Prognostic value of blood urea nitrogen and high-density lipoprotein cholesterol combined with the quick Sequential Organ Failure Assessment for in-hospital mortality prediction in sepsis_West China Medical Journal

Authors：

LIU Shihao ^1,2 , ZHONG Zhitao ^2,3 ,  XU Ping ^1,2,3

1. Emergency Department, Affiliated Hospital of Southwest Medical University, Luzhou, Sichuan 646000, P. R. China;
2. Emergency Department, Zigong Fourth People’s Hospital, Zigong, Sichuan 643000, P. R. China;
3. Institute of Medical Big Data, Zigong Academy of Artificial Intelligence and Big Data for Medical Science, Zigong, Sichuan 643000, P. R. China;

Corresponding?author：

XU Ping, Email: xp1657@126.com

Keywords：

Sepsis; quick Sequential Organ Failure Assessment; blood urea nitrogen; high-density lipoprotein cholesterol; predictive model

DOI：

10.7507/1002-0179.202510002

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Objective To identify independent risk factors for in-hospital all-cause mortality in patients with sepsis and to integrate them into the quick Sequential Organ Failure Assessment (qSOFA) score to construct modified models, thereby improving the ability of the original qSOFA to predict mortality risk. Methods This retrospective study included adult patients who met the Sepsis-3 criteria for sepsis and were admitted to the Intensive Care Unit or Emergency Intensive Care Unit of Zigong Fourth People’ s Hospital between January 2018 and December 2023. Demographic characteristics, vital signs, comorbidities, and laboratory parameters were collected, and the Sequential Organ Failure Assessment (SOFA) and qSOFA scores were calculated. Multivariable logistic regression analysis was used to identify independent predictors of in-hospital mortality. Independent predictors were dichotomized according to cut-off values derived from receiver operating characteristic (ROC) curves and combined with qSOFA to construct new models. The ROC analysis with bootstrap validation was used to assess predictive performance, and comparative performance was further evaluated using net reclassification improvement (NRI) and integrated discrimination improvement (IDI). Results A total of 218 patients were included. Multivariable logistic regression analysis identified blood urea nitrogen (BUN) [odds ratio (OR)=1.100, 95% confidence interval (CI) (1.040, 1.170)] and qSOFA [OR=2.610, 95%CI (1.450, 4.920)] as independent risk factors for in-hospital mortality, whereas high-density lipoprotein cholesterol (HDL-C) was an independent protective factor [OR=0.250, 95%CI (0.065, 0.841)]. After dichotomization by ROC-derived cut-off values, BUN and HDL-C were incorporated into qSOFA to generate B-qSOFA, H-qSOFA, and BH-qSOFA. Bootstrap ROC analysis showed that BH-qSOFA exhibited the highest discriminatory ability compared with all combined models as well as the conventional SOFA and qSOFA scores [area under the curve=0.803, 95%CI (0.735, 0.863)]. NRI and IDI analyses demonstrated that BH-qSOFA provided incremental prognostic improvement over qSOFA (NRI=0.969, IDI=0.165), B-qSOFA (NRI=0.644, IDI=0.054), and H-qSOFA (NRI=0.804, IDI=0.091) (all P<0.05). Conclusions Elevated BUN and qSOFA and decreased HDL-C are independent predictors of in-hospital mortality in sepsis. The BH-qSOFA model is simple and clinically practical, exhibits superior predictive performance over the original qSOFA. It may serve as a useful early instrument for prognostic risk stratification in patients with sepsis.

Citation： LIU Shihao, ZHONG Zhitao, XU Ping. Prognostic value of blood urea nitrogen and high-density lipoprotein cholesterol combined with the quick Sequential Organ Failure Assessment for in-hospital mortality prediction in sepsis. West China Medical Journal, 2025, 40(11): 1754-1760. doi: 10.7507/1002-0179.202510002 Copy

1.	Cohen M, Banerjee D. Biomarkers in sepsis: a current review of new technologies. J Intensive Care Med, 2024, 39(5): 399-405.
2.	Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 2016, 315(8): 801-810.
3.	Cheng L, Cao Y, Liu S, et al. Unveiling the research advances of sepsis: pathogenesis, precise intervention and clinical perspective. Int J Surg, 2025, 111(9): 6260-6289.
4.	La Via L, Sangiorgio G, Stefani S, et al. The global burden of sepsis and septic shock. Epidemiologia (Basel), 2024, 5(3): 456-478.
5.	Fleischmann-Struzek C, Mellhammar L, Rose N, et al. Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis. Intensive Care Med, 2020, 46(8): 1552-1562.
6.	Su Y, Guo C, Zhou S, et al. Early predicting 30-day mortality in sepsis in MIMIC-III by an artificial neural networks model. Eur J Med Res, 2022, 27(1): 294.
7.	Zhong Z, Fan M, Lv L, et al. Inflammatory burden index as a predictor of mortality in septic patients: a retrospective study using the MIMIC-IV database. BMC Infect Dis, 2025, 25(1): 552.
8.	Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA, 2017, 317(3): 301-308.
9.	Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA, 2017, 317(3): 290-300.
10.	Ruan H, Ke D, Liao D. Prognostic accuracy of qSOFA and SIRS for mortality in the emergency department: a meta-analysis and systematic review of prospective studies. Emerg Med Int, 2022, 2022: 1802707.
11.	Lu J, Dong Z, Ye L, et al. Predictive value of SOFA, PCT, Lactate, qSOFA and their combinations for mortality in patients with sepsis: a systematic review and meta-analysis. PLoS One, 2025, 20(9): e0332525.
12.	Qiu X, Lei YP, Zhou RX. SIRS, SOFA, qSOFA, and NEWS in the diagnosis of sepsis and prediction of adverse outcomes: a systematic review and meta-analysis. Expert Rev Anti Infect Ther, 2023, 21(8): 891-900.
13.	范銘炎, 徐平, 呂祿楷, 等. 血清尿素氮水平對重癥監護室膿毒癥患者住院期間死亡風險的預測價值研究. 臨床急診雜志, 2025, 26(1): 55-60.
14.	Xu P, Ye L, Li L, et al. Comparison of the prognostic value, feasibility, and reproducibility among different scoring methods of 8-point lung ultrasonography in patients with acute heart failure. Intern Emerg Med, 2023, 18(8): 2321-2332.
15.	Li X, Zheng R, Zhang T, et al. Association between blood urea nitrogen and 30-day mortality in patients with sepsis: a retrospective analysis. Ann Palliat Med, 2021, 10(11): 11653-11663.
16.	楊光耀, 鄭文龍, 盛鷹, 等. 血尿素氮聯合快速序貫器官衰竭評分對老年膿毒癥患者預后的評估價值. 中國急救醫學, 2022, 42(3): 209-213.
17.	Taylor R, Zhang C, George D, et al. Low circulatory levels of total cholesterol, HDL-C and LDL-C are associated with death of patients with sepsis and critical illness: systematic review, meta-analysis, and perspective of observational studies. EBioMedicine, 2024, 100: 104981.
18.	Hofmaenner DA, Arina P, Kleyman A, et al. Association between hypocholesterolemia and mortality in critically ill patients with sepsis: a systematic review and meta-analysis. Crit Care Explor, 2023, 5(2): e0860.
19.	Min J, Lu J, Zhong L, et al. The correlation study between blood urea nitrogen to serum albumin ratio and prognosis of patients with sepsis during hospitalization. BMC Anesthesiol, 2022, 22(1): 404.
20.	Arihan O, Wernly B, Lichtenauer M, et al. Blood Urea Nitrogen (BUN) is independently associated with mortality in critically ill patients admitted to ICU. PLoS One, 2018, 13(1): e0191697.
21.	Rousseau AF, Martindale R. Nutritional and metabolic modulation of inflammation in critically ill patients: a narrative review of rationale, evidence and grey areas. Ann Intensive Care, 2024, 14(1): 121.
22.	Peerapornratana S, Manrique-Caballero CL, Gómez H, et al. Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney Int, 2019, 96(5): 1083-1099.
23.	Brunham LR. The role of high-density lipoproteins in sepsis. J Lipid Res, 2025, 66(1): 100728.
24.	Reisinger AC, Schuller M, Sourij H, et al. Impact of sepsis on high-density lipoprotein metabolism. Front Cell Dev Biol, 2022, 9: 795460.

1. Cohen M, Banerjee D. Biomarkers in sepsis: a current review of new technologies. J Intensive Care Med, 2024, 39(5): 399-405.
2. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA, 2016, 315(8): 801-810.
3. Cheng L, Cao Y, Liu S, et al. Unveiling the research advances of sepsis: pathogenesis, precise intervention and clinical perspective. Int J Surg, 2025, 111(9): 6260-6289.
4. La Via L, Sangiorgio G, Stefani S, et al. The global burden of sepsis and septic shock. Epidemiologia (Basel), 2024, 5(3): 456-478.
5. Fleischmann-Struzek C, Mellhammar L, Rose N, et al. Incidence and mortality of hospital- and ICU-treated sepsis: results from an updated and expanded systematic review and meta-analysis. Intensive Care Med, 2020, 46(8): 1552-1562.
6. Su Y, Guo C, Zhou S, et al. Early predicting 30-day mortality in sepsis in MIMIC-III by an artificial neural networks model. Eur J Med Res, 2022, 27(1): 294.
7. Zhong Z, Fan M, Lv L, et al. Inflammatory burden index as a predictor of mortality in septic patients: a retrospective study using the MIMIC-IV database. BMC Infect Dis, 2025, 25(1): 552.
8. Freund Y, Lemachatti N, Krastinova E, et al. Prognostic accuracy of Sepsis-3 criteria for in-hospital mortality among patients with suspected infection presenting to the emergency department. JAMA, 2017, 317(3): 301-308.
9. Raith EP, Udy AA, Bailey M, et al. Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA, 2017, 317(3): 290-300.
10. Ruan H, Ke D, Liao D. Prognostic accuracy of qSOFA and SIRS for mortality in the emergency department: a meta-analysis and systematic review of prospective studies. Emerg Med Int, 2022, 2022: 1802707.
11. Lu J, Dong Z, Ye L, et al. Predictive value of SOFA, PCT, Lactate, qSOFA and their combinations for mortality in patients with sepsis: a systematic review and meta-analysis. PLoS One, 2025, 20(9): e0332525.
12. Qiu X, Lei YP, Zhou RX. SIRS, SOFA, qSOFA, and NEWS in the diagnosis of sepsis and prediction of adverse outcomes: a systematic review and meta-analysis. Expert Rev Anti Infect Ther, 2023, 21(8): 891-900.
13. 范銘炎, 徐平, 呂祿楷, 等. 血清尿素氮水平對重癥監護室膿毒癥患者住院期間死亡風險的預測價值研究. 臨床急診雜志, 2025, 26(1): 55-60.
14. Xu P, Ye L, Li L, et al. Comparison of the prognostic value, feasibility, and reproducibility among different scoring methods of 8-point lung ultrasonography in patients with acute heart failure. Intern Emerg Med, 2023, 18(8): 2321-2332.
15. Li X, Zheng R, Zhang T, et al. Association between blood urea nitrogen and 30-day mortality in patients with sepsis: a retrospective analysis. Ann Palliat Med, 2021, 10(11): 11653-11663.
16. 楊光耀, 鄭文龍, 盛鷹, 等. 血尿素氮聯合快速序貫器官衰竭評分對老年膿毒癥患者預后的評估價值. 中國急救醫學, 2022, 42(3): 209-213.
17. Taylor R, Zhang C, George D, et al. Low circulatory levels of total cholesterol, HDL-C and LDL-C are associated with death of patients with sepsis and critical illness: systematic review, meta-analysis, and perspective of observational studies. EBioMedicine, 2024, 100: 104981.
18. Hofmaenner DA, Arina P, Kleyman A, et al. Association between hypocholesterolemia and mortality in critically ill patients with sepsis: a systematic review and meta-analysis. Crit Care Explor, 2023, 5(2): e0860.
19. Min J, Lu J, Zhong L, et al. The correlation study between blood urea nitrogen to serum albumin ratio and prognosis of patients with sepsis during hospitalization. BMC Anesthesiol, 2022, 22(1): 404.
20. Arihan O, Wernly B, Lichtenauer M, et al. Blood Urea Nitrogen (BUN) is independently associated with mortality in critically ill patients admitted to ICU. PLoS One, 2018, 13(1): e0191697.
21. Rousseau AF, Martindale R. Nutritional and metabolic modulation of inflammation in critically ill patients: a narrative review of rationale, evidence and grey areas. Ann Intensive Care, 2024, 14(1): 121.
22. Peerapornratana S, Manrique-Caballero CL, Gómez H, et al. Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment. Kidney Int, 2019, 96(5): 1083-1099.
23. Brunham LR. The role of high-density lipoproteins in sepsis. J Lipid Res, 2025, 66(1): 100728.
24. Reisinger AC, Schuller M, Sourij H, et al. Impact of sepsis on high-density lipoprotein metabolism. Front Cell Dev Biol, 2022, 9: 795460.

West China Medical Journal

Prognostic value of blood urea nitrogen and high-density lipoprotein cholesterol combined with the quick Sequential Organ Failure Assessment for in-hospital mortality prediction in sepsis

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