research and Data Quality Indicators (SDG 17)

   • Use of multicenter, standardized protocols for BAC testing and liver function assessment.
   • Availability of anonymized patient data for research purposes.

4. Equity Indicators (SDG 10)

   • Prevalence of comorbidities such as alcohol abuse, drug abuse, and psychiatric disorders among burn patients.
   • Access to specialized burn care and rehabilitation services for vulnerable populations.

4. Table of SDGs, Targets, and Indicators

SDGs	Targets	Indicators
SDG 3: Good Health and Well-being	3.4: Reduce premature mortality from non-communicable diseases. 3.8: Achieve universal health coverage. 3.c: Increase health workforce capacity.	Mortality rate in burn patients with alcohol-related liver injury. Length of hospital and ICU stay. Incidence of postoperative complications (wound infections, pneumonia). Predictive accuracy of liver fibrosis scores (FIB-4, APRI) for mortality (AUC values). Prevalence of chronic liver disease and alcohol abuse in burn patients. Integration of liver function screening in burn care protocols.
SDG 10: Reduced Inequalities	10.2: Promote social, economic, and political inclusion of all.	Prevalence of comorbidities (alcohol abuse, drug abuse, psychiatric disorders) in burn patients. Access to specialized burn and rehabilitation services.
SDG 17: Partnerships for the Goals	17.6: Enhance international cooperation on science and technology. 17.18: Increase availability of high-quality, timely data.	Use of multicenter, standardized protocols for BAC and liver function testing. Availability and sharing of anonymized patient data for research.

Source: nature.com