MELD is not enough--enough of MELD?

MELD3.0 is superior to MELDNa and MELD for prediction of mortality in patients with cirrhosis: An external validation in a multi-ethnic population

Background and Aim

The model for end-stage liver disease (MELD) was updated to MELDNa and recently to MELD3.0 to predict survival of cirrhotic patients. We validated the prognostic performance of MELD3.0 and compared with MELDNa and MELD amongst cirrhotic inpatients.

Methods

Demographical, clinical, biochemical, and survival data of cirrhotic inpatients in Singapore General Hospital (SGH) from 01 January 2018 to 31 December 2018, were studied retrospectively. Patients were followed up from first admission in 2018 until death or until 01 April 2023. Area under the receiver operating characteristic curves (AUROC) were computed for the discriminative effects of MELD3.0, MELDNa, and MELD to predict 30-, 90-, and 365-day mortalities. AUROC was compared with DeLong's test. The cutoff MELD3.0 score for patients at high risk of 30-day mortality was determined using Youden's Index. Survival curves of patients with MELD3.0 score above and below the cutoff were estimated with Kaplan-Meier method and compared with log-rank analysis.

Results

Totally 862 patients were included (median age 71.0 years [interquartile range, IQR: 64.0-79.0], 65.4% males, 75.8% Chinese). Proportion of patients with Child-Turcotte-Pugh classes A/B/C were 55.5%/35.5%/9.0%. Median MELD3.0/MELDNa/MELD scores were 12.2 (IQR: 8.7-18.3)/11.0 (IQR: 8.0-17.5)/10.3 (IQR: 7.8-15.0). Median time of follow-up was 51.9 months (IQR: 8.5-59.6). The proportion of 30-/90-/365-day mortalities was 5.7%/13.2%/26.9%. AUROC of MELD3.0/MELDNa/MELD in predicting 30-, 90-, and 365-day mortalities, respectively, were 0.823/0.793/0.783, 0.754/0.724/0.707, 0.682/0.654/0.644 (P < 0.05). Optimal cutoff to predict 30-day mortality was MELD3.0 > 19 (sensitivity = 67.4%, specificity = 82.4%). Patients with MELD3.0 > 19, compared with patients with MELD3.0 ≤ 19, had shorter median time to death (98.0 days [IQR: 28.8-398.0] vs 390.0 days [IQR: 134.3-927.5]), and higher proportion of 30-day mortality (68.8% vs 43.0%) (P < 0.001).

Conclusion

MELD3.0 performs better than MELDNa and MELD in predicting mortality in cirrhotic inpatients. MELD3.0 > 19 predicts higher 30-day mortality.

PRO-C3 is a predictor of clinical outcomes in distinct cohorts of patients with advanced liver disease

Background & Aims

Fibroblast activity is a key feature of fibrosis progression and organ function loss, leading to liver-related complications and mortality. The fibrogenesis marker, PRO-C3, has been shown to have prognostic significance in relation to fibrosis progression and as a treatment efficacy marker. We investigated whether PRO-C3 was prognostic for clinical outcome and mortality in two distinct cohorts of compensated cirrhosis.

Methods

Cohort 1 was a rapid fibrosis progression cohort including 104 patients with HCV and biopsy-proven Ishak fibrosis stage ≥3 without prior clinical events. Cohort 2 was a prospective cohort including 172 patients with compensated cirrhosis of mixed aetiology. Patients were assessed for clinical outcomes. PRO-C3 was assessed in serum at baseline in cohorts 1 and 2, and compared with model for end-stage liver disease and albumin-bilirubin (ALBI) scores.

Results

In cohort 1, a 2-fold increase in PRO-C3 was associated with 2.7-fold increased hazard of liver-related events (95% CI 1.6-4.6), whereas a one unit increase in ALBI score was associated with a 6.5-fold increased hazard (95% CI 2.9-14.6). In cohort 2, a 2-fold increase in PRO-C3 was associated with a 2.7-fold increased hazard (95% CI 1.8-3.9), whereas a one unit increase in ALBI score was associated with a 6.3-fold increased hazard (95% CI 3.0-13.2). A multivariable Cox regression analysis identified PRO-C3 and ALBI as being independently associated with the hazard of liver-related outcomes.

Conclusions

PRO-C3 and ALBI were independent prognostic factors for predicting liver-related clinical outcomes. Understanding the dynamic range of PRO-C3 might enhance its use for both drug development and clinical practice.

Impact and Implications

We tested novel proteins of liver scarring (PRO-C3) in two groups of liver patients with advanced disease to see if they could predict clinical events. We found that this marker and an established test called ALBI were both independently associated with future liver-related clinical outcomes.

Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document

Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.

Serum cystatin C as a predictor of 90-day mortality among patients admitted with complications of cirrhosis

BACKGROUND AND AIM

Cystatin C (Cys) is not affected by age, sex, and muscle mass. We evaluated to compare the predictive performance of serum Cys level and model for end-stage liver disease (MELD) score and developed a new model to predict 90-day mortality among patients admitted with cirrhosis complications.

METHODS

A prospective cohort study was performed from December 2018 to December 2019. All cirrhotic patients admitted with acute decompensated liver cirrhosis or acute on chronic liver failure had laboratory values measured within 48 h of admission.

RESULTS

A cohort of 225 patients with cirrhosis was admitted during the study period. Sixty-five patients were eligible for analysis. Twenty-seven of these patients (41.4%) died within 90 days of follow-up. The median of MELD score was 20.5 (15, 24). Serum Cys level of >1.45 mg/L had the highest 90-day mortality prediction with the sensitivity and specificity of 66.7% and 68.4%, respectively. Cys and MELD scores were predictive of 90-day mortality: Cys hazard ratio (HR) = 2.04 (95% CI 1.01-4.14, P = 0.048); MELD score HR = 1.01 (95% CI 0.51-2.01, P = 0.970). C-statistic of Cys, MELD score, model for end-stage liver disease-cystatin C (MELD-Cys) score, combined Cys with MELD-Cys score to predict 90-day mortality were 0.67, 0.58, 0.58, and 0.63, respectively. Adding Cys to the MELD score did not improve the predictive of 90-day mortality.

CONCLUSION

Serum Cys is superior to MELD score, and the new MELD-Cys model is comparable to the MELD score in predicting mortality among patients with cirrhosis admitted with complications.

Validation of a Model for Identification of Patients With Compensated Cirrhosis at High Risk of Decompensation

BACKGROUND & AIMS

It is important to rapidly identify patients with advanced liver disease. Routine tests to assess liver function and fibrosis provide data that can be used to determine patients' prognoses. We tested the validated the ability of combined data from the ALBI and FIB-4 scoring systems to identify patients with compensated cirrhosis at highest risk for decompensation.

METHODS

We collected data from 145 patients with compensated cirrhosis (91% Child A cirrhosis and median MELD scores below 8) from a cohort in Nottingham, United Kingdom, followed for a median 4.59 years (development cohort). We collected baseline clinical features and recorded decompensation events. We used these data to develop a model based on liver function (assessed by the ALBI score) and extent of fibrosis (assessed by the FIB-4 index) to determine risk of decompensation. We validated the model in 2 independent external cohorts (1 in Dublin, Ireland and 1 in Menoufia, Egypt) comprising 234 patients.

RESULTS

In the development cohort, 19.3% of the patients developed decompensated cirrhosis. Using a combination of ALBI and FIB-4 scores, we developed a model that identified patients at low vs high risk of decompensation (hazard ratio [HR] for decompensation in patients with high risk score was 7.10). When we tested the scoring system in the validation cohorts, the HR for decompensation in patients with a high-risk score was 12.54 in the Ireland cohort and 5.10 in the Egypt cohort.

CONCLUSION

We developed scoring system, based on a combination of ALBI and FIB-4 scores, that identifies patients at risk for liver decompensation. We validated the scoring system in 2 independent international cohorts (Europe and the Middle East), so it appears to apply to diverse populations.

Performance of Disease-Specific Scoring Models in Intensive Care Patients with Severe Liver Diseases

INTRODUCTION

Egypt has the highest prevalence of Hepatitis C Virus (HCV) in the world, estimated nationally at 14.7%. HCV treatment consumes 20% ($80 million) of Egypt's annual health budget. Outcomes of cirrhotic patients admitted to the ICU may, in fact, largely depend on differences in the state of the disease, criteria and indications for admission, resource utilization, and intensity of treatment.

AIM

The aim of the present study was to evaluate the efficacy of liver specific scoring models in predicting the outcome of critically ill cirrhotic patients in the ICU as it may help in prioritization of high risk patients and preservation of ICU resources.

MATERIALS AND METHODS

Over one year, a total of 777 patients with End Stage Liver Disease (ESLD) due to HCV infection were included in this retrospective non-randomized human study. All statistical analyses were performed by the statistical software SPSS version 22.0 (SPSS, Chicago, IL, USA). Child Turcotte Pugh (CTP) score, MELD score, MELD-Na, MESO, iMELD, Refit MELD and Refit MELD-Na were calculated on ICU admission.

RESULTS

ICU admission was mainly due to Gastrointestinal (GI) bleeding and Hepatic Encephalopathy (HE). Overall mortality was 27%. Age and sex showed no statistical difference between survivors and non survivors. Significantly higher mean values were observed for all models among individuals who died compared to survivors. MELD-Na was the most specific compared to the other scores. MELD-Na was highly predictive of mortality at an optimized cut-off value of 20.4 (AURC=0.789±0.03-CI 95%=0.711-0.865) while original MELD was highly predictive of mortality at an optimized cut-off value of 17.4 (AURC=0.678±0.01-CI 95%=0.613-0.682) denoting the importance of adding serum sodium to the original MELD. INR, serum creatinine, bilirubin, white blood cells count and hyponatremia were significantly higher in non survivors compared to survivors, while hypoalbuminemia showed no statistical difference. The advent of Hepatorenal Syndrome (HRS) and Spontaneous Bacterial Peritonitis (SBP) carried worse prognosis. Hyponatremia and number of transfused blood bags were additional independent predictors of mortality.

CONCLUSION

In cirrhosis of liver, due to HCV infection, patients who died during their ICU stay displayed significantly higher values on all prognostic scores at admission. The addition of sodium to MELD score greatly improves the predictive accuracy of mortality. MELD-Na showed the highest predictive value of all scores.

Prognostic Models for Survival in Patients with Stable Cirrhosis: A Multicenter Cohort Study

BACKGROUND

Two models are mostly used to predict survival in cirrhosis: the Child-Pugh score (CP score) and the model for end-stage liver disease score (MELD score).

AIMS

The aim of this study is to evaluate the CP score and the MELD score for short- and long-term prognosis in cirrhosis, as well as CP-creatinine score, MELD-Na score, and UKELD score.

METHODS

One thousand and forty-seven patients from five referral centers were included: men/women: 620/427, median age: 58 years (IQR 48-66), median follow-up: 33 months (IQR 12-74), CP (A/B/C): 493/357/147, CP score: 7 (IQR 5-9), MELD score: 12 (IQR 9-16). The performance of each score was evaluated by the Cox hazard model in terms of their: discrimination ability (C-index and Somer's D) and calibration (3, 12 months). Internal validation was done with bootstrapping (100 samples).

RESULTS

Three hundred and fifty-two patients (33.6%) died. All scores were significantly associated with overall mortality, when assessed by univariate Cox analysis. CP-creatinine score performed significantly better than all other scores [bootstrap C-index 0.672, 95% CI 0.642-0.703, bootstrap Somer's D 0.344 (0.285-0.401)], apart from CP score, which showed similar performance. Inclusion in the multivariable Cox model of age together with CP-creatinine score improved the discriminative ability of the model [bootstrap C-index (95% CI) 0.700 (0.661-0.740)]. In terms of calibration, CP-creatinine score was the best for both 3- and 12-month survival in the total population.

CONCLUSIONS

CP score and CP-creatinine score have better prognostic value compared to MELD score, MELD-Na score, and UKELD score for predicting short- and long-term mortality in patients with stable cirrhosis.

Multivariate metabotyping of plasma predicts survival in patients with decompensated cirrhosis

BACKGROUND & AIMS

Predicting survival in decompensated cirrhosis (DC) is important in decision making for liver transplantation and resource allocation. We investigated whether high-resolution metabolic profiling can determine a metabolic phenotype associated with 90-day survival.

METHODS

Two hundred and forty-eight subjects underwent plasma metabotyping by (1)H nuclear magnetic resonance (NMR) spectroscopy and reversed-phase ultra-performance liquid chromatography coupled to time-of-flight mass spectrometry (UPLC-TOF-MS; DC: 80-derivation set, 101-validation; stable cirrhosis (CLD) 20 and 47 healthy controls (HC)).

RESULTS

(1)H NMR metabotyping accurately discriminated between surviving and non-surviving patients with DC. The NMR plasma profiles of non-survivors were attributed to reduced phosphatidylcholines and lipid resonances, with increased lactate, tyrosine, methionine and phenylalanine signal intensities. This was confirmed on external validation (area under the receiver operating curve [AUROC]=0.96 (95% CI 0.90-1.00, sensitivity 98%, specificity 89%). UPLC-TOF-MS confirmed that lysophosphatidylcholines and phosphatidylcholines [LPC/PC] were downregulated in non-survivors (UPLC-TOF-MS profiles AUROC of 0.94 (95% CI 0.89-0.98, sensitivity 100%, specificity 85% [positive ion detection])). LPC concentrations negatively correlated with circulating markers of cell death (M30 and M65) levels in DC. Histological examination of liver tissue from DC patients confirmed increased hepatocyte cell death compared to controls. Cross liver sampling at time of liver transplantation demonstrated that hepatic endothelial beds are a source of increased circulating total cytokeratin-18 in DC.

CONCLUSION

Plasma metabotyping accurately predicts mortality in DC. LPC and amino acid dysregulation is associated with increased mortality and severity of disease reflecting hepatocyte cell death.

Child-Turcotte score versus MELD for prognosis in a randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis

BACKGROUND AND AIMS

Bleeding esophageal varices is responsible for much of the high mortality rate in cirrhosis. An important objective of management of bleeding varices is to develop reliable tools for predicting survival, controlling bleeding and encephalopathy, and improve quality of life. This study compared two widely used prognostic tools, the model for end-stage liver disease (MELD) and the Child-Turcotte (C-T) score, in a randomized controlled trial of emergency treatment of bleeding varices.

METHODS

We randomized 211 unselected consecutive patients with cirrhosis and bleeding varices to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnosis and treatment were accomplished within 20 hours. Follow-up was 100% for 10 y. We compared the prognostic powers of MELD and C-T upon entry, and then monthly for the first year and every 3 months thereafter. Statistical analysis included computation of receiver operating curves, the area under the curve, and the proportion of variability.

RESULTS

In baseline determinations of MELD versus C-T, there were no significant differences in predicting survival, recurrent encephalopathy, and rebleeding. The Child-Turcotte score was a stronger predictor than MELD of hospital readmissions and readmission days. In serial determinations over years, the prognostic power of both MELD and C-T was substantial, but C-T was significantly more effective in predicting survival and time to recurrent encephalopathy.

CONCLUSIONS

In this first long-term comparison of MELD versus C-T in cirrhosis with bleeding varices, C-T was consistently as effective as MELD in predicting survival, encephalopathy, rebleeding, hospital readmissions, and readmission days. In some measures, C-T was a more effective prognostic tool than MELD.

Clinical profile and predictors of mortality in patients of acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is characterised by acute hepatic insult manifesting as jaundice and coagulopathy, complicated within 4 weeks by ascites and/or encephalopathy in patients with previously diagnosed or undiagnosed chronic liver disease. We studied the clinical, biochemical and etiological profiles of ACLF patients investigating variables which could predict mortality.

METHODS

Consecutive ACLF patients were enrolled and given standard intensive care management. They were monitored for predictors of 90-day mortality.

RESULTS

91 patients were included; besides jaundice (median bilirubin 23.1mg/dL) and coagulopathy, acute onset ascites with or without encephalopathy was the presenting symptom in 92%. In all patients a first diagnosis of chronic liver disease was made, mainly due to hepatitis B (37%) or alcohol (34%). Reactivation of chronic hepatitis B and alcoholic hepatitis were the common acute insults. The 90-day mortality was 63%. On multivariate analysis, hepatic encephalopathy, low serum sodium, and high INR were found to be independent baseline predictors of mortality. Amongst all severity scores studied, MELD, SOFA and APACHE-II scores had AUROCs of >0.8 which was significantly higher than that of Child-Turcotte-Pugh.

CONCLUSIONS

ACLF has very high mortality. Hepatic encephalopathy, low serum sodium and high INR predict poor outcome. Mortality can also be predicted by baseline MELD, SOFA or APACHE-II scores.

Preditores de injúria renal aguda em pacientes submetidos ao transplante ortotópico de fígado convencional sem desvio venovenoso

RADICAL: Injúria renal aguda é uma das complicações mais comuns do transplante ortotópico de fígado. A ausência de critério universal para sua definição nestas condições dificulta as comparações entre os estudos. A técnica convencional para o transplante consiste na excisão total da veia cava inferior retro-hepática durante a hepatectomia nativa. Controvérsias sobre o efeito da técnica convencional sem desvio venovenoso na função renal continuam. OBJETIVO: Estimar a incidência e os fatores de risco de injúria renal aguda entre os receptores de transplante ortotópico de fígado convencional sem desvio venovenoso. MÉTODOS: Foram avaliados 375 pacientes submetidos a transplante ortotópico de fígado. Foram analisadas as variáveis pré, intra e pós-operatórias em 153 pacientes submetidos a transplante ortotópico de fígado convencional sem desvio venovenoso. O critério para a injúria renal aguda foi valor da creatinina sérica > 1,5 mg/dl ou débito urinário < 500 ml/24h dentro dos primeiros três dias pós-transplante. Foi realizada análise univariada e multivariada por regressão logística. RESULTADOS: Todos os transplantes foram realizados com enxerto de doador falecido. Sessenta pacientes (39,2%) apresentaram injúria renal aguda. Idade, índice de massa corpórea, escore de Child-Turcotte-Pugh, ureia, hipertensão arterial sistêmica e creatinina sérica pré-operatória apresentaram maiores valores no grupo injúria renal aguda. Durante o período intraoperatório, o grupo injúria renal aguda apresentou mais síndrome de reperfusão, transfusão de concentrado de hemácias, plasma fresco e plaquetas. No pós-operatório, o tempo de permanência em ventilação mecânica e creatinina pós-operatória também foram variáveis, com diferenças significativas para o grupo injúria renal aguda. Após regressão logística, a síndrome de reperfusão, a classe C do Child-Turcotte-Pugh e a creatinina sérica pós-operatória apresentaram diferenças. CONCLUSÃO: Injúria renal aguda após transplante ortotópico de fígado convencional sem desvio venovenoso é uma desordem comum, mas apresenta bom prognóstico. Síndrome de reperfusão, creatinina sérica no pós-operatório e Child C são fatores associados a injúria renal aguda pós-transplante ortotópico de fígado convencional sem desvio venovenoso.

Disparities in organ allocation and access to liver transplantation in the USA

Liver transplantation has become the standard of care for the treatment of chronic liver disease. In 1986, the United Network for Organ Sharing (UNOS) was formed to ensure the just and equitable allocation of donor livers. At the time, UNOS decided to use the Childs-Turcotte-Pugh scoring system to determine the degree of liver disease in potential transplant patients. Unfortunately, it was shown that the Childs-Turcotte-Pugh system was easily manipulated and did not provide equal access to donor organs. Owing to this fact, the Model of End Stage Liver Disease (MELD) score was instituted by UNOS in February 2002. While the institution of MELD has shown an improvement in organ allocation and outcomes, disparities still exist. This article discusses UNOS and the MELD allocation system as well as the racial, geographic and gender disparities that occur despite the institution of the MELD system.

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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Model for End-Stage Liver Disease (MELD) score system to evaluate patients with viral hepatitis on the waiting list: better than the Child-Turcotte-Pugh (CTP) system?

BACKGROUND

The Model for End-Stage Liver Disease (MELD), based on creatinine, bilirubin, and International normalized ratio (INR), has been shown to be superior to the Child-Turcotte-Pugh (CTP) score in predicting 3-month mortality among patients on the transplant waiting list due to end-stage liver disease (ESLD). An additional advantage of MELD is the possibility to add "adjustment points" for exceptional patients at risk for death because of liver disease not identified by changes in the used parameters, as occurs in the case of hepatocellular carcinoma (HCC). Although it is useful, MELD has some important limitations: There are no differences for patients with or without ascites, and for the absence of other laboratory parameters involved in the etiology of disease. In this study, we evaluated dropouts of patients on the waiting list for orthotopic liver transplantation (OLT) based upon the characteristics of these subjects before and after introduction of the MELD score.

METHODS

All patients on the OLT waiting list from June 1, 2006 to June 30, 2007 were enrolled in the MELD group (A) and evaluated with CHILD and MELD score, while those listed from January 1, 2004 to May 31, 2005 were enrolled in pre-MELD group (B) to be evaluated with CHILD. In these subjects we assessed the drop out frequency and waiting time and we compared the results to assess possible differences (U Mann-Whitney Test; P<.05).

RESULTS

The total number of patients included in this study was 176: 116 patients in Group A and 60 in Group B. We had a drop-out frequency of 21% with a median of 9+/-6 S.E. months in Group A, while 9% with a median of 15+/-8 months S.E. in Group B. The dropout frequencies were as follows: Group A--16 deaths (1 HCC--15 disease complications) while in Group B we had 13 drop outs, 10 exitus (4 HCC and 6 disease complications) and three exclusions for nonmedical reasons. In Group A we had a higher number of deaths due to disease complications than in group B (P<.05). Further, we had 32 OLTx in Group A and 45 in Group B. Survival rate did not show any differences between the two groups while number needed to harm was 11.

CONCLUSIONS

The use of MELD score in this group of patients produced an advantage for HCC, but seemed to cutoff patients with viral hepatitis complications during the waiting time. Particularly, about one in every 11 patients may receive an harm using this score system. Other parameters should be introduced as adjustment points to make the MELD score suitable also for patients with infectious liver diseases.

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.

Different methods of creatinine measurement significantly affect MELD scores

Bilirubin (Bil) interferes with creatinine (Cr) measurement. Different laboratory methods are used to overcome this problem. Model for end-stage liver disease (MELD) scoring incorporates Cr and is used to prioritize patients for liver transplantation. Thus, MELD scores may vary with different Cr measurements influencing patients' priority. Our aim was to evaluate 4 different Cr assays (O'Leary modified Jaffe [mJCr], compensated [rate blanked] kinetic Jaffe [cJCr], enzymatic [ECr], and standard kinetic Jaffe [JCr]) in patients with abnormal liver function tests and assess changes in MELD score. A total of 403 consecutive samples from 158 patients' Cr assays were evaluated.. Bland-Altman plots and MELD scores were also evaluated for each assay. Agreement was found to be poor among all Cr assays. Increased variability in Cr occurred with increasing Bil concentrations: Bil <100 micromol/L <or=3-point MELD variation - 3-point difference in 2%; Bil >or=400micromol/L <or=7-point MELD variation - >or=3-point difference in 78%. When MELD was >or=25 (mJCr as reference; mean, 30.5 points), MELD variation was greatest: mean, 28 (MELD cJCr), 27.5 (MELD ECr), and 28.4 (MELD JCr) (P < 0.001). In conclusion, there is poor agreement among different assays for Cr. As Bil concentration rises, there is greater variability in each creatinine measurements and thus greater variability in MELD scores that, this affect prioritization for liver transplantation.

Nutritional status and prognosis in cirrhotic patients

BACKGROUND AND AIM

The potential prognostic value for survival of nutritional status in cirrhotics after adjusting Child-Pugh classification and Model for End-Stage Liver Disease has not been evaluated.

METHODS

We used Kaplan-Meier and Cox proportional hazards regression models to identify factors associated with mortality in a cohort of 222 cirrhotics [M/F:145/77 median age 52 (18-68) years] with prospectively collected nutritional parameters as well as modified subjective global nutritional assessment, Royal Free Hospital-Subjective Global Assessment index. Follow-up was censored at the time of transplantation. Other variables were ones in Child-Pugh and Model for End-Stage Liver Disease scores, age, aetiology of cirrhosis and renal function.

RESULTS

Pretransplant mortality (Kaplan-Meier) was 21% by 2 years (135 patients were transplanted). Among the nutritional parameters, only Royal Free Hospital-Subjective Global Assessment remained significantly associated with mortality in multivariable models (P = 0.0006). The final model included the following variables: urea (P = 0.0001), Royal Free Hospital-Subjective Global Assessment (P = 0.003), age (P = 0.0001), Child-Pugh grade (P = 0.009) and prothrombin time (P = 0.003). The results were similar when the Child-Pugh grade was replaced by the Model for End-Stage Liver Disease score in the model, and whether a competing risks model was used.

CONCLUSIONS

Nutritional indices add significantly to both Child-Pugh grade and Model for End-Stage Liver Disease scores when assessing the patient prognosis.

A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation

The Model for End-Stage Liver Disease (MELD) score is now used for allocation in liver transplantation (LT) waiting lists, replacing the Child-Turcotte-Pugh (CTP) score. However, there is debate as whether it is superior to CTP score to predict mortality in patients with cirrhosis on the LT waiting list and after LT. We reviewed studies comparing the accuracy of MELD vs. CTP score in transplantation settings. We found that in studies of the LT waiting list (12,532 patients with cirrhosis), only 4 of 11 showed MELD to be superior to CTP in predicting short-term (3-month) mortality. In addition, 2 of 3 studies (n = 1,679) evaluating the changes in MELD score (DeltaMELD) showed that DeltaMELD had better prediction for mortality than the baseline MELD score. The impact of MELD on post-LT mortality was assessed in 15 studies (20,456 patients); only 6 (9,522 patients) evaluated the discriminative ability of MELD score using the concordance (c) statistic (the MELD score had always a c-statistic < 0.70). In 11 studies (19,311 patients), high MELD score indicated poor post-LT mortality for cutoff values of 24-40 points. In re-LT patients, 2 of 4 studies evaluated the discriminative ability of MELD score on post-LT mortality. Finally, several studies have shown that the predictive ability of MELD score increases by adding clinical variables (hepatic encephalopathy, ascites) or laboratory (sodium) parameters. On the basis of the current literature, MELD score does not perform better than the CTP score for patients with cirrhosis on the waiting list and cannot predict post-LT mortality.

Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit

BACKGROUND

Prognostic scores in an intensive care unit (ICU) evaluate outcomes, but derive from cohorts containing few cirrhotic patients.

AIMS

To evaluate 6-week mortality in cirrhotic patients admitted to an ICU, and to compare general and liver-specific prognostic scores.

METHODS

A total of 312 consecutive cirrhotic patients (65% alcoholic; mean age 49.6 years). Multivariable logistic regression to evaluate admission factors associated with survival. Child-Pugh, Model for End-stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores were compared by receiver operating characteristic curves.

RESULTS

Major indication for admission was respiratory failure (35.6%). Median (range) Child-Pugh, APACHE II, MELD and SOFA scores were 11 (5-15), 18 (0-44), 24 (6-40) and 11 (0-21), respectively; 65% (n = 203) died. Survival improved over time (P = 0.005). Multivariate model factors: more organs failing (FOS) (<3 = 49.5%, > or =3 = 90%), higher FiO(2), lactate, urea and bilirubin; resulting in good discrimination [area under receiver operating characteristic curve (AUC) = 0.83], similar to SOFA and MELD (AUC = 0.83 and 0.81, respectively) and superior to APACHE II and Child-Pugh (AUC = 0.78 and 0.72, respectively).

CONCLUSIONS

Cirrhotics admitted to ICU with > or =3 failing organ systems have 90% mortality. The Royal Free model discriminated well and contained key variables of organ function. SOFA and MELD were better predictors than APACHE II or Child-Pugh scores.

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.