Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death

Effect of hyponatraemia on outcomes following orthotopic liver transplantation

BACKGROUND

Hyponatraemia increases risk of adverse outcomes following orthotopic liver transplantation (OLT), but it is unclear whether improvement of pretransplant hyponatraemia ameliorates post-transplant complications.

AIMS

To assess impact of pretransplant hyponatraemia on post-transplant outcomes.

METHODS

We performed a retrospective analysis of 213 patients with cirrhosis who underwent liver transplantation. Patients with serum sodium <or=130 mEq/L immediately before transplantation ('hyponatraemia at OLT'; n=34) were compared with those who had experienced hyponatraemia but subsequently improved to a serum sodium >130 mEq/L at transplantation ('resolved hyponatraemia'; n=56) and to those without history of hyponatraemia before transplantation ('never hyponatraemic'; n=123). Primary endpoint was survival at 180 days post-OLT. Secondary outcomes included time until discharge alive, complications during hospitalization, length of time ventilated and length of post-transplant intensive care unit stay.

RESULTS

There was no survival difference at 180 days post-OLT between groups. After transplantation, patients with either hyponatraemia at OLT or resolved hyponatraemia had longer time until discharge alive and had higher rates of delirium, acute renal failure, acute cellular rejection and infection than those who were never hyponatraemic. As compared with patients with hyponatraemia at OLT, those with resolved hyponatraemia were more likely to be discharged alive within 3 weeks, but other outcomes, including survival, did not differ significantly.

CONCLUSIONS

We conclude that hyponatraemia at any time before liver transplantation is associated with adverse post-transplant outcome, even when hyponatraemia has resolved.

Comparison and improvement of MELD and Child-Pugh score accuracies for the prediction of 6-month mortality in cirrhotic patients

BACKGROUND/GOALS

Superiority of the model for end-stage liver disease (MELD) over the Child-Pugh score for the prediction of outcome in patients with chronic liver disease is still debated. The main objective of this prospective study was to evaluate the accuracy of the Child-Pugh score, the MELD, and the new score, MELD-Na, combining MELD and serum sodium (Na), for the prediction of 6-month mortality in cirrhotic patients.

STUDY

In all, 308 consecutive cirrhotic patients were included. Child-Pugh score, MELD, and MELD-Na were calculated at the inclusion.

RESULTS

In all, 154 patients (50.0%) had decompensated cirrhosis. Forty-five patients died during the 6-month follow-up: 3 in the subgroup of compensated cirrhosis and 42 in the decompensated subgroup (1.9% vs. 27.3%, P<10(-3)). Area under the receiver operating characteristic curve for the prediction of 6-month mortality of Child-Pugh score, MELD, and MELD-Na were, respectively, in the whole population: 0.882, 0.866, and 0.887 (P=NS), and in the subgroup of decompensated cirrhosis: 0.796, 0.800, and 0.833 (P=NS). MELD-Na had the highest accuracy but the difference reached statistical significance only with the Child-Pugh score in the subgroup of patients with decompensated cirrhosis (79.9% vs. 68.0%, P=0.006). The combination of Child-Pugh score or MELD with other variables reflecting the circulatory dysfunction observed in end-stage liver disease significantly improved the accuracy of these 2 models.

CONCLUSIONS

Child-Pugh score remains a simple and effective tool for the prognostic assessment of cirrhotic patients at bedside and can still be used in clinical practice. MELD, and especially MELD-Na, should be reserved for patients with decompensated cirrhosis.

Liver transplantation: from Child to MELD

The widespread availability of transplantation in most major medical centers in the United States, together with a growing number of transplant candidates, has made it necessary for primary care providers, especially internal medicine and family practice physicians to be active in the clinical care of these patients before and after transplantation. This review provides an overview of the liver transplantation process, including indications, contraindications, time of referral to a transplant center, the current organ allocation system, and briefly touches on the expanding field of living donor liver transplantation.

Management and treatment of patients with cirrhosis and portal hypertension: recommendations from the Department of Veterans Affairs Hepatitis C Resource Center Program and the National Hepatitis C Program

Cirrhosis represents the end stage of any chronic liver disease. Hepatitis C and alcohol are currently the main causes of cirrhosis in the United States. Although initially cirrhosis is compensated, it eventually becomes decompensated, as defined by the presence of ascites, variceal hemorrhage, encephalopathy, and/or jaundice. These management recommendations are divided according to the status, compensated or decompensated, of the cirrhotic patient, with a separate section for the screening, diagnosis, and management of hepatocellular carcinoma (HCC), as this applies to patients with both compensated and decompensated cirrhosis. In the compensated patient, the main objective is to prevent variceal hemorrhage and any practice that could lead to decompensation. In the decompensated patient, acute variceal hemorrhage and spontaneous bacterial peritonitis are severe complications that require hospitalization. Hepatorenal syndrome is also a severe complication of cirrhosis but one that usually occurs in patients who are already in the hospital and, as it represents an extreme of the hemodynamic alterations that lead to ascites formation, it is placed under treatment of ascites. Recent advances in the pathophysiology of the complications of cirrhosis have allowed for a more rational management of cirrhosis and also for the stratification of patients into different risk groups that require different management. These recommendations are based on evidence in the literature, mainly from randomized clinical trials and meta-analyses of these trials. When few or no data exist from well-designed prospective trials, emphasis is given to results from large series and consensus conferences with involvement of recognized experts. A rational management of cirrhosis will result in improvements in quality of life, treatment adherence, and, ultimately, in outcomes.

Application of a biochemical and clinical model to predict individual survival in patients with end-stage liver disease

AIM: To investigate the capability of a biochemical and clinical model, BioCliM, in predicting the survival of cirrhotic patients.

METHODS: We prospectively evaluated the survival of 172 cirrhotic patients. The model was constructed using clinical (ascites, encephalopathy and variceal bleeding) and biochemical (serum creatinine and serum total bilirubin) variables that were selected from a Cox proportional hazards model. It was applied to estimate 12-, 52- and 104-wk survival. The model’s calibration using the Hosmer-Lemeshow statistic was computed at 104 wk in a validation dataset. Finally, the model’s validity was tested among an independent set of 85 patients who were stratified into 2 risk groups (low risk ≤ 8 and high risk > 8).

RESULTS: In the validation cohort, all measures of fit, discrimination and calibration were improved when the biochemical and clinical model was used. The proposed model had better predictive values (c-statistic: 0.90, 0.91, 0.91) than the Model for End-stage Liver Disease (MELD) and Child-Pugh (CP) scores for 12-, 52- and 104-wk mortality, respectively. In addition, the Hosmer-Lemeshow (H-L) statistic revealed that the biochemical and clinical model (H-L, 4.69) is better calibrated than MELD (H-L, 17.06) and CP (H-L, 14.23). There were no significant differences between the observed and expected survival curves in the stratified risk groups (low risk, P = 0.61; high risk, P = 0.77).

CONCLUSION: Our data suggest that the proposed model is able to accurately predict survival in cirrhotic patients.

The association between the serum sodium level and the severity of complications in liver cirrhosis

BACKGROUND/AIMS

Dilutional hyponatremia associated with liver cirrhosis is caused by impaired free water clearance. Several studies have shown that serum sodium levels correlate with survival in cirrhotic patients. Little is known, however, regarding the relationship between the degree of dilutional hyponatremia and development of cirrhotic complications. The aim of this study was to evaluate the association between the serum sodium level and the severity of complications in liver cirrhosis.

METHODS

Data of inpatients with cirrhotic complications were collected retrospectively. The serum sodium levels and severity of complications of 188 inpatients were analyzed.

RESULTS

The prevalence of dilutional hyponatremia, classified as serum sodium concentrations of <or=135 mmol/L, <or=130 mmol/L, and <or=125 mmol/L, were 20.8%, 14.9%, and 12.2%, respectively. The serum sodium level was strongly associated with the severity of liver function impairment as assessed by Child-Pugh and MELD scores (p<0.0001). Even a mild hyponatremia with a serum sodium concentration of 131-135 mmol/L was associated with severe complications. Sodium levels less than 130 mmol/L indicated the existence of massive ascites (OR, 2.685; CI, 1.316-5.477; p=0.007), grade III or higher hepatic encephalopathy (OR, 5.891; CI, 1.490-23.300; p=0.011), spontaneous bacterial peritonitis (OR, 2.562; CI, 1.162-5.653; p=0.020), and hepatic hydrothorax (OR, 5.723; CI, 1.889-17.336; p=0.002).

CONCLUSIONS

Hyponatremia, especially serum levels <or=130 mmol/L, may indicate the existence of severe complications associated with liver cirrhosis.

Value of the model for end-stage liver disease for predicting survival in hepatocellular carcinoma patients treated with transarterial chemoembolization

OBJECTIVE

The aim of this study was to evaluate the prognostic value of the model for end-stage liver disease (MELD) and its modified forms, and to compare these scoring systems with other staging systems for hepatocellular carcinoma (HCC) patients treated with transarterial chemoembolization (TACE).

MATERIAL AND METHODS

A total of 325 patients who underwent TACE for the initial treatment of HCC between January 2000 and May 2007 were enrolled in the study. Before TACE was carried out, MELD, MELD-Na, Child-Pugh score, Okuda stage, CLIP score, JIS score, BCLC stage, and UICC stage were checked. After one month, delta MELD and delta MELD-Na were calculated.

RESULTS

Mean MELD/MELD-Na/delta MELD/delta MELD-Na scores were 7.5+/-3.7, 8.0+/-4.7, -0.2+/-3.5 and 0.04+/-4.5, respectively. MELD (p=0.009) and MELD-Na (p=0.017) significantly correlated with survival, but delta MELD and delta MELD-Na did not (p >0.05). The Child-Pugh score and other staging systems correlated significantly with survival (p <0.05). The AUROC values for 3, 12, and 36 months' survival were 0.633, 0.545, and 0.615 for MELD; 0.655, 0.555, and 0.612 for MELD-Na; 0.639, 0.616, and 0.691 for Child-Pugh score; 0.714, 0.662, and 0.717 for the Okuda score; 0.837, 0.86, and 0.792 for the CLIP score; 0.859, 0.814, and 0.808 for the JIS score; 0.846, 0.833, and 0.749 for BCLC stage; and 0.878, 0.812, and 0.735 for UICC stage, respectively.

CONCLUSIONS

MELD and MELD-Na showed good correlations with survival, especially for patients with early-stage disease. However, these were not superior to those of other staging systems or Child-Pugh score. These parameters should only be used as supportive data.

Impact of pretransplant hyponatremia on outcome following liver transplantation

Hyponatremia is associated with reduced survival in patients with cirrhosis awaiting orthotopic liver transplantation (OLT). However, data are sparse regarding the impact of hyponatremia on outcome following OLT. We investigated the effect of hyponatremia at the time of OLT on mortality and morbidity following the procedure. The study included 2,175 primary OLT recipients between 1990 and 2000. Serum sodium concentrations obtained immediately prior to OLT were correlated with subsequent survival using proportional hazards analysis. Morbidity associated with hyponatremia was assessed, including length of hospitalization, length of intensive care unit (ICU) admission, and occurrence of central pontine myelinolysis (CPM). Out of 2,175 subjects, 1,495 (68.7%) had normal serum sodium (>135 mEq/L) at OLT, whereas mild hyponatremia (125-134 mEq/L) was present in 615 (28.3%) and severe hyponatremia (<125 mEq/L) in 65 (3.0%). Serum sodium had no impact on survival up to 90 days after OLT (multivariate hazard ratio = 1.00, P = 0.99). Patients with severe hyponatremia tended to have a longer stay in the ICU (median = 4.5 days) and hospital (17.0 days) compared to normonatremic recipients (median ICU stay = 3.0 days, hospital stay = 14.0 days; P = 0.02 and 0.08, respectively). There were 10 subjects that developed CPM, with an overall incidence of 0.5%. Although infrequent, the incidence of CPM did correlate with serum sodium levels (P < 0.01).

CONCLUSION

Pre-OLT serum sodium does not have a statistically significant impact on survival following OLT. The incidence of CPM correlates with hyponatremia, although its overall incidence is low. Incorporation of serum sodium in organ allocation may not adversely affect the overall post-OLT outcome.

Clinical features and predictors of outcome in acute hepatitis A and hepatitis E virus hepatitis on cirrhosis

BACKGROUND AND OBJECTIVES

Acute hepatitis A and E are recognized triggers of hepatic decompensation in patients with cirrhosis, particularly from the Indian subcontinent. However, the resulting acute-on-chronic liver failure (ACLF) has not been well characterized and no large studies are available. Our study aimed to evaluate the clinical profile and predictors of 3-month mortality in patients with this distinctive form of liver failure.

METHODS

ACLF was diagnosed in patients with acute hepatitis A or E [abrupt rise in serum bilirubin and/or alanine aminotransferase with positive immunoglobulin M anti-hepatitis A virus (HAV)/anti-hepatitis E virus (HEV)] presenting with clinical evidence of liver failure (significant ascites and/or hepatic encephalopathy) and clinical, biochemical, endoscopic (oesophageal varices at least grade II in size), ultrasonographical (presence of nodular irregular liver with porto-systemic collaterals) or histological evidence of cirrhosis. Clinical and laboratory profile were evaluated, predictors of 3-month mortality were determined using univariate and multivariate logistic regression and a prognostic model was constructed. Receiver-operating curves were plotted to measure performance of the present prognostic model, model for end-stage liver disease (MELD) score and Child-Turcotte-Pugh (CTP) score.

RESULTS

ACLF occurred in 121 (3.75%) of 3220 patients (mean age 36.3+/-18.0 years; M:F 85:36) with liver cirrhosis admitted from January 2000 to June 2006. It was due to HEV in 80 (61.1%), HAV in 33 (27.2%) and both in 8 (6.1%). The underlying liver cirrhosis was due to HBV (37), alcohol (17), Wilson's disease (8), HCV (5), autoimmune (6), Budd-Chiari syndrome (2), haemochromatosis (2) and was cryptogenic in the rest (42). Common presentations were jaundice (100%), ascites (78%) and hepatic encephalopathy (55%). Mean (SD) CTP score was 11.4+/-1.6 and mean MELD score was 28.6+/-9.06. Three-month mortality was 54 (44.6%). Complications seen were sepsis in 42 (31.8%), renal failure in 45 (34%), spontaneous bacterial peritonitis in 27 (20.5%), UGI bleeding in 15(11%) and hyponatraemia in 50 (41.3%). On univariate analysis, ascites, hepatic encephalopathy, renal failure, GI bleeding, total bilirubin, hyponatraemia and coagulopathy were significant predictors of mortality. Multivariate analysis revealed grades 3 and 4 HE [odds ratio (OR 32.1)], hyponatraemia (OR 9.2) and renal failure (OR 16.8) as significant predictors of 3-month mortality and a prognostic model using these predictors was constructed. Areas under the curve for the present predicted prognostic model, MELD, and CTP were 0.952, 0.941 and 0.636 respectively.

CONCLUSIONS

ACLF due to hepatitis A or E super infection results in significant short-term mortality. The predictors of ominous outcome include grades 3 and 4 encephalopathy, hyponatraemia and renal failure. Present prognostic model and MELD scoring system were better predictors of 3-month outcome than CTP score in these patients. Early recognition of those with dismal prognosis may permit timely use of liver replacement/supportive therapies.

Clinically relevant differences in the model for end-stage liver disease and model for end-stage liver disease-sodium scores determined at three university-based laboratories of the same area

The Model for End-Stage Liver Disease (MELD) score is considered an objective and reliable measure of liver disease severity. However, the use of specific laboratory methodologies may introduce significant and clinically relevant variations into the score. It has been suggested that the incorporation of sodium into MELD (MELD-Na) can provide a more accurate survival prediction than MELD alone. Before implementing organ allocation based on the MELD score in an area with 3 transplant centers, we studied whether there were significant variations in MELD and MELD-Na scores determined at each center. Seventy patients on the waiting list were studied simultaneously. Blood samples for each patient were divided into 3 aliquots and were processed in the 3 laboratories in order to calculate MELD and MELD-Na scores. There were statistical differences between the 3 laboratories in the MELD and MELD-Na scores and their parameters. The MELD score was identical in the 3 laboratories for only 6 of the 70 patients, and the MELD-Na score was identical for only 9. MELD and MELD-Na scores from 2 laboratories differed by 1 point or more in 54% and 47% of cases, respectively. Our study confirms that there is major variability in the MELD score, serum sodium, and MELD-Na score. These differences are clinically relevant, and in order to guarantee equitable organ allocation based on the MELD score, similar laboratory methodologies should be implemented at all centers in the same organ procurement area. Alternatively, the possibility of setting up a central laboratory in each organ procurement area should be considered.

Model for end-stage liver disease, model for end-stage liver disease-sodium and Child-Turcotte-Pugh scores over time for the prediction of complications of liver cirrhosis

BACKGROUND/AIMS

There has been no report concerning the predictive capability of each scoring system in determining the development of complications of liver cirrhosis such as variceal bleeding and/or hepatic encephalopathy.

METHODS

We retrospectively studied 128 patients with liver cirrhosis [92 males; mean (standard deviation) 54.2 (11.2) years] admitted to our institution from March 2004 to April 2006. Seventy-three patients (57.0%, group 1) were admitted because of complications of cirrhosis and 55 patients (43.0%, group 2) were admitted for causes unrelated to complications of cirrhosis. We calculated values for model for end-stage liver disease (MELD), MELD-sodium (MELD-Na) and Child-Turcotte-Pugh (CTP) scores on admission and at 3 and 6 months before admission. Each delta score was defined as the difference in the scores of 3 and 6 months before admission.

RESULTS

The relative risk for complications in the patients with DeltaMELD/3 months >/=1.35, DeltaMELD-Na/3 months >/=1.35 and DeltaCTP/3 months >/=1 was 2.05 [95% confidence intervals (CI) 1.47-2.85, P<0.01], 2.04 (95% CI 1.45-2.88, P<0.01) and 1.98 (95% CI 1.39-2.81, P<0.01) respectively. The area under the receiver-operating characteristic curves of DeltaMELD/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months for the occurrence of cirrhotic complications were 0.691, 0.694 and 0.722 respectively. A higher DeltaMELD/3 months (>/=1.35), DeltaMELD-Na/3 months (>/=1.35) and DeltaCTP/3 months (>/=1) was associated with decreased survival.

CONCLUSIONS

Delta model for end-stage liver disease/3 months, DeltaMELD-Na/3 months and DeltaCTP/3 months were clinically useful parameters for predicting the occurrence of cirrhotic complications.

D-MELD, a simple predictor of post liver transplant mortality for optimization of donor/recipient matching

Numerous donor and recipient risk factors interact to influence the probability of survival after liver transplantation. We developed a statistic, D-MELD, the product of donor age and preoperative MELD, calculated from laboratory values. Using the UNOS STAR national transplant data base, we analyzed survival for first liver transplant recipients with chronic liver failure from deceased after brain death donors. Preoperative D-MELD score effectively stratified posttransplant survival. Using a cutoff D-MELD score of 1600, we defined a subgroup of donor-recipient matches with significantly poorer short- and long-term outcomes as measured by survival and length of stay (LOS). Avoidance of D-MELD scores above 1600 improved results for subgroups of high-risk patients with donor age >/=60 and those with preoperative MELD >/=30. D-MELD >/=1600 accurately predicted worse outcome in recipients with and without hepatitis C. There is significant regional variation in average D-MELD scores at transplant, however, regions with larger numbers of high D-MELD matches do not have higher survival rates. D-MELD is a simple, highly predictive tool for estimating outcomes after liver transplantation. This statistic could assist surgeons and their patients in making organ acceptance decisions. Applying D-MELD to liver allocation could eliminate many donor/recipient matches likely to have inferior outcome.

Disorders of sodium and water balance in hospitalized patients

PURPOSE

To review and discuss the epidemiology, contributing factors, and approach to clinical management of disorders of sodium and water balance in hospitalized patients.

SOURCE

An electronic search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases and a search of the bibliographies of all relevant studies and review articles for recent reports on hyponatremia and hypernatremia with a focus on critically ill patients.

PRINCIPAL FINDINGS

Disorders of sodium and water balance are exceedingly common in hospitalized patients, particularly those with critical illness and are often iatrogenic. These disorders are broadly categorized as hypo-osmolar or hyper-osmolar, depending on the balance (i.e., excess or deficit) of total body water relative to total body sodium content and are classically recognized as either hyponatremia or hypernatremia. These disorders may represent a surrogate for increased neurohormonal activation, organ dysfunction, worsening severity of illness, or progression of underlying chronic disease. Hyponatremic disorders may be caused by appropriately elevated (volume depletion) or inappropriately elevated (SIADH) arginine vasopressin levels, appropriately suppressed arginine vasopressin levels (kidney dysfunction), or alterations in plasma osmolality (drugs or body cavity irrigation with hypotonic solutions). Hypernatremia is most commonly due to unreplaced hypotonic water depletion (impaired mental status and/or access to free water), but it may also be caused by transient water shift into cells (from convulsive seizures) and iatrogenic sodium loading (from salt intake or administration of hypertonic solutions).

CONCLUSION

In hospitalized patients, hyponatremia and hypernatremia are often iatrogenic and may contribute to serious morbidity and increased risk of death. These disorders require timely recognition and can often be reversed with appropriate intervention and treatment of underlying predisposing factors.

Comparison of four models for end-stage liver disease in evaluating the prognosis of cirrhosis

AIM: To investigate the prognostic value of the model for end-stage liver disease (MELD) and three new MELD-based models combination with serum sodium in decompensated cirrhosis patients-the MELD with the incorporation of serum sodium (MELD-Na), the integrated MELD (iMELD), and the MELD to sodium (MESO) index.

METHODS: A total of 166 patients with decompensated cirrhosis were enrolled into the study. MELD, MELD-Na, iMELD and MESO scores were calculated for each patient following the original formula on the first day of admission. All patients were followed up at least 1 year. The predictive prognosis related with the four models was determined by the area under the receiver operating characteristic curve (AUC) of the four parameters. Kaplan-Meier survival curves were made using the cut-offs identified by means of receiver operating characteristic (ROC).

RESULTS: Out of 166 patients, 38 patients with significantly higher MELD-Na (28.84 ± 2.43 vs 14.72 ± 0.60), iMELD (49.04 ± 1.72 vs 35.52 ± 0.67), MESO scores (1.59 ± 0.82 vs 0.99 ± 0.42) compared to the survivors died within 3 mo (P < 0.001). Of 166 patients, 75 with markedly higher MELD-Na (23.01 ± 1.51 vs 13.78 ± 0.69), iMELD (44.06 ± 1.19 vs 34.12 ± 0.69), MESO scores (1.37 ± 0.70 vs 0.93 ± 0.40) than the survivors died within 1 year (P < 0.001). At 3 mo of enrollment, the iMELD had the highest AUC (0.841), and was followed by the MELD-Na (0.766), MESO (0.723), all larger than MELD (0.773); At 1 year, the iMELD still had the highest AUC (0.783), the difference between the iMELD and MELD was statistically significant (P < 0.05). Survival curves showed that the three new models were all clearly discriminated the patients who survived or died in short-term as well as intermediate-term (P < 0.001).

CONCLUSION: Three new models, changed with serum sodium (MELD-Na, iMELD, MESO) can exactly predict the prognosis of patients with decompensated cirrhosis for short and intermediate period, and may enhance the prognostic accuracy of MELD. The iMELD is better prognostic model for outcome prediction in patients with decompensated cirrhosis.

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The MELD-Na is an independent short- and long-term prognostic predictor for hepatocellular carcinoma: a prospective survey

BACKGROUND AND AIM

Serum sodium has been suggested to incorporate into the model for end-stage liver disease to enhance its prognostic ability for cirrhosis. A mathematical equation based on model for end-stage liver disease and sodium, known as "MELD-Na", was developed for outcome prediction for cirrhosis. The severity of liver cirrhosis is a key component to predict survival in patients with hepatocellular carcinoma. This study investigated the prognostic role of MELD-Na for hepatocellular carcinoma.

PATIENTS AND METHODS

A total of 535 unselected hepatocellular carcinoma patients were prospectively enrolled to evaluate the performance of MELD-Na.

RESULTS

The MELD-Na was better than model for end-stage liver disease in predicting 6-month mortality by comparing the area under receiver operating characteristic curve (0.782 vs. 0.761, p=0.101). MELD-Na, but not model for end-stage liver disease, was an independent predictor associated with 6-month mortality in multivariate logistic regression analysis (odds ratio: 1.14, p=0.001). In the survival analysis, MELD-Na also independently predicted mortality, with an additional risk of 4.3% per unit increment of the score (p<0.001). Patients with MELD-Na scores between 10 and 20 and scores >20 had 2.1-fold (p<0.001) and 7.5-fold (p<0.001) risk of mortality, respectively, compared to patients with a score <10 in the Cox proportional hazard model.

CONCLUSION

The MELD-Na score is a feasible and independent prognostic predictor for both short- and long-term outcome predictions in patients with hepatocellular carcinoma.

Elevated soluble tumor necrosis factor receptor 75 concentrations identify patients with liver cirrhosis at risk of death

BACKGROUND & AIMS

Elevated levels of the soluble 75-kd receptor for tumor necrosis factor-alpha (sTNF-R 75) are better predictors of mortality in cirrhosis than the Child-Turcotte-Pugh (CTP) score. Thus, we compared sTNF-R 75 with the Model for End-Stage Liver Disease (MELD), CTP, and the sTNF-R 75/55 ratio.

METHODS

Ninety-two patients with liver cirrhosis (mean age, 55 years; range, 19-76 years; male, 66%; CTP stage C, 41%) were included in our prospective single-center survival study. The study setting was a tertiary care university clinic. Soluble TNF-R levels were determined, and the primary end point was death.

RESULTS

During > or =730 days, 44 patients died. Multivariate Cox regression analysis revealed sTNF-R 75 (> or =14 ng/mL) as an independent predictor of mortality (hazard ratio, 2.53; P = .006). By receiver operating characteristic, MELD and sTNF-R 75 were more accurate in predicting 6-, 15-, and 24-month mortality than CTP and sTNF-R 75/55. This was significant for 6 months (MELD, 0.78; sTNF-R 75, 0.75 vs sTNF-R 75/55, 0.60). In patients with high MELD scores (> or =15), survival was further reduced if sTNF-R 75 values were elevated (P = .035).

CONCLUSIONS

Elevated sTNF-R 75 levels independently predicted mortality and improved MELD on the basis of evaluation of prognosis, especially in patients with high MELD scores. Thus, sTNF-R 75 levels might be a useful cytokine-based prognostic marker in patients with liver cirrhosis.

The changing face of patients presenting for liver transplantation

PURPOSE OF REVIEW

Significant changes have been witnessed recently in patients presenting for liver transplantation. The growing number of liver transplantations performed, the increasingly successful outcomes, the expansion of indications, and the implementation of the Model for End-Stage Liver Disease (MELD) system are driving forces for those changes. The purpose of this review is to examine those changes and their effect in perioperative management.

RECENT FINDINGS

Patients who present for liver transplantation today have higher MELD scores and more advanced liver disease. Studies show that high MELD score patients are associated with high perioperative risks and undergo a more difficult perioperative course than patients with low MELD score. More specifically, they have more preoperative comorbidities, more baseline laboratory abnormalities, and higher requirements for intraoperative transfusion and vasopressors. Progress has been also made in management in patients with hepatocellular carcinoma, fulminant hepatic failure, and coronary artery disease prior to liver transplantation.

SUMMARY

Patients who present for liver transplantation today are more acutely ill compared with a few years ago and have more comorbidities, higher perioperative risks, and a more difficult perioperative course. Further characterization of the changes and associated perioperative risks and strategies to manage those risks are needed.

Inequities of the Model for End-Stage Liver Disease: an examination of current components and future additions

PURPOSE OF REVIEW

The aim of this article is to examine the limitations of the Model for End-Stage Liver Disease (MELD) components and summarize data on promising new predictor variables.

RECENT FINDINGS

Promising modifications to MELD have been aimed at identifying more accurate measurements of the current MELD components and at improving survival prediction in earlier stages of cirrhosis. Incorporation of new measurements of cholestasis, coagulopathy and renal dysfunction should improve accuracy and reliability of MELD in predicting mortality in end stage liver disease. Direct bilirubin may be a more specific surrogate marker of liver disease than total bilirubin and further investigation of its use in liver mortality risk models in warranted. The recently developed liver-specific international normalized ratio may mitigate thromboplastin-related variation in international normalized ratio measurements. The incorporation of more accurate assessments of renal function into MELD should improve prognostic accuracy and would avert systematic biases associated with serum creatinine. Hepatic venous pressure gradient and serum sodium are promising predictors of liver-related mortality that may warrant further consideration.

SUMMARY

Modification to MELD, particularly if intended for use in liver transplant allocation, should be based upon objective, reliable, reproducible and readily available predictors; and be able to withstand rigorous model development and validation.

Hyponatremia and mortality among patients on the liver-transplant waiting list

BACKGROUND

Under the current liver-transplantation policy, donor organs are offered to patients with the highest risk of death.

METHODS

Using data derived from all adult candidates for primary liver transplantation who were registered with the Organ Procurement and Transplantation Network in 2005 and 2006, we developed and validated a multivariable survival model to predict mortality at 90 days after registration. The predictor variable was the Model for End-Stage Liver Disease (MELD) score with and without the addition of the serum sodium concentration. The MELD score (on a scale of 6 to 40, with higher values indicating more severe disease) is calculated on the basis of the serum bilirubin and creatinine concentrations and the international normalized ratio for the prothrombin time.

RESULTS

In 2005, there were 6769 registrants, including 1781 who underwent liver transplantation and 422 who died within 90 days after registration on the waiting list. Both the MELD score and the serum sodium concentration were significantly associated with mortality (hazard ratio for death, 1.21 per MELD point and 1.05 per 1-unit decrease in the serum sodium concentration for values between 125 and 140 mmol per liter; P<0.001 for both variables). Furthermore, a significant interaction was found between the MELD score and the serum sodium concentration, indicating that the effect of the serum sodium concentration was greater in patients with a low MELD score. When applied to the data from 2006, when 477 patients died within 3 months after registration on the waiting list, the combination of the MELD score and the serum sodium concentration was considerably higher than the MELD score alone in 32 patients who died (7%). Thus, assignment of priority according to the MELD score combined with the serum sodium concentration might have resulted in transplantation and prevented death.

CONCLUSIONS

This population-wide study shows that the MELD score and the serum sodium concentration are important predictors of survival among candidates for liver transplantation.

Hyponatremia in cirrhosis: pathogenesis, clinical significance, and management

Hyponatremia is a frequent complication of advanced cirrhosis related to an impairment in the renal capacity to eliminate solute-free water that causes a retention of water that is disproportionate to the retention of sodium, thus causing a reduction in serum sodium concentration and hypo-osmolality. The main pathogenic factor responsible for hyponatremia is a nonosmotic hypersecretion of arginine vasopressin (or antidiuretic hormone) from the neurohypophysis related to circulatory dysfunction. Hyponatremia in cirrhosis is associated with increased morbidity and mortality. There is evidence suggesting that hyponatremia may affect brain function and predispose to hepatic encephalopathy. Hyponatremia also represents a risk factor for liver transplantation as it is associated with increased frequency of complications and impaired short-term survival after transplantation. The current standard of care based on fluid restriction is unsatisfactory. Currently, a new family of drugs, known as vaptans, which act by antagonizing specifically the effects of arginine vasopressin on the V2 receptors located in the kidney tubules, is being evaluated for their role in the management of hyponatremia. The short-term treatment with vaptans is associated with a marked increase in renal solute-free water excretion and improvement of hyponatremia. Long-term administration of vaptans seems to be effective in maintaining the improvement of serum sodium concentration, but the available information is still limited. Treatment with vaptans represents a novel approach to improving serum sodium concentration in cirrhosis.

Hot topics in liver transplantation: organ allocation--extended criteria donor--living donor liver transplantation

Liver transplantation has become the mainstay for the treatment of end-stage liver disease, hepatocellular cancer and some metabolic disorders. Its main drawback, though, is the disparity between the number of donors and the patients needing a liver graft. In this review we will discuss the recent changes regarding organ allocation, extended donor criteria, living donor liver transplantation and potential room for improvement. The gap between the number of donors and patients needing a liver graft forced the transplant community to introduce an objective model such as the modified model for end-stage liver disease (MELD) in order to obtain a transparent and fair organ allocation system. The use of extended criteria donor livers such as organs from older donors or steatotic grafts is one possibility to reduce the gap between patients on the waiting list and available donors. Finally, living donor liver transplantation has become a standard procedure in specialized centers as another possibility to reduce the donor shortage. Recent data clearly indicate that center experience is of major importance in achieving good results. Great progress has been made in recent years. However, further research is needed to improve results in the future.

Comparison of four model for end-stage liver disease-based prognostic systems for cirrhosis

Serum sodium (Na) has been suggested for incorporation into the Model for End-Stage Liver Disease (MELD) to enhance its prognostic ability for patients with cirrhosis. Three Na-containing models--the Model for End-Stage Liver Disease with the incorporation of serum sodium (MELD-Na), the integrated Model for End-Stage Liver Disease (iMELD), and the Model for End-Stage Liver Disease to sodium (MESO) index--were independently proposed for this purpose. This study investigated the accuracy of these 4 MELD-based models for outcome prediction. The c-statistic equivalent to the area under the receiver operating characteristic curve (AUC), used to predict 3- and 6-month mortality, was calculated and compared in 825 patients with cirrhosis. The MELD score tended to be lower with increasing Na level. At 3 months of enrollment, the iMELD had the highest AUC (0.807) and was followed by the MELD-Na (0.801), MESO (0.784), and MELD (0.773); the difference between the MESO and MELD was statistically significant (P = 0.013). At 6 months, the iMELD still had the highest AUC (0.797) and was followed by the MELD-Na (0.778), MESO (0.747), and MELD (0.735); all comparisons showed significant differences between each other (all P < 0.01), with the exception of iMELD and MELD-Na (P = 0.18). With the most discriminative cutoffs, the specificity and negative predictive value were 70%-85% and 89%-97%, respectively, at 3 and 6 months for the 4 models. Patients with spontaneous bacterial peritonitis (SBP) consistently had significantly higher MELD-derived scores in all 4 models compared to patients without SBP (all P < 0.01). Patients with hepatic encephalopathy also had higher scores in all 4 models, although the statistical significance was established only for the iMELD (41.0 +/- 11.5 versus 37.6 +/- 9.1, P = 0.037). In conclusion, the incorporation of Na into the MELD may enhance prognostic accuracy. Both the iMELD and MELD-Na are better prognostic models for outcome prediction in patients with cirrhosis. Patients with SBP have a higher MELD-derived score. Future studies are warranted to define the optimal MELD-based prognostic model for cirrhosis.

[Dilutional hyponatremia, hepatorenal syndrome and liver transplantation]

Cirrhosis is a chronic, progressive disease characterized by complications associated with portal hypertension and liver failure. Renal function disorders are a common complication in patients with cirrhosis and are associated with high morbidity and mortality and poor prognosis. Renal function alterations in these patients include sodium and water retention and renal vasoconstriction. Sodium retention causes the formation of ascites and edema, solute-free water leads to dilutional hyponatremia, and renal vasoconstriction gives rise to the development of hepatorenal syndrome (HRS). Due to their poor prognosis, the presence of ascites, dilutional hyponatremia and HRS are indications for liver transplantation (LT). Recent studies have allowed new prognostic factors in these patients to be identified, novel treatments for dilutional hyponatremia and HRS to be applied, and the association of these complications with disease course and outcome before and after LT to be described. The present review discusses new concepts of the physiopathology, evaluation and treatment of cirrhotic patients with dilutional hyponatremia and HRS and the relationship of these entities with LT.

Selecting an optimal prognostic system for liver cirrhosis: the model for end-stage liver disease and beyond

In comparison with the Child-Turcotte-Pugh (CTP) system, recent studies suggested that the model for end-stage liver disease (MELD) may more accurately predict the survival for patients with cirrhosis. In the US, the liver allocation system was changed in 2002 from a status-based algorithm utilizing CTP scores to one using continuous MELD severity scores as a reference system in prioritizing adult patients on the waiting list. Direct evidence that demonstrates the benefits of MELD is the fact that the mortality rates of transplant candidates on the waiting list have remarkably decreased after the implementation of the MELD. The MELD score is closely associated with the degree of portal hypertension as reflected by the hepatic venous pressure gradient. Hyponatraemia occurs as a result of advanced cirrhosis, and a serum sodium (Na) level <126 mEq/L at the time of listing for transplantation is a strong independent predictor of mortality. Several MELD-derived prognostic models that incorporate serum Na into calculation have been proposed in the hopes of further improving the MELD's prognostic accuracy. Additionally, serum parameters such as creatinine and international normalized ratio are subject to interlaboratory variations and may need unifying standartisations. Patients with refractory complications of cirrhosis may need a priority MELD score to prioritize them on the waiting list. Appropriate modifications and the fine-tuning of the MELD based on well-designed prospective studies are necessary in solving the current controversial issues.

Development of a survival evaluation model for liver transplant recipients with hepatocellular carcinoma secondary to hepatitis B

AIM

To develop a model using easily obtainable, objective, verifiable preoperative parameters, to help evaluate post transplant survival probability for hepatocellular carcinoma (HCC) patients with hepatitis B.

METHODS

We retrospectively examined a cohort of 150 consecutive primary cadaveric liver transplants with HCC in our center over 6 years. Thirteen preoperative biochemical parameters and six tumor-related factors were analyzed to identify their correlation with post transplant survival using the Cox proportional-hazards regression model. The predictive power of a new model and the model for end stage liver disease was compared by the receiver operating characteristic curve.

RESULTS

In univariate analysis, the factors significantly associated with post transplant survival were serum concentrations of albumin, total bilirubin, alkaline phosphatase, alpha-fetoprotein, gamma-glutamyltransferase, aspartate aminotransferase, sodium, tumor diameter and the number of tumor nodules. Multivariate analysis showed alpha-fetoprotein, serum sodium, alkaline phosphatase and the number of tumor nodules were significantly associated with the post transplant outcome. Based on the four variables, we established a new model with a c-statistic of 0.72 which was significantly greater than 0.50 (P = 0.001), and the c-statistic of MELD was 0.59 (P = 0.146).

CONCLUSION

The new model based on four objective tumor-related parameters has the capacity to evaluate the risk of post transplant mortality for HCC patients with hepatitis B.

What's new in the treatment of ascites and spontaneous bacterial peritonitis

In recent years, there have been important advances in the clinical management of ascites and its related complications, such as hyponatremia, hepatorenal syndrome (HRS), and spontaneous bacterial peritonitis (SBP). Moreover, new drugs are currently being investigated for their potential usefulness in managing these complications. This article is not intended to comprehensively review all the literature published in recent years; rather, the authors discuss only studies they believe represent a potentially significant advance in this field. The following review is divided into two parts; the first discusses ascites and renal function abnormalities, including hyponatremia and HRS, and the second discusses SBP management.

Treatment of hyponatremia

Hyponatremia is an electrolyte disorder that is defined by a serum sodium concentration of less than 136 mmol/L. Hyponatremia occurs at a high incidence. It is commonly associated with mild to moderate mental impairment. Hypoosmolar hyponatremia occurs in the setting of plasma volume deficiency ("hypovolemia", e. g. after gastrointestinal fluid loss), liver cirrhosis and cardiac failure ("hypervolemic" hyponatremia) and syndrome of inappropriate antidiuretic hormone secretion ("euvolemic" hyponatremia). Excessive antidiuretic hormone and continued fluid intake are the pathogenetic causes of these hyponatremias. Whereas hypovolemic hyponatremia is best corrected by isotonic saline, conventional proposals for euvolemic and hypervolemic hyponatremia consist of the following: fluid restriction, lithium carbonate, demeclocycline, urea and loop diuretic. None of these nonspecific treatments is entirely satisfactory. Recently a new class of pharmacological agents -orally available vasopressin antagonists, collectively called vaptans- have been described. A number of clinical trials using vaptans have been performed already. They showed vaptans to be effective, specific and safe in the treatment of euvolemic and hypervolemic hyponatremia.

Current concepts in the evaluation of patients for liver transplantation

Candidates for liver transplantation undergo a thorough medical, surgical, psychosocial and financial evaluation prior to listing for transplantation. Prioritization for allocating livers is based upon the model for end-stage liver disease score and waiting-time mortality with the fundamental concept of giving organs to the sickest first. In the upcoming years the allocation system may be modified to include other factors associated with mortality, such as serum sodium, and may incorporate both pre- and post-transplant mortality. Strategies to expand the donor pool include utilizing livers from donors after cardiac death, split liver transplantation and living donor liver transplantation. Future challenges for liver transplantation will include the obesity epidemic and the prevention and treatment of recurrent disease, particularly hepatitis C.

Factors prognostic of survival in patients awaiting liver transplantation for end-stage liver disease

In this study, we investigated possible independent predictive factors for survival, other than MELD score, in patients with cirrhosis. We reviewed the serum sodium, cholesterol, albumin, and platelet levels of 99 patients with cirrhosis and investigated the possible correlation of these parameters with survival period. We found that 77% and 81% of patients with cirrhosis were hypocholesterolemic and hypoalbuminemic, respectively. We noted that the survival time of 6 months in patients with serum sodium levels <125 mM at the time of admission to the study was 27% less than that in patients with sodium levels >130 mM. Patients with cirrhosis and serum sodium levels >130 mM survived for more than 1 year (95% CI). MELD scores of patients with serum sodium levels >130, between 125 and 129, and <125 mM were 15.8 to 19.9, 19.7 to 23.6, and 23.3 to 27.2, respectively (95% CI). In conclusion, we suggest that although all of these parameters are correlated with survival in patients with cirrhosis, the serum sodium level is the most accurate prognostic factor and a valid tool for predicting survival when considered in combination with the MELD score.

Relationship between laboratory parameters and intensive care unit stay post-liver transplantation: proposal of a model

The aim of this study was to create a model that forecasted the stay in the intensive care unit in post-liver transplantation.

METHODS

Twenty-three consecutive patients who underwent liver transplantation provided samples for serum sodium, serum creatinine, total bilirubin, cholesterol, aspartate and alanine aminotransferase, alkaline phosphatase (ALP), albumin, and platelet count for correlation together with age at transplantation in a Pearson correlation model with intensive care unit stay. Multivariate analysis used a regression model to evaluate the relationship between the dependent variable "intensive care unit stay" and the predictor variables that were correlated by a Pearson correlation test. To test the acceptability and strength of the model, analyses of variance was performed and a multiple correlation coefficient R was calculated for the model.

RESULTS

Pearson correlation test showed a strong correlation between intensive care unit stay and creatinine (correlation coefficient = 0.34, P = .03), serum sodium (correlation coefficient = -0.42, P < .01), and total bilirubin (correlation coefficient = -0.29, P = .06). Other variables showed no significant correlation, namely correlation coefficients < 0.24 (P > .1). The final model to evaluate the relationship between the dependent variable "intensive care unit stay" and laboratory parameters included ALP, serum creatinine, serum sodium, and total bilirubin as well as a correction for age.

CONCLUSIONS

The most significant parameters were total bilirubin, serum creatinine, and serum sodium. The proposal model significantly correlated with the variable "intensive care unit stay." Such data are particularly important since increased intensive care unit stay correlates with a significant reduction in 1-year survival rate.

Hepatic encephalopathy as a predictor of survival in patients with end-stage liver disease

Hepatic encephalopathy (HE) is an important component of hepatic decompensation, which reduces survival in patients with cirrhosis. The Model for End-Stage Liver Disease (MELD) score has been used to predict survival of patients with cirrhosis. The aims of this study were to determine whether HE is a predictor of survival of patients with cirrhosis and to examine the degree to which HE may add to the survival prediction of MELD. Patients with end-stage liver disease whose data were included in 2 databases were included in the analysis: 223 patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) insertion, and 271 patients hospitalized with hepatic decompensation. In univariate analysis, HE grade 3 or higher was associated with a 3.7-fold (95% confidence interval, 1.9-7.3, P<0.01) increase in the risk of death in the TIPS patients and HE grade 2 or higher was associated 3.9-fold increase (95% confidence interval [95% CI], 2.6-5.7, P<0.01) in hospitalized patients. As expected, MELD and Child-Turcotte-Pugh scores (with and without HE included) were also markedly associated with survival. When HE (grade 2 or higher) and MELD were considered together, HE remained strongly statistically significant in the hospitalized patients (hazard ratio=2.6, 95% CI, 1.7-3.8, P<0.01). The effect became smaller in the TIPS patients (hazard ratio=1.1; 95% CI, 0.7-1.6, P=0.76). In conclusion, this retrospective study demonstrates that HE is an important event in the natural history of cirrhosis that affects subsequent survival of patients. HE may provide additional prognostic information independent of MELD, which warrants prospective validation.

Performance of the new MELD-Na score in predicting 3-month and 1-year mortality in Chinese patients with chronic hepatitis B

The new Model for End-Stage Liver Disease (MELD)-Na score has been validated in a population predominantly affected by chronic hepatitis C and alcoholic liver disease. We aimed to validate the score in Chinese patients with chronic hepatitis B-related complications admitted to the hospital from 1996 to 2003. MELD and the new MELD-Na scores (MELD-Na = MELD + 1.59 [135 - Na] with maximum and minimum Na of 135 and 120 mmol/L, respectively) on initial admissions were calculated. Cox proportional hazard model was used to assess factors associated with mortality. The area under the receiver operator characteristic curve (AUC) was used to compare the predictive abilities of MELD and MELD-Na scores for 3-month and 1-yr mortalities. Patients with hepatocellular carcinoma were excluded. A total of 2,073 patients with liver disease were admitted during the study period and 363 patients had chronic hepatitis B-related complications other than hepatocellular carcinoma. At a median follow-up of 106 weeks, 134 patients died and 14 received liver transplantation. Patients with MELD-Na scores 11-20, 21-30, and >30 had mortality increased by 2.0-fold, 4.7-fold, and 7.6-fold, respectively, compared to patients with scores < or =10. At 3 months and 1 yr, the AUC of the MELD-Na score (0.75 and 0.79, respectively) was superior to those of the MELD score (0.72 and 0.75, respectively) (P = 0.004) in predicting mortality. In conclusion, the new MELD-Na score is a valid model to predict mortality in patients with complications of chronic hepatitis B.

Transjugular intrahepatic portosystemic shunt for refractory ascites: a meta-analysis of individual patient data

BACKGROUND & AIMS

Several randomized controlled trials have compared a transjugular intrahepatic portosystemic shunt (TIPS) with large-volume paracentesis in cirrhotic patients with refractory ascites. Although all agree that TIPS reduces the recurrence rate of ascites, survival is controversial. The aim of this study was to compare the effects of TIPS and large-volume paracentesis in cirrhotic patients with refractory ascites by means of meta-analysis of individual patient data from 4 randomized controlled trials.

METHODS

The study population consisted of 305 patients: 149 allocated to TIPS and 156 to paracentesis. Cumulative probabilities of transplant-free survival and of hepatic encephalopathy (HE) were estimated by the Kaplan-Meier method and differences assessed by log-rank test. The total number of HE episodes per patient was also compared between TIPS and paracentesis.

RESULTS

Tense ascites recurred in 42% of patients allocated to TIPS and 89% allocated to paracentesis (P < .0001). Sixty-five patients in the TIPS group and 78 in the paracentesis group died. The actuarial probability of transplant-free survival was significantly better in the TIPS group (P = .035). Cox regression analysis performed in a subgroup of 235 patients (114 allocated to TIPS and 121 to paracentesis) showed that age, serum bilirubin level, plasma sodium level, and treatment allocation were independently associated with transplant-free survival. The average number of HE episodes was significantly higher in the TIPS group (1.13 +/- 1.93 vs 0.63 +/- 1.18; P = .006), although the cumulative probability of developing the first episode of HE was similar between the groups (P = .19).

CONCLUSIONS

The present meta-analysis of individual patient data provides further evidence to the previous meta-analyses of literature data showing that TIPS significantly improves transplant-free survival of cirrhotic patients with refractory ascites.

An integrated MELD model including serum sodium and age improves the prediction of early mortality in patients with cirrhosis

The Model for End-Stage Liver Disease (MELD) is widely used to predict the short-term mortality in patients with cirrhosis, but potential limitations of this score have been reported. The aim of this study was to improve the score's prognostic accuracy by assessing new objective variables. Data of 310 consecutive patients with cirrhosis who underwent elective transjugular intrahepatic portosystemic shunt placement between July 1995 and March 2005 were analyzed retrospectively. Bivariate and multivariate analyses were performed by proportional hazard Cox regression models. The area under the receiver operating characteristic curve (auROC) and the likelihood ratio test were used to evaluate the performance of the models for predicting early mortality. Findings were validated in a cohort of 451 consecutive patients with cirrhosis on waiting list for liver transplantation. Bivariate analyses showed that the following variables correlated with time to death: age, serum bilirubin, serum creatinine, international normalized ratio of prothrombin time, serum albumin, serum sodium, and MELD. Multivariate analysis revealed that MELD, serum sodium, and age were independently associated with the risk of death. The integrated MELD model (iMELD, incorporating serum sodium and age) was better than original MELD in predicting 12-month mortality: auROC increased by 13.4% and the likelihood ratio statistic from 23.5 to 48.2. The improved accuracy of iMELD was confirmed in the validation sample of 451 patients with cirrhosis on the waiting list for liver transplantation by increasing auROC (+8%) and likelihood ratio statistic (from 41.4 to 82.0). This study shows that in patients with cirrhosis, serum sodium and age are predictors of mortality independent of the MELD score. The incorporation of these variables into the original MELD formula improves the predictive accuracy of time to death.

The impact of serum sodium concentration on mortality after liver transplantation: a cohort multicenter study

Modification of the current allocation system for donor livers in the United States to incorporate recipient serum sodium concentration ([Na]) has recently been proposed. However, the impact of this parameter on posttransplantation mortality has not been previously examined in a large risk-adjusted analysis. We assessed the effect of recipient [Na] on the survival of all adults with chronic liver disease who received a first single organ liver transplant in the UK and Ireland during the period March 1, 1994 to March 31, 2005 (n=5,152) at 3 years, during the first 90 days, and beyond the first 90 days, adjusting for a wide range of recipient, donor, and graft characteristics. Compared to those with normal [Na] (135-145 meq/L; n=3,066), severely hyponatremic recipients ([Na]<130 meq/L, n=541), had a higher risk-adjusted mortality at 3 years (hazard ratio [HR] 1.28; 95% confidence interval [CI], 1.04-1.59; P<0.02). The excess mortality was, however, confined to the first 90 days (HR 1.55; 95% CI, 1.18-2.04; P<0.002) with no significant difference thereafter. This was also true for hypernatremic recipients ([Na]>45 meq/L, n=81), who had an even greater risk-adjusted mortality compared to normonatremic recipients (overall: HR 1.85; 95% CI, 1.25-2.73; P<0.002; <or=90 days: HR 2.29; 95% CI, 1.42-3.70; P<0.001; >90 days: HR 1.12; 95% CI, 0.55-2.29; P=0.8), whereas mildly hyponatremic recipients ([Na] 130-134 meq/L, n=1,127) had similar risk-adjusted mortality to those with normal [Na] at the same time points. In conclusion, recipient [Na] is an independent predictor of death following liver transplantation. Attempts to correct the [Na] toward the normal reference range are an important aspect of pretransplantation management.

Correlation and comparison of the model for end-stage liver disease, portal pressure, and serum sodium for outcome prediction in patients with liver cirrhosis

BACKGROUND

The model for end-stage liver disease (MELD), hepatic venous pressure gradient (HVPG), and serum sodium (SNa) are important prognostic markers for patients with liver cirrhosis. The correlation among these markers and their predictive accuracy for survival are unclear.

METHODS

A total of 213 cirrhotic patients undergoing hemodynamic measurement were analyzed. The correlations between MELD score, SNa, and hemodynamic parameters were investigated.

RESULTS

There was a significant correlation between MELD and HVPG (r=0.255, P<0.001), between SNa and MELD (r=-0.483, P<0.001), and between HVPG and SNa (r=-0.213, P=0.002). Using mortality as the end-point, the area under receiver operating characteristic curve (AUC) for MELD was 0.789, compared with 0.659 for HVPG (P=0.165) and 0.860 for SNa (P=0.34) at 3 months; the difference between HVPG and SNa was significant (P=0.015). The AUC at 6 months was significantly higher for SNa and MELD compared with that of HVPG. Among 134 patients with low (<14) MELD scores, a high (>16 mm Hg) HVPG, and low SNa (<135 mEq/L) predicted early mortality. In the Cox multivariate model, MELD, HVPG, and Child-Turcotte-Pugh scores were consistently identified as independent poor prognostic predictors when they were treated either as dichotomous or continuous variables in the model.

CONCLUSIONS

MELD score is closely associated with HVPG and SNa in cirrhotic patients. HVPG is not superior to MELD score or SNa for short-term outcome prediction. High HVPG and low SNa may identify high-risk patients with low MELD scores. High MELD, HVPG, and Child-Turcotte-Pugh scores are independent predictors of poor long-term survival.

Applicability of MELD as a short-term prognostic indicator in patients with chronic liver disease: an Indian experience

BACKGROUND

The model for end-stage liver disease (MELD), which employs objective variables, statistical weighting and a continuous scale, has replaced the Child-Turcotte-Pugh (CTP) classification as the scoring system of choice in several liver transplant centers. However, the predictive ability of MELD has never been prospectively evaluated in India. The aim of this study was to examine the MELD score, the CTP score and the recently proposed modified CTP score in Indian patients with liver cirrhosis to determine their correlation and compare their prognostic significance for short-term survival.

METHODS

A total of 76 patients with cirrhosis (mean age 46.97 years) were prospectively evaluated and followed up for 6 months. MELD score, CTP score and modified CTP score were calculated at baseline. The correlation between variables was evaluated by Pearson's correlation test. Receiver-operating characteristic (ROC) curves were used to determine the cutoff values for each score with the best sensitivity and specificity in discriminating between patients who survived and those who died.

RESULTS

Alcoholic liver disease was the most common (50%) etiology of cirrhosis. MELD score and CTP score showed very good correlation (Pearson correlation r = 0.983). ROC curve showed area under curve (c-statistics) for MELD score, CTP score and modified CTP score as 0.764, 0.804 and 0.817, respectively.

CONCLUSION

The MELD score was not found to be superior to CTP score and modified CTP score for short-term prognostication of patients with cirrhosis in this study.

Vaptans: a promising therapy in the management of advanced cirrhosis

BACKGROUND/AIMS

Hyponatremia (serum sodium concentration, <135 mmol/L) is a predictor of death among patients with chronic heart failure and cirrhosis. At present, therapy for acute and chronic hyponatremia is often ineffective and poorly tolerated. We investigated whether tolvaptan, an orally active vasopressin V(2)-receptor antagonist that promotes aquaresis--excretion of electrolyte-free water--might be of benefit in hyponatremia.

METHODS

In two multicenter, randomized, double-blind, placebo-controlled trials, the efficacy of tolvaptan was evaluated in patients with euvolemic or hypervolemic hyponatremia. Patients were randomly assigned to oral placebo (223 patients) or oral tolvaptan (225) at a dose of 15mg daily. The dose of tolvaptan was increased to 30 mg daily and then to 60 mg daily, if necessary, on the basis of serum sodium concentrations. The two primary end points for all patients were the change in the average daily area under the curve for the serum sodium concentration from baseline to day 4 and the change from baseline to day 30.

RESULTS

Serum sodium concentrations increased more in the tolvaptan group than in the placebo group during the first 4 days (P<0.001) and after the full 30 days of therapy (P<0.001). The condition of patients with mild or marked hyponatremia improved (P<0.001 for all comparisons). During the week after discontinuation of tolvaptan on day 30, hyponatremia recurred. Side effects associated with tolvaptan included increased thirst, dry mouth, and increased urination. A planned analysis that combined the two trials showed significant improvement from baseline to day 30 in the tolvaptan group according to scores on the Mental Component of the Medical Outcomes Study 12-item Short-Form General Health Survey.

CONCLUSIONS

In patients with euvolemic or hypervolemic hyponatremia, tolvaptan, an oral vasopressin V2-receptor antagonist, was effective in increasing serum sodium concentrations at day 4 and day 30. [Abstract reproduced by permission of N Engl J Med 2006;355:2099-2112].

The model for end-stage liver disease comes of age

The care of patients who have chronic liver disease has evolved considerably since the Model for End-stage Liver Disease (MELD) was first described 6 years ago. This article traces the progress in liver allocation and clinical liver disease research that includes the MELD score and highlights the management of areas in which MELD and the principles underlying MELD enhance the clinician's ability to understand better the patient who has chronic liver disease.

Liver transplantation: an update 2007

PURPOSE OF REVIEW

Recent attention in liver transplantation has focused on equity in organ allocation and management of posttransplant complications.

RECENT FINDINGS

Adoption of the model for end-stage liver disease for liver allocation has been successful in implementing a system based on medical urgency rather than waiting time. Refinements are being studied in improving the prediction of mortality and improving transplant benefit by balancing pretransplant mortality and posttransplant survival. Emerging literature is examining expansion of the current criteria for transplantation of hepatocellular carcinoma and the role of neoadjuvant therapy. Chronic renal dysfunction after liver transplantation is a source of considerable morbidity. Nephron-sparing immunosuppression regimens are emerging with encouraging results. Hepatitis C virus infection is difficult to differentiate histologically from rejection, although newer markers are being developed. Antiviral and immunosuppressive strategies for reducing the severity of hepatitis C virus recurrence are discussed. Alcohol relapse is common after liver transplant in alcoholic liver disease patients and can lead to worse outcomes.

SUMMARY

Organ allocation tends to evolve under the model for end-stage liver disease with a focus on maximizing transplant benefit. Hepatitis C virus, hepatocellular carcinoma, chronic renal dysfunction and alcohol relapse are major challenges, and continued research in these areas will undoubtedly lead to better outcomes for transplant recipients.