Comparison of MELD, Child-Pugh, and Emory model for the prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting

Prognostic factors for patients with cirrhosis and kidney dysfunction in the era of MELD: results of a prospective study

BACKGROUND/AIM

Hepatorenal syndrome (HRS) is associated with a poor prognosis. The incidence and prognostic impact of kidney dysfunction due to other causes in cirrhotic patients are less well known. The current study prospectively evaluated the incidence and the prognostic relevance of different etiologies of kidney failure in cirrhotic patients.

METHODS

Eighty-eight consecutive patients with cirrhosis and serum creatinine > or =1.5 mg/dl were enrolled. The etiologies of kidney dysfunction were analyzed, and prognostic factors including Model for End-Stage Liver Disease (MELD) score were evaluated in a multivariate Cox model.

RESULTS

HRS was present in 35 (40%) patients (15 HRS 1, 20 HRS 2), followed by renal parenchymal disease (23%), drug-induced kidney dysfunction (19%) and prerenal failure due to bleeding or infections (15%). HRS patients had a significantly higher MELD score and shorter survival. In addition to the MELD score, only HRS 1 was independently predictive for survival. HRS 2 patients had a similar outcome as patients with non-HRS kidney dysfunction.

CONCLUSIONS

In patients with cirrhosis and renal failure, hepatorenal syndrome is associated with a worse prognosis than kidney dysfunction due to other conditions but only HRS type 1 has independent prognostic relevance in addition to the MELD score in these patients.

Evaluation of model for end-stage liver disease for prediction of mortality in decompensated chronic hepatitis B

OBJECTIVES

We aimed to study the predictive ability of model for end-stage liver disease (MELD) for short-term mortality in chronic hepatitis B.

METHODS

All patients admitted from 1996 to 2003 because of chronic hepatitis B and its related complications were identified by electronic search of the hospital database. MELD and Child-Turcotte-Pugh (CTP) scores on initial admissions were calculated. Cox proportional hazard model was used to determine the factors associated with mortality. The area under receiver operator characteristics curve (AUC) was used to determine the predictive abilities of the two models for 3-month and 1-yr mortalities.

RESULTS

A total of 2,073 patients was admitted because of liver-related problems and 506 patients had chronic hepatitis B-related complications. Two hundred fifty-six (51%) patients died and 16 (3%) patients underwent liver transplantation. In multivariate analysis, MELD and CTP scores were independent predictors of 3-month and 1-yr mortality. Other independent predictors of mortality included older age, hepatocellular carcinoma (HCC), lamivudine treatment, and lower serum sodium. At both 3 months and 1 yr, the AUC of the MELD score (0.65 and 0.63, respectively) was significantly lower than that of the CTP score (0.75 and 0.77, respectively) (p < 0.0001). The differences remained significant when only liver cirrhosis patients without HCC at presentation were analyzed, but the AUC of the two scores became comparable when patients on lamivudine were excluded.

CONCLUSIONS

The MELD score is a valid prognostic model in decompensated chronic hepatitis B. Lamivudine treatment may affect the performance of MELD score. Other variables including those in CTP score may improve its predictive ability.

Predictive indices of morbidity and mortality after liver resection

OBJECTIVE

To determine if use of Model for End-Stage Liver Disease (MELD) scores to elective resections accurately predicts short-term morbidity or mortality.

SUMMARY BACKGROUND DATA

MELD scores have been validated in the setting of end-stage liver disease for patients awaiting transplantation or undergoing transvenous intrahepatic portosystemic shunt procedures. Its use in predicting outcomes after elective hepatic resection has not been evaluated.

METHODS

Records of 587 patients who underwent elective hepatic resection and were included in the National Surgical Quality Improvement Program Database were reviewed. MELD score, CTP score, Charlson Index of Comorbidity, American Society of Anesthesiology classification, and age were evaluated for their ability to predict short-term morbidity and mortality. Morbidity was defined as the development of one or more of the following complications: pulmonary edema or embolism, myocardial infarction, stroke, renal failure or insufficiency, pneumonia, deep venous thrombosis, bleeding, deep wound infection, reoperation, or hyperbilirubinemia. The analysis was repeated with patients divided according to their procedure and their primary diagnosis. Parametric or nonparametric analyses were performed as appropriate. Also, a new index was developed by dividing the patients into a development and a validation cohort, to predict morbidity and mortality in patients undergoing elective hepatic resection. ROC curves were also constructed for each of the primary indices.

RESULTS

CTP and ASA scores were superior in predicting outcome. Also, patients undergoing resection of primary malignancies had a higher rate of mortality but no difference in morbidity.

CONCLUSION

MELD scores should not be used to predict outcomes in the setting of elective hepatic resection.

Interventional radiology in liver transplantation

Improvements in surgical technique, advances in the field of immunosuppresion and the early diagnosis and treatment of complications related to liver transplantation have all led to prolonged survival after liver transplantation. In particular, advances in diagnostic and interventional radiology have allowed the Interventional Radiologist, as part of the transplant team, to intervene early in patients presenting with complications related to organ transplant with resultant increase in graft and patient survival. Such interventions are often achieved using minimally invasive percutaneous endovascular techniques. Herein we present an overview of some of these diagnostic and therapeutic approaches in the treatment and management of patients before and after liver transplantation.

Occurrence of cirrhosis-related complications is a time-dependent prognostic predictor independent of baseline model for end-stage liver disease score

BACKGROUND

The model for end-stage liver disease (MELD) is used to prioritize cirrhotic patients awaiting liver transplantation. Many cirrhosis-related complications are indications for transplantation but are not included in MELD. This study investigated the impact of these complications on survival and association with MELD.

METHODS

The mortality risk of cirrhosis-related complications, including bleeding esophageal varices, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome and hepatic decompensation, was analyzed using a time-dependent Cox regression model in 227 cirrhotic patients.

RESULTS

A total of 281 episodes of complications occurred in 142 (63%) patients. Patients who died had a significantly higher baseline MELD score compared with those who survived (14.5 +/- 4.5 vs 12.8 +/- 3.9, P = 0.004). There was no significant difference in the MELD score between patients with and without the occurrence of complications (13.6 +/- 4.3 vs 12.9 +/- 4.0, P = 0.093). Patients with a higher baseline MELD score tended to develop early complications (rho = -0.598, P< 0.001). Using the Cox regression model, the risk ratio of mortality was 4.9 (95% confidence interval: 3.9-6.3, P< 0.0001) for each additional episode of complication.

CONCLUSIONS

The mortality risk increases as the number of complication episodes increases. While patients with repeated complications have a poor outcome, they do not necessarily have a higher baseline MELD score and could be down-staged in the MELD era.

Role of emergency transjugular intrahepatic portosystemic shunts

Transjugular intrahepatic portosystemic shunts (TIPS) is a highly effective treatment for bleeding esophageal varices, with control of the bleeding in over 90% of the patients. TIPS is recommended as "rescue" treatment if primary hemostasis cannot be obtained with endoscopic and pharmacological therapy, or if uncontrollable early rebleeding occurs within 48 hours. TIPS is also a very effective technique for patients presenting with severe refractory bleeding gastric and ectopic varices, cases where endoscopic techniques are less effective. Emergency TIPS should be considered early in patients with refractory variceal bleeding once medical treatment and sclerotherapy fail, before the clinical condition worsens. Every effort should be made to stabilize the patient before TIPS, including the use of tamponade tubes and aggressive correction of coagulopathy. Patients with acute variceal bleeding with a Child-Pugh score > 12, Apache score II > 18 points, hemodynamically unstable, receiving vasopressors and coagulopathy, and/or bilirrubin > 6 mg/dL have a high risk of early death after TIPS. Expedite liver transplantation after emergency TIPS should be considered for high-risk patients.

Systematic review: The model for end-stage liver disease--should it replace Child-Pugh's classification for assessing prognosis in cirrhosis?

BACKGROUND

Prognosis in cirrhotic patients has had a resurgence of interest because of liver transplantation and new therapies for complications of end-stage cirrhosis. The model for end-stage liver disease score is now used for allocation in liver transplantation waiting lists, replacing Child-Turcotte-Pugh score. However, there is debate as whether it is better in other settings of cirrhosis.

AIM

To review studies comparing the accuracy of model for end-stage liver disease score vs. Child-Turcotte-Pugh score in non-transplant settings.

RESULTS

Transjugular intrahepatic portosystemic shunt studies (with 1360 cirrhotics) only one of five, showed model for end-stage liver disease to be superior to Child-Turcotte-Pugh to predict 3-month mortality, but not for 12-month mortality. Prognosis of cirrhosis studies (with 2569 patients) none of four showed significant differences between the two scores for either short- or long-term prognosis whereas no differences for variceal bleeding studies (with 411 cirrhotics). Modified Child-Turcotte-Pugh score, by adding creatinine, performed similarly to model for end-stage liver disease score. Hepatic encephalopathy and hyponatraemia (as an index of ascites), both components of Child-Turcotte-Pugh score, add to the prognostic performance of model for end-stage liver disease score.

CONCLUSIONS

Based on current literature, model for end-stage liver disease score does not perform better than Child-Turcotte-Pugh score in non-transplant settings. Modified Child-Turcotte-Pugh and model for end-stage liver disease scores need further evaluation.

An Overview of Solid Organ Transplantation

Once a medical curiosity, solid organ transplantation is now a commonplace occurrence, with more than 27,000 procedures performed in the United States in 2004 alone. This article offers an overview of the various solid organ transplant procedures to provide a context within which subsequent articles on pulmonary complications can be viewed.

Transjugular intrahepatic portosystemic shunt for acute variceal bleeding in patients with viral liver cirrhosis: predictors of early mortality

OBJECTIVE

The purpose of our study was to assess the predictors of early mortality after the creation of transjugular intrahepatic portosystemic shunts (TIPS) for acute variceal bleeding in patients with viral liver cirrhosis.

MATERIALS AND METHODS

Seventy-three patients (56 men and 17 women; mean age, 51.3 years) with viral liver cirrhosis who underwent TIPS placement for acute variceal bleeding were studied. Multiple covariates, including demographic, clinical, and biochemical parameters, were included in univariate and multivariate analyses to determine their association with early (30-day) mortality.

RESULTS

During the follow-up period (mean, 35 months 3 days), shunt dysfunction occurred in 33 patients (45.2%). Forty-three patients (58.9%) died, and 23 patients (31.5%) died within 30 days of TIPS. Early death was predicted independently by hyperbilirubinemia (> 3 mg/dL; p = 0.004; odds ratio, 10.6) and elevated serum creatinine level (> 1.7 mg/dL; p =0.018; odds ratio, 12.0).

CONCLUSION

Hyperbilirubinemia and elevated serum creatinine level are predictive of early mortality after TIPS creation for acute variceal bleeding in patients with viral liver cirrhosis.

MELD score as a predictor of early death in patients undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) procedures

PURPOSE

To Evaluate the MELD score as a predictor of 30-day mortality in patients undergoing elective TIPS procedures.

METHODS

This was a retrospective, IRB-approved study. The medical records of all patients who underwent a TIPS procedure between May 1, 1999 and June 1, 2003 in a single institution were reviewed. Patients who underwent elective TIPS were selected. Elective TIPS was performed in 119 patients with a mean age of 55.1 (+/- 9.6) years. The MELD and Child-Pugh scores before TIPS, etiology of cirrhosis, portosystemic gradients before and after TIPS, procedure time, and procedural complications were obtained from the medical records. The MELD and Child-Pugh scores before TIPS were compared between the survivor group (SG) and the early death (EDG) group. The early death rate was calculated for MELD score subgroups (1-10, 11-17, 18-24, and >24). Data were analyzed using the Fisher exact test, chi-square test and independent-sample t-test. A p value of less than 0.05 was considered significant.

RESULTS

Technical success rate was 100%. The early death rate was 10.9% (13/119). The mean MELD scores before TIPS were 19.4 (+/- 5.9) (EDG) and 14 (+/- 4.2) (SG) (p = 0.025). The early death rate was highest in the pre-TIPS MELD > 24 subgroup. The Child-Pugh scores were 9.0 (+/- 1.6) (SG) and 9.8 +/- 1.06 (EDG) (p = 0.08). The mean portosystemic gradients before TIPS were 20.5 (+/- 7.7) mmHg (EDG) and 22.7 (+/- 7.3) (SG) (p > 1) and the mean portosystemic gradients after TIPS were 6.5 (+/- 3.5) (EDG) and 6.9 (+/- 2.4) (SG) (p > 1). The mean procedural times were 95.6 (+/- 8.4) min (EDG) and 89.2 (+/- 7.5) min (SG) (p > 1). No early death was attributed to a fatal complication during TIPS.

CONCLUSION

The MELD score is useful in identifying patients at a higher risk of early death after an elective TIPS. On th basis of our results, we do not endorse elective TIPS in patients with MELD scores > 24.

Regional variation and use of exception letters for cadaveric liver allocation in children with chronic liver disease

The Pediatric End-Stage Liver Disease (PELD) score was designed to reduce subjectivity in liver allocation and to advantage patients with a higher probability of waiting list mortality. The aims of this study were to determine the impact of PELD implementation for children with chronic liver disease and to assess whether PELD met its goal of standardization of liver allocation for children. This study used data reported to the United Network for Organ Sharing (UNOS) registry for children with chronic liver disease receiving primary cadaveric liver transplant between January 2000 and December 2001 (pre-PELD) and March 2002 and July 2003 (PELD). PELD reduced the percentage of children transplanted while in an intensive care unit and as status 1. A calculated PELD score was used for allocation in only 52% of recipients. Thirty percent were status 1 at transplant and PELD scores granted by exception were used for allocation in 18% of patients. There was regional variation in PELD score at allocation and use of exception scores with a significant relationship between PELD score and percentage of exception cases. Regional variation suggests that PELD has not resulted in standardization of listing practices in pediatric liver transplantation.

Evaluation of the increase in model for end-stage liver disease (DeltaMELD) score over time as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child-Turcotte-Pugh score

BACKGROUND/AIMS

The model for end-stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. The change in MELD score over time (DeltaMELD) may have additional prognostic value. We investigated the ability of DeltaMELD to predict the outcome of advanced cirrhosis and prospectively assessed the factors associated with increasing DeltaMELD.

METHODS

Risk factors were determined in 58 prospectively followed-up patients. The predictive power of DeltaMELD, initial MELD and Child-Turcotte-Pugh (CTP) score was compared by using c-statistic in 351 patients.

RESULTS

Ascites (P=0.020) and hepatic encephalopathy (P=0.023) were significantly associated with increasing MELD score at 3 months. The area under receiver operating characteristic (ROC) curve for DeltaMELD/month was 0.779 compared with 0.718 for MELD (P=0.130) and 0.528 for CTP score (P<0.001) at 6 months; the area was 0.822, 0.744 and 0.528, respectively (P=0.018 and <0.001, respectively) at 12 months. DeltaMELD/month >2.5 was the only significant prognostic predictor at 6 (odds ratio: 9.8, P<0.001) and 12 months (odds ratio: 16.3, P<0.001) in multivariate logistic analysis.

CONCLUSIONS

Increasing MELD score is associated with the onset of ascites and encephalopathy. DeltaMELD is superior to initial MELD and CTP scores to predict intermediate term outcome in patients with advanced cirrhosis.

MELD vs Child-Pugh and creatinine-modified Child-Pugh score for predicting survival in patients with decompensated cirrhosis

AIM: Model of End-stage Liver Disease (MELD) score has recently gained wide acceptance over the old Child-Pugh score in predicting survival in patients with decompensated cirrhosis, although it is more sophisticated. We compared the predictive values of MELD, Child-Pugh and creatinine-modified Child-Pugh scores in decompensated cirrhosis.

METHODS: A cohort of 102 patients with decompensated cirrhosis followed-up for a median of 6 mo was studied. Two types of modified Child-Pugh scores estimated by adding 0-4 points to the original score using creatinine levels as a sixth categorical variable were evaluated.

RESULTS: The areas under the receiver operating charac-teristic curves did not differ significantly among the four scores, but none had excellent diagnostic accuracy (areas: 0.71-0.79). Child-Pugh score appeared to be the worst, while the accuracy of MELD was almost identical with that of modified Child-Pugh in predicting short-term and slightly better in predicting medium-term survival. In Cox regression analysis, all four scores were significantly associated with survival, while MELD and creatinine-modified Child-Pugh scores had better predictive values (c-statistics: 0.73 and 0.69-0.70) than Child-Pugh score (c-statistics: 0.65). Adjustment for gamma-glutamate transpeptidase levels increased the predictive values of all systems (c-statistics: 0.77-0.81). Analysis of the expected and observed survival curves in patients subgroups according to their prognosis showed that all models fit the data reasonably well with MELD probably discriminating better the subgroups with worse prognosis.

CONCLUSION: MELD compared to the old Child-Pugh and particularly to creatinine-modified Child-Pugh scores does not appear to offer a clear advantage in predicting survival in patients with decompensated cirrhosis in daily clinical practice.

Selection Criteria for Patients Undergoing Transjugular Intrahepatic Portosystemic Shunt Procedures: Current Status

The transjugular intrahepatic portosystemic shunt (TIPS) procedure has a well-established role in the management of patients with complications of portal hypertension such as variceal bleeding or refractory ascites. Several clinical variables have been described to be associated with a poor prognosis after a TIPS procedure, including the presence of uncontrollable ascites, the number of sclerotherapy sessions to control a bleeding episode, the use of drugs for hemodynamic support, the use of balloon tamponade to control bleeding, the need for an emergency TIPS procedure, the need for mechanical ventilation, prothrombin time, increased serum creatinine, increased serum bilirubin, encephalopathy, and sepsis. In addition, several scoring systems have been developed and applied to patients undergoing TIPS procedures in an attempt to improve patient selection criteria for this invasive procedure. This article reviews the most important scoring systems that have been developed and applied to patients undergoing emergency or elective TIPS procedures, with particular emphasis on the prognostic index designed for patients undergoing emergency TIPS procedures and the Model for End-stage Liver Disease score designed for patients undergoing elective TIPS procedures. The most practical application of these scoring systems is probably that, with the information provided, the operator is able to discuss with referring physicians, patients, and family members the expected outcomes of this challenging procedure.

Comparison of MELD and Child-Pugh scores to predict survival after chemoembolization for hepatocellular carcinoma

PURPOSE

To compare the value of the Child-Pugh and Model for End-stage Liver Disease (MELD) scores to predict patient survival rates after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-seven patients underwent 169 TACE sessions. Child-Pugh and MELD values were calculated before initial treatment. Survival length was tracked from the date of the first TACE procedure. Transplant recipients were censored from the study at the time of surgery. Child-Pugh and MELD scores as well as bilirubin and albumin levels and International Normalized Ratio were placed in high and low categories defined by their respective medians. Patient survival was compared at 3 months, 6 months, 12 months, and 24 months, and patterns were tested with chi2 or Fisher exact tests. Survival over the entire period was examined with Kaplan-Meier analysis and differences were tested with log-rank tests.

RESULTS

Mean and median survival times for all patients were 24 and 17 months, respectively. Sixteen patients were censored for transplantation at a mean of 12.9 months. MELD and Child-Pugh scores correlated well with each other (r = 0.68). Child-Pugh score (r = -0.35, P = .04) correlated more strongly with 12-month survival than did MELD score (r = -0.26, P = .12). After high/low score category division, a significantly greater survival difference was predicted by Child-Pugh score (27.2 months vs 10.3 months; P = .03) versus MELD score (27.5 months vs 15.8 months; P = .19). An albumin level greater than 3.4 g/dL was also associated with significantly improved survival (29.3 months vs 10.1 months; P = .0032). Survival differences between high-risk and low-risk groups at the 3-, 6-, 12-, and 24-month intervals were significant for low Child-Pugh scores and for albumin levels greater than 3.4 g/dL. Statistical significance was not approached at any of the time lengths with MELD scores.

CONCLUSIONS

Child-Pugh score correlates better than MELD score to overall patient survival and is a better predictor than MELD score of survival at specific time points. Of the components of the Child-Pugh and MELD systems, albumin level is the most useful predictor of survival.

H-graft portacaval shunts versus TIPS: ten-year follow-up of a randomized trial with comparison to predicted survivals

OBJECTIVE

To report long-term outcome of patients undergoing prosthetic 8-mm H-graft portacaval shunts (HGPCS) or TIPS and to compare actual with predicted survival data.

METHODS

A randomized trial comparing TIPS to HGPCS for bleeding varices began in 1993. Predicted survival was determined using MELD (Model for End-stage Liver Disease).

RESULTS

Patients undergoing TIPS (N = 66) or HGPCS (N = 66) were very similar by Child's class and MELD scores and predicted survival. After TIPS (P = 0.01) and HGPCS (P = 0.001), actual survival was superior to predicted survival. Through 24 months, actual survival after HGPCS was superior to actual survival after TIPS (P = 0.04). Compared with TIPS, survival was superior after HGPCS for patients of Child's class A and B (P = 0.07) and with MELD scores less than 13 (P = 0.04) with follow-up at 5 to 10 years. Shunt failure was less following HGPCS (P < 0.01).

CONCLUSIONS

Predicted survival data for patients undergoing TIPS or HGPCS confirms an unbiased randomization. Actual survival following TIPS or HGPCS was superior to predicted survival. Shunt failure favored HGPCS, as did survival after shunting, particularly for the first few years after shunting and for patients of Child's class A or B or with MELD scores less than 13. This trial irrefutably establishes a role for surgical shunting, particularly HGPCS.

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Transjugular intrahepatic portosystemic shunt

The transjugular intrahepatic portosystemic shunt (TIPS) is an interventional treatment resulting in decompression of the portal system by creation of a side-to-side portosystemic anastomosis. Since its introduction 16 years ago, more than 1,000 publications have appeared demonstrating broad acceptance and increasing clinical use. This review summarizes our present knowledge about technical aspects and complications, follow-up of patients and indications. A technical success rate near 100% and a low occurrence of complications clearly depend on the skills of the operator. The follow-up of the TIPS patient has to assess shunt patency, liver function, hepatic encephalopathy and the possible development of hepatocellular carcinoma. Shunt patency can best be monitored by duplex sonography and can avoid routine radiological revision. Short-term patency may be improved by anticoagulation, while such a treatment does not influence long-term patency. Stent grafts covered with expanded polytetrafluoroethylene show promising long-term patency comparable with that of surgical shunts. With respect to the indications of TIPS, much is known about treatment of variceal bleeding and refractory ascites. The thirteen randomized studies that are available to date show that survival is comparable in patients receiving TIPS or endoscopic treatment for acute or recurrent variceal bleeding. Another group comprises patients with refractory ascites and related complications, such as hepatorenal syndrome and hepatic hydrothorax. It has been demonstrated that TIPS improves these complications. Five randomized studies comparing TIPS with paracentesis and one study comparing TIPS with the peritoneo-venous shunt showed good response of ascites but controversial results on survival. In addition, TIPS has been successfully applied to patients with Budd-Chiari syndrome, portal vein thrombosis, before liver transplantation, and for the treatment of ectopic variceal bleeding.

MELD score versus conventional UNOS status in predicting short-term mortality after liver transplantation*

The Model for End-stage Liver Disease (MELD) provides a score able to predict short-term mortality in patients awaiting liver transplantation (LT). In the early 2002, United Network for Organ Sharing (UNOS) has proposed to replace the conventional statuses 3, 2B, and 2A with a modified MELD score. However, the accuracy of the MELD model to predict post-transplantation outcome is fairly elusive. In the present study we investigated the predictive value of the MELD score for short-term patient and graft mortality in comparison with conventional UNOS status. Sixty-nine patients listed at UNOS status 3 (n = 5), 2B (n = 55) or 2A (n = 9) who underwent LT were enrolled according to strict criteria. No donor-related parameters affected 3-month patient survival. Through univariate Cox regression, pretransplantation international normalized ratio (P = 0.049) and activated partial thromboplastin time (P = 0.032) were significantly associated with 3-month patient survival, although not in the subsequent multivariate analysis. The overall MELD score was 17 +/- 6.63 (median: 16, range: 4-34), increasing from UNOS Status 3 to 2A (r(2) = 0.171, P = 0.0001). No significant difference occurred in the median MELD score between patients who underwent a second LT and those who did not (P =0.458). The inter-rate agreement between UNOS status and MELD score after categorization for clinical urgency showed a fair agreement (kappa = 0.244). The 3-month patient and graft mortality was 15.94% and 20.29% respectively. The concordance statistic did not find significance between UNOS status and MELD score for 3-month patient (P = 0.283) or graft mortality (P = 0.957), although the MELD score revealed a major sensitivity for short-term patient mortality (0.637; 95%CI: 0.513-0.75). These findings suggest the need to implement MELD model accuracy for both inter-rate agreement with UNOS Status and patient outcome.

Determination of the optimal model for end-stage liver disease score in patients with small hepatocellular carcinoma undergoing loco-regional therapy

The model for end-stage liver disease (MELD) has been a prevailing system to prioritize cirrhotic patients awaiting liver transplantation. An "exceptional" MELD score of 20 and 24 points is assigned for stage T1 and T2 patients with small hepatocellular carcinoma (HCC), respectively. However, this strategy is based on scarce data and the optimal score for these patients remains uncertain. We investigated 238 patients with small HCC who were candidates for liver transplantation and underwent arterial chemoembolization or percutaneous injection therapy using acetic acid or ethanol. Tumor stage (P = .001) and Child-Turcotte-Pugh (CTP) class (P < .001) were independent risk factors predicting tumor progression or death in survival analysis. The risk of disease progression in HCC patients stratified by tumor stage was mapped and equated with the risk of mortality of 456 cirrhotic patients without HCC. The 6- and 12-month rates of disease progression were 4% and 6%, respectively, for stage T1 HCC patients (n = 50; mean MELD: 9.5). These rates were close to and no higher than the mortality rate in MELD category 8-12 at the corresponding time period (7.1% and 11.3%, respectively; n = 141). For stage T2 patients (n = 188; mean MELD: 9.3), the corresponding rates were 5.3% and 13.8%, respectively, which were close to and no higher than the mortality rate in MELD category 10-14 (9.0% and 13.9%, respectively, n = 166). In conclusion, the risk of disease progression is quite low for selected HCC patients undergoing loco-regional therapy. A lower MELD score may be suggested to be equivalent to the risk of short- and mid-term mortality in the cirrhosis group.

TIPS versus peritoneovenous shunt in the treatment of medically intractable ascites: a prospective randomized trial

OBJECTIVE

We undertook a prospective randomized clinical trial comparing TIPS to peritoneovenous (PV) shunts in the treatment of medically intractable ascites to establish relative efficacy and morbidity, and thereby superiority, between these shunts.

METHODS

Thirty-two patients were prospectively randomized to undergo TIPS or peritoneovenous (Denver) shunts. All patients had failed medical therapy.

RESULTS

After TIPS versus peritoneovenous shunts, median (mean +/- SD) duration of shunt patency was similar: 4.4 months (6 +/- 6.6 months) versus 4.0 months (5 +/- 4.6 months). Assisted shunt patency was longer after TIPS: 31.1 months (41 +/- 25.9 months) versus 13.1 months (19 +/- 17.3 months) (P < 0.01, Wilcoxon test). Ultimately, after TIPS 19% of patients had irreversible shunt occlusion versus 38% of patients after peritoneovenous shunts. Survival after TIPS was 28.7 months (41 +/- 28.7 months) versus 16.1 months (28 +/- 29.7 months) after peritoneovenous shunts. Control of ascites was achieved sooner after peritoneovenous shunts than after TIPS (73% vs. 46% after 1 month), but longer-term efficacy favored TIPS (eg, 85% vs. 40% at 3 years).

CONCLUSION

TIPS and peritoneovenous shunts treat medically intractable ascites. Absence of ascites after either is uncommon. PV shunts control ascites sooner, although TIPS provides better long-term efficacy. After either shunt, numerous interventions are required to assist patency. Assisted shunt patency is better after TIPS. Treating medically refractory ascites with TIPS risks early shunt-related mortality for prospects of longer survival with ascites control. This study promotes the application of TIPS for medically intractable ascites if patients undergoing TIPS have prospects beyond short-term survival.

Acute renal failure after transarterial chemoembolization for hepatocellular carcinoma: a retrospective study of the incidence, risk factors, clinical course and long-term outcome

BACKGROUND

Transarterial chemoembolization is effective for hepatocellular carcinoma. Acute renal failure may occur after transarterial chemoembolization because of radiocontrast agent, but its clinical aspects are unknown.

AIM

To investigate the incidence, risk factors and outcome of acute renal failure, defined as increase of serum creatinine > 1.5 mg/dL, after transarterial chemoembolization.

METHODS

A total of 235 hepatocellular carcinoma patients with 843 transarterial chemoembolization treatment sessions were analysed.

RESULTS

Acute renal failure developed in 56 (23.8%) patients and the estimated risk of developing acute renal failure was 6.6% in each treatment session. Comparison between the episodes of transarterial chemoembolization with and without acute renal failure by using the generalized estimating equation disclosed that Child-Pugh class B (odds ratio: 2.6, P = 0.007) and treatment session (odds ratio: 1.3; P < 0.0001) were independent risk factors of acute renal failure. Twenty-seven patients had prolonged renal function impairment. Multivariate analysis by generalized estimating equation showed that Child-Pugh class B (odds ratio: 4.3, P = 0.0004) and diabetes mellitus (odds ratio: 5.2, P < 0.0001) were linked with prolonged acute renal failure, which independently predicted a decreased survival (relative risk: 2.3, P = 0.002).

CONCLUSIONS

Acute renal failure after transarterial chemoembolization appears to be dose-related and is associated with the severity of cirrhosis. Patients with diabetes mellitus or Child-Pugh class B more frequently develop prolonged acute renal failure, which in turn is a poor prognostic predictor.