LAUSR

I thank Drs. Huang and Windsor (1) for their interest in our study (2) and ensuing discussion. I agree with the opinion that the development of infected pancreatic necrosis (IPN) is a very important prognostic factor in the evolution of acute pancreatitis and should be considered in its classification. Nevertheless, I want to make two considerations. First, IPN is not the only important local complication and should be considered together with intraabdominal hemorrhage and intestinal perforation (3), in a variable called “local complications.” Second, it is important to consider the association with organ failure, especially if it is persistent. According to our data, patients with acute pancreatitis in critical care show four different clinical patterns and could be separated in four categories. Group 1: patients with transient organ failure, without local complications, and with low morbidity and mortality. Group 2: patients with transient organ failure and local complications, with high morbidity and low mortality. Group 3: patients with persistent organ failure and without local complications, with low morbidity, and with high mortality. Group 4: patients with persistent organ failure and local complications and with high morbidity and mortality. Patients in groups 2 and 3 should not be considered in the same category, as Determinant-Based Classification does. Another difficult topic is the classification of patients with aggressive presentation, developing severe organ failure in the first 48 hours of evolution (Fulminant or Early Severe Acute Pancreatitis), particularly if they die in this period. I agree with the inclusion of these patients in the category of severe acute pancreatitis (group 3 in our proposal) if they meet also a severity criterion (enough to endanger the life of the patient). The approach proposed by authors is not sufficient in my opinion, due to the fact that patients with two or more organ dysfunctions can evolve favorably with standard measures in a short time. I suggest using an organ failure score value, with a cutpoint predicting a high mortality, such as a Sequential Organ Failure Assessment higher than 9 points (predicted mortality higher of 40%) (4) or a multiple organ dysfunction syndrome score higher than 9 points (predicted mortality of 50%) (5). The author has disclosed that he does not have any potential conflicts of interest.