Model for End-stage Liver Disease excluding INR (MELD-XI) score in critically ill patients: Easily available and of prognostic relevance

Association of Cardiopulmonary Hemodynamics and Mortality in Veterans With Liver Cirrhosis: A Retrospective Cohort Study

BACKGROUND

Portopulmonary hypertension (PoPH), associated with increased mortality, can limit treatment options for liver diseases. Data on the continuum of clinical risk related to cardiopulmonary hemodynamics in PoPH are lacking.

METHODS AND RESULTS

As part of the United States national Veterans Affairs Clinical Assessment, Reporting, and Tracking database, we performed a retrospective cohort study of adults with cirrhosis undergoing right heart catheterization between October 1, 2017, and September 30, 2022. Pulmonary hypertension (mean pulmonary arterial pressure [mPAP] >20 mm Hg without PoPH) and PoPH (mPAP >20 mm Hg+pulmonary artery wedge pressure ≤15 mm Hg+pulmonary vascular resistance ≥3 WU) were defined by right heart catheterization hemodynamics. Multivariable Cox proportional hazards using natural splines for hemodynamic variables were used to evaluate the association between cardiopulmonary hemodynamics and mortality following right heart catheterization. A total of 4409 patients were included in the final analysis, predominantly men (96.3%), with a mean age of 68.5 years. Pulmonary hypertension and PoPH were observed in 71.6% and 10.2% of the cohort, respectively. Compared with a reference cardiac index of 2.5 L/min per m2, the hazard for mortality increased progressively with decreasing cardiac index, even after adjustment for mPAP and pulmonary vascular resistance. The minority of patients with PoPH (N=65, 14.5%) were prescribed pulmonary vasodilator therapy.

CONCLUSIONS

These data suggest that pulmonary hypertension and PoPH are prevalent in veterans with chronic liver disease, but low use of targeted PoPH therapy persists. Cardiac function discriminated mortality risk across a wide range of mPAP and pulmonary vascular resistance values and may diagnose and clarify prognosis in this patient population.

Utilization of hepatitis C virus infected donors in heart transplant recipients with elevated MELD-XI score

BACKGROUND

The advent of direct-acting antivirals has helped to increase the safe utilization of organs from hepatitis C virus positive (HCV+) donors. However, the outcomes of heart transplantation (HT) using an HCV+ donor are unclear in recipients with underlying liver disease represented by an elevated model for end-stage liver disease excluding international normalized ratio (MELD-XI).

METHODS

The United Network of Organ Sharing database was queried from Jan 2016 to Dec 2021. Post-transplant outcomes stratified by recipient MELD-XI score (low <10.37, medium, 10.38-13.39, and high >13.4) was compared between patients with HT from HCV+ (N = 792) and patients with HT from HCV-negative donors (N = 15,266).

RESULTS

The median MELD-XI score was comparable (HCV+, 12.1, vs. HCV-negative, 11.8, p = .37). In the HCV+ group, donors were older (33 vs. 31 years, p < .001). Ischemic time of donor hearts (3.48 vs. 3.28 h, p < .001) and travel distance (250 vs. 157 miles, p < .001) were longer in HCV+ group. In the Kaplan Meier analysis with a median follow-up of 750 days, survival was comparable between the two groups (2-year survival, MELD-XI Low: HCV+, 92.4 ± 3.6% vs. HCV-negative, 91.1 ±.8%, p = .83, Medium: HCV+ 89.2 ± 4.3% vs. HCV-negative, 88.2 ± 1.0%, p = .68, and High: HCV+, 84.9 ± 4.5% vs. HCV-negative, 84.6 ± 1.1%, p = .75) In multivariate Cox hazard models, HCV donors were not associated with mortality in each MELD-XI subgroup (Low: adjusted hazard ratio (aHR), 1.02, p = .94; Medium: aHR, .95, p = .81; and High: aHR, .93, p = .68).

CONCLUSION

Utilization of HCV+ hearts was not associated with an increased risk of adverse outcomes in recipients with an elevated MELD- XI score.

Predicting outcomes following short-term ventricular assist device implant with the MELD-XI score

BACKGROUND

Short-term continuous flow (STCF) ventricular assist devices (VADs) are utilized in adults with cardiogenic shock; however, mortality remains high. Previous studies have found that high pre-operative MELD-XI scores in durable VAD patients are associated with mortality. The use of the MELD-XI score to predict outcomes in STCF-VAD patients has not been explored. We sought to determine the relationship between MELD-XI and outcomes in adults with STCF-VADs.

METHODS

This was a retrospective review of adults implanted with STCF-VADs between 2009 and 2019. Receiver operating characteristic (ROC) analysis was performed to predict outcomes and Kaplan-Meier analysis was done to assess survival.

RESULTS

Seventy-nine patients were included with a median MELD-XI score of 21.2 (IQR 13.5, 27.0). Patients with an unsuccessful wean from support (p < 0.001) or major post-operative bleeding (p = 0.03) had significantly higher pre-implant MELD-XI scores. The optimal MELD-XI cut-point for mortality was 24.9 with 27.8 for major bleeding. Survival was worse among patients in the high-risk MELD-XI group, however, not statistically significant (p = 0.09). Prior ECMO support, but not MELD-XI, was an independent predictor of unsuccessful wean (p = 0.03).

CONCLUSIONS

Pre-operative MELD-XI score was a moderate predictor of unsuccessful wean with limited utility in predicting bleeding in patients on STCF-VAD support. This scoring system may be useful in the clinical setting for pre-implant risk stratification and counseling among patients and outcomes.

The predictive value of the MELD-XI score for short- and long-term mortality in elderly patients with non-ST elevation myocardial infarction

BACKGROUND

In this study, we investigated the utility of the Model for End-stage Liver Disease excluding INR (MELD-XI) score in predicting short- and long-term mortality in elderly patients with non-ST elevation myocardial infarction (NSTEMI) who underwent coronary angiography (CAG).

METHODS

In total, we analyzed 228 elderly NSTEMI patients above the age of 75. We used the modified 5-item frailty index and the Charlson Comorbidity Index (CCI) to assess the comorbidities. The MELD-XI score was calculated using the logarithmic relationship between the serum creatinine and total bilirubin.

RESULTS

The median long-term follow-up was 530 [interquartile range (IQR) = 303-817] days and the short- and long-term mortality rates were 11.8% (n = 27) and 16.4% (n = 33), respectively. Patients who did not survive had a substantially higher MELD-XI score than those who did [10.1 (IQR = 7.8-15.1) vs. 4.5 (IQR = 1.9-6.9), p < 0.001, respectively]. Multivariable Cox regression analyses indicated that the MELD-XI score predicted both short- and long-term mortality independently. When the MELD-XI score, serum creatinine, and total bilirubin area under the curve (AUC) values were compared to predict long-term mortality, the MELD-XI score had the highest value (AUC: 0.833), followed by the serum creatinine (AUC: 0.741), and the total bilirubin (AUC: 0.723). The accuracy of the MELD-XI score was further tested with the GRACE risk score, which demonstrated noninferiority.

CONCLUSION

This was the first investigation which indicated that elderly NSTEMI patients with a high MELD-XI score had poor prognosis in the short- and long-term period.

Associations Between Clinical Outcomes and a Recently Proposed Adult Congenital Heart Disease Anatomic and Physiological Classification System

Background

American Heart Association and American College of Cardiology consensus guidelines introduce an adult congenital heart disease anatomic and physiological (AP) classification system. We assessed the association between AP classification and clinical outcomes.

Methods and Results

Data were collected for 1000 outpatients with ACHD prospectively enrolled between 2012 and 2019. AP classification was assigned based on consensus definitions. Primary outcomes were (1) all‐cause mortality and (2) a composite of all‐cause mortality or nonelective cardiovascular hospitalization. Cox regression models were developed for AP classification, each component variable, and additional clinical models. Discrimination was assessed using the Harrell C statistic. Over a median follow‐up of 2.5 years (1.4–3.9 years), the composite outcome occurred in 185 participants, including 49 deaths. Moderately or severely complex anatomic class (class II/III) and severe physiological stage (stage D) had increased risk of the composite outcome (AP class IID and IIID hazard ratio, 4.46 and 3.73, respectively, versus IIC). AP classification discriminated moderately between patients who did and did not suffer the composite outcome (C statistic, 0.69 [95% CI, 0.67–0.71]), similar to New York Heart Association functional class and NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide); it was more strongly associated with mortality (C statistic, 0.81 [95% CI, 0.78–0.84]), as were NT‐proBNP and functional class. A model with AP class and NT‐proBNP provided the strongest discrimination for the composite outcome (C statistic, 0.73 [95% CI, 0.71–0.75]) and mortality (C statistic, 0.85 [95% CI, 0.82–0.88]).

Conclusions

The addition of physiological stage modestly improves the discriminative ability of a purely anatomic classification, but simpler approaches offer equivalent prognostic information. The AP system may be improved by addition of key variables, such as circulating biomarkers, and by avoiding categorization of continuous variables.

Early evaluation of organ failure using MELD-XI in critically ill elderly COVID-19 patients

PURPOSECritically ill elderly patients who suffer from Sars-CoV-2 disease are at high risk for organ failure. The modified MELD-XI score has not been evaluated for outcome prediction in these most vulnerable patients.METHODSThe Corona Virus disease (COVID19) in Very Elderly Intensive Care Patients study (COVIP, NCT04321265) prospectively recruited patients on intensive care units (ICU), who were = 70 years. Data were collected from March 2020 to February 2021. The MELD-XI score was calculated using the highest serum bilirubin and creatinine on ICU admission. Univariate and multivariable logistic regression analyses were performed to assess associations between the MELD-XI score and mortality. The primary outcome was 30-day-mortality, the secondary outcomes were ICU- and 3-month-mortality.RESULTSIn total, data from 2,993 patients were analyzed. Most patients had a MELD-XI <12 on admission (76%). The patients with MELD-XI = 12 had a significantly higher 30-day-, ICU- and 3-month-mortality (44%vs 64%, and 42%vs. 59%, and 57%vs. 76%, p < 0.001). After adjustment for multiple confounders, MELD-XI = 12 remained significantly associated with 30-day- (aOR 1.572, CI 1.268-1.949, p < 0.001), ICU-, and 3-month-mortality.CONCLUSIONIn critically ill elderly intensive care patients with COVID-19, the MELD-XI score constitutes a valuable tool for an early outcome prediction.

ICU-Mortality in Old and Very Old Patients Suffering From Sepsis and Septic Shock

Purpose: Old (>64 years) and very old (>79 years) intensive care patients with sepsis have a high mortality. In the very old, the value of critical care has been questioned. We aimed to compare the mortality, rates of organ support, and the length of stay in old vs. very old patients with sepsis and septic shock in intensive care.

Methods: This analysis included 9,385 patients, from the multi-center eICU Collaborative Research Database, with sepsis; 6184 were old (aged 65–79 years), and 3,201 were very old patients (aged 80 years and older). A multi-level logistic regression analysis was used to fit three sequential regression models for the binary primary outcome of ICU mortality. A sensitivity analysis in septic shock patients (n = 1054) was also conducted.

Results: In the very old patients, the median length of stay was shorter (50 ± 67 vs. 56 ± 72 h; p < 0.001), and the rate of a prolonged ICU stay was lower (>168 h; 9 vs. 12%; p < 0.001) than the old patients. The mortality from sepsis was higher in very old patients (13 vs. 11%; p = 0.005), and after multi-variable adjustment being very old was associated with higher odds for ICU mortality (aOR 1.32, 95% CI 1.09–1.59; p = 0.004). In patients with septic shock, mortality was also higher in the very old patients (38 vs. 36%; aOR 1.50, 95% CI 1.10–2.06; p = 0.01).

Conclusion: Very old ICU-patients suffer from a slightly higher ICU mortality compared with old ICU-patients. However, despite the statistically significant differences in mortality, the clinical relevance of such minor differences seems to be negligible.

Complicated postoperative course in isolated tricuspid valve surgery: Looking for predictors

BACKGROUND

This study aims at better defining the profile of patients with a complicated versus noncomplicated postoperative course following isolated tricuspid valve (TV) surgery to identify predictors of a favorable/unfavorable hospital outcome.

METHODS

All patients treated with isolated tricuspid surgery from March 1997 to January 2020 at our institution were retrospectively reviewed. Considering the complexity of most of these patients, a regular postoperative course was arbitrarily defined as a length-of-stay in intensive care unit less than 4 days and/or postoperative length-of-stay less than 10days. Patients were therefore divided accordingly in two groups.

RESULTS

One hundred and seventy-two patients were considered, among whom 97 (56.3%) had a regular (REG) and 75 (43.6%) a non-regular (NEG) postoperative course. The latter had worse baseline clinical and echocardiographic characteristics, with higher rate of renal insufficiency, previous heart failure hospitalizations, cardiac operations, and right ventricular dysfunction. NEG patients more frequently needed tricuspid replacement and experienced a greater number of complications (p < .001) and higher in-hospital mortality (13% vs. 0%, p < .001). The majority of these complications were related to more advanced stage of the tricuspid disease. Among most important predictors of a negative outcome univariate analysis identified chronic kidney disease, ascites, previous right heart failure hospitalizations, right ventricular dysfunction, previous cardiac surgeries, TV replacement and higher MELD scores. At multivariate analysis, liver enzymes and diuretics' dose were predictors of complicated postoperative course.

CONCLUSION

In isolated TV surgery a complicated postoperative course is observed in patients with more advanced right heart failure and organ damage. Earlier surgical referral is associated to excellent outcomes and should be recommended.

Thinking fast and slow: Lactate and MELD-XI (Model for End-Stage Liver Disease Excluding INR) are useful for estimating mortality after cardiopulmonary resuscitation

BACKGROUND

Intensivists keep getting challenged with prognostication after cardiopulmonary resuscitation (CPR). The model for end-stage liver disease, excluding INR (MELD-XI) score has proven valuable for assessing illness severity. Serum lactate is a readily available and established indicator of general stress and tissue hypoxia. We aimed to evaluate the prognostic value of MELD-XI combined with serum lactate in patients after CPR.

METHODS

A retrospective analysis on 106 patients after CPR was performed. Multivariable Cox regression was performed to evaluate associations with 30-day mortality and neurological outcome by means of Cerebral Performance Category (CPC). An optimal cut-off was calculated by means of the Youden index. Patients were then divided into subgroups based on the optimal cut-offs for MELD-XI and serum lactate.

RESULTS

MELD-XI and lactate were independently associated with mortality. The respective cut-offs were MELD-XI >12 and lactate ≥2.5 mmol/L. Patients were split into three groups: lactate <2.5 mmol/L and MELD-XI ≤12 (low-risk; n=32), lactate ≥2.5 mmol/L or MELD-XI >12 (medium-risk; n=39), and lactate ≥ 2.5mmol/L and MELD-XI >12 (high-risk; n=33). The mortality rates were 6%, 26% and 61% in the low, medium and high-risk group. This combined model yielded in the highest predictive abilities (AUC 0.78 95%CI 0.68-0.85; p=0.03 vs. AUC 0.66 for SOFA score). Worse neurological outcome (CPC 3 or 4) was more common in the medium and high-risk group (6.25%, 10.3% and 9.1%).

CONCLUSIONS

The combination of MELD-XI and lactate concentration at ICU admission was superior to the more complex SOFA score for prediction of mortality after CPR.

Risk factors of acute renal injury and in-hospital mortality in adult patients with postcardiotomy cardiogenic shock requiring veno-arterial extracorporeal membrane oxygenation: utility of MELD-XI score

BACKGROUND

The suitability of model for end-stage liver disease excluding international normalized ratio (MELD-XI) score to predict the incidence of acute kidney injury (AKI) and in-hospital mortality in adult patients with postcardiotomy cardiogenic shock (PCS) requiring venoarterial extracorporeal membrane oxygenation (VA ECMO) remains uncertain. This study was performed to explore whether the MELD-XI score has the association with the incidence of AKI and in-hospital mortality in these patients.

METHODS

Adult patients with PCS requiring VA ECMO from January 2012 to December 2017 were enrolled and first classified into AKI group (n = 151) versus no-AKI group (n = 132), then classified into survival group (n = 143) versus no-survival group (n = 140). Multivariate logistic regressions were performed to identify factors independently associated with AKI and mortality. Baseline data were defined as the first measurement available.

RESULTS

Of 283 patients, the incidence of AKI was 53.36%. The in-hospital mortality rates were 63.58% and 33.33% in patients with and without AKI (p < 0.0001). Baseline MELD-XI score, baseline serum total bilirubin (T-Bil), baseline blood urea nitrogen (BUN), baseline left ventricular ejection fraction (LVEF), sequential organ failure assessment (SOFA) score, and lactate level at ECMO initiation were shown to be associated with the AKI. Vasoactive-inotropic score (VIS) and SOFA score at ECMO initiation as well as renal failure requiring renal replacement therapy (RRT) were shown to be associated with in-hospital mortality.

CONCLUSIONS

The baseline MELD-XI score, baseline BUN, baseline T-Bil, baseline LVEF, SOFA score and lactate at the initiation of ECMO were associated with AKI. AKI, SOFA score, and VIS at the initiation of ECMO were associated with in-hospital mortality, whereas MELD-XI score was not found to be associated with in-hospital mortality. A specific MELD-XI score as a threshold, as well as its sensitivity and specificity, needs to be confirmed in further studies.

Postoperative outcome after reoperative isolated tricuspid valve surgery-is there a predictor for survival?

OBJECTIVES

Reoperative tricuspid valve (TV) surgery is considered high risk even in the absence of additional concomitant cardiac procedures. The purpose of this study was to evaluate preoperative clinical parameters as predictors for survival after isolated reoperative TV surgery.

METHODS

From January 2005 to January 2019, 85 patients (mean age: 66.7 ± 10.3 years, 34 male) with severe isolated TV regurgitation and prior cardiac surgery were referred to our centre for elective or urgent TV repair/replacement; patients with endocarditis were excluded. We retrospectively analysed preoperative hepatorenal function [reflected by widely used clinical and laboratory parameters and the Model of End-stage-Liver Disease excluding International Normalized Ratio (MELD-XI) score] as a predictor for postoperative survival.

RESULTS

At hospital admission, the patients' average preoperative New York Heart Association class was 2.9 ± 0.6, left ventricular ejection fraction 52.5 ± 10.6%, mean pulmonary artery pressure 24.7 ± 8.0 mmHg, creatinine 115.4 ± 66.6 μmol/l, bilirubin 20.0 ± 19.6 μmol/l and the mean MELD-XI score was 13.3 ± 4.0 μmol/l. The mean follow-up was 5.4 ± 4.2 years. Thirty-day mortality was 5%, 5-year survival was 60.6 ± 5.4% and 10-year survival was 42.9 ± 6.5%. The multivariable Cox regression analysis evaluated the MELD-XI score [hazard ratio (HR 1.144, confidence interval 95% 1.0-1.3, P = 0.005] and diabetes mellitus (HR 2.27, confidence interval 95% 1.0-5.0, P = 0.04) as significant predictors for excess mortality while age and mean pulmonary artery pressure did not reliably predict clinical outcome.

CONCLUSIONS

Hepatorenal dysfunction was one main factor accounting for limited postoperative survival in our patient cohort. The MELD-XI score is easy to calculate and seems to reliably predict the perioperative risk in patients with prior cardiac surgery and indication for TV surgery.

MELD and MELD XI Scores as Predictors of Mortality After Pericardiectomy for Constrictive Pericarditis

OBJECTIVE

To assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis.

PATIENTS AND METHODS

Patients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity.

RESULTS

A total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays.

CONCLUSION

Among patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis.

Modified model for end-stage liver disease score predicts 30-day mortality in high-risk patients with acute pulmonary embolism admitted to intensive care units

OBJECTIVES

The Model for End-stage Liver Disease excluding the international normalised ratio that is derived from prothrombin time which is calculated as a ratio of the patient's prothrombin time to a control prothrombin time standardized (MELD-XI) and modified MELD, which uses albumin in place of the international normalised ratio (MELD-Albumin) scores reflect liver and renal function and are predictors of mortality. However, their prognostic value in acute pulmonary embolism (APE) has not been studied.

DESIGN

We assessed the predictive value of the MELD scores in patients diagnosed with high-risk APE admitted to the intensive care unit. The primary outcome was 30-day mortality.

RESULTS

Of the 273 patients included in the study, 231 were survivors and 42 were non-survivors. The mortality rate was 15.3%. The mean MELD-XI and MELD-Albumin scores were significantly higher in the non-survivors than in the survivors (MELD XI, 11.8 ± 1.8 and 10.6 ± 1.43, respectively; p = .002; MELD-Albumin, 10.5 ± 1.6 and 8.7 ± 1.1, respectively; p = .001). The multiple logistic regression analysis identified the MELD-XI (hazard ratio: 3.029, confidence interval: 1.06-1.21, p = .007) and MELD-Albumin (hazard ratio: 1.13, confidence interval: 1.06-1.21, p = .002) scores as independent predictors of mortality. Receiver operating characteristic analysis revealed that the predictive power of the MELD-Albumin score (0.871 ± 0.014; p < .001) was higher than those of the MELD-XI (0.726 ± 0.022, p < .001), APACHE III (0.682 ± 0.024, p < .001), and PESI (0.624 ± 0.023, p < .001) scores.

CONCLUSIONS

The MELD-Albumin score is an easily calculable, reliable, and practical risk assessment tool and independent predictor of 30-day mortality in patients with high-risk APE.

Interobserver agreement of the anatomic and physiological classification system for adult congenital heart disease

The Anatomic and Physiological (AP) classification system proposed in the 2018 American College of Cardiology/American Heart Association adult congenital heart disease (ACHD) guidelines assigns 2 dimensions to each patient: anatomic class (AnatC) and physiological stage (PhyS). This approach has not been tested in practice; we assessed interrater reliability and identified sources of disagreement.

METHODS

Consensus definitions for AP categories were developed with input from 4 experts. Research assistants (RAs) assigned AnatC/PhyS for patients in the Boston ACHD Biobank, a prospectively enrolled cohort of ambulatory ACHD patients ≥18 years old seen between 2012 and 2019. Two (of 4) expert reviewers then independently assigned AnatC/PhyS for 41 patients. Interrater reliability was assessed with linearly weighted kappa (κ_ω) for agreement between (1) experts and (2) an RA and an expert. Experts examined disagreements and identified sources of variability and areas requiring clarification.

RESULTS

Interexpert agreement for AnatC was excellent, with agreement on 38/41 (92.7%) cases and κ_ω 0.88 [0.75, 1.01]. Agreement for PhyS was less robust, with consensus on 24/41 cases (59.5%), κ_ω 0.57 [0.39, 0.75]. Expert-RA agreement was lower for AnatC (κ_ω 0.77 [0.60, 0.95]), whereas PhyS was similar to interexpert agreement (κ_ω 0.53 [0.34, 0.72]). There was ambiguity in the definitions of (1) arrhythmia status, (2) cyanotic CHD, and (3) valve disease.

CONCLUSIONS

Although AnatC can be assessed reliably, that is not true for the PhyS part of the AP classification proposed in the 2018 American College of Cardiology/American Heart Association guidelines. Reliability of PhyS would be strengthened by more precise definitions readily interpretable in clinical practice.

Hepcidin and MELD-XI score as markers of multiple organ failure in patients with heart failure with preserved and reduced ejection fraction

Data on the changes in hepcidin levels in heart failure (HF) patients are contradictory and do not give an answer about its effect on the progression of multiple organ failure. Since the model of end-stage liver disease excluding INR (MELD-XI) reflects the severity of liver and kidney dysfunction, these markers have been suggested to be associated with decompensated HF.

Aim. To assess the MELD-XI score and serum hepcidin levels in patients with decompensated HF with different values of left ventricular ejection fraction (EF).

Material and methods. The study included 68 patients (29 women, 39 men; mean age 72,3±11,7 years) hospitalized due to decompensated HF. Patients were divided into three groups: reduced (HFrEF) (n=20), mid-range (HFmrEF) (n=23), and preserved EF (HFpEF) (n=24)). Upon admission, along with standard diagnostic tests, all patients were examined for hepcidin-25 levels by enzyme-linked immunosorbent assay. MELD-XI score was calculated. Statistical processing was carried out using the software package Statistica 8.0.

Results. Hepcidin levels in the HFrEF group (31,63 ng/ml [22,0; 71,6]) were significantly higher than in the HFmrEF (23,89 ng/ml [21,1; 27,9]) (p<0,05) and HFpEF (26,91 ng/ml [18,6; 31,1]) (p<0,05) groups. In HFpEF, there was a correlation of hepcidin level with body mass index (r=0,47, p<0,05) and chronic obstructive airway diseases (r=0,44, p<0,05). A correlation of hepcidin level with significant cardiac arrhythmias (r=0,61, p<0,05) was revealed in HFmrEF patients. MELD-XI score were significantly increased from 9,44±3,96 for HFpEF and 11,53±3,82 for HFmrEF to 14,3±4,3 for HFrEF (p<0,005). We also revealed correlation of MELD-XI score with hepcidin levels (r=0,3, p<0,05) and EF (r=-0,43, p<0,0003). Patients with a MELD-XI score of >10,4 were more likely to have NYHA class III-IV HF, HFrEF and significantly higher levels of hepcidin (p<0,05 for all) These patients were also more likely to have chronic kidney disease (p<0,05).

Conclusion. Hepcidin level and MELD-XI score in patients with decompensated HF are inversely related to left ventricular EF. There is a direct relationship between hepcidin levels and other clinical parameters: body mass index, the presence of chronic obstructive airway diseases and cardiac arrhythmias.

A Propensity-matched Survival Analysis: Do Simultaneous Liver-lung Transplant Recipients Need a Liver?

BACKGROUND

There is debate whether simultaneous lung-liver transplant (LLT) long-term outcomes warrant allocation of 2 organs to a single recipient. We hypothesized that LLT recipients would have improved posttransplant survival compared with matched single-organ lung recipients with an equivalent degree of liver dysfunction.

METHODS

The Organ Procurement and Transplant Network/United Network for Organ Sharing STAR file was queried for adult candidates for LLT and isolated lung transplantation from 2006 to 2016. Waitlist mortality and transplant odds were calculated for all candidates. Donor and recipient demographic characteristics were compiled and compared. The LLT recipients were matched 1:2 with a nearest neighbor method to single-organ lung recipients. Kaplan-Meier methods with log-rank test compared long-term survival between groups. Univariate regression was used to calculate the association of LLT and mortality within 6 months of transplant. A proportional hazards model was used to calculate risk-adjusted mortality after 6 months posttransplantation.

RESULTS

Thirty-eight LLT patients were matched to 75 single-organ lung recipients. After matching, no differences in baseline demographics or liver function were observed between cohorts. Length of stay was significantly longer in LLT recipients compared to isolated lung recipients (45.89 days vs 22.44 days, P < 0.001). There was no significant difference in survival probability between LLT and isolated lung transplant (1 y, 89.5% vs 86.7%; 5 y, 67.0% vs 64.6%; P = 0.20).

CONCLUSIONS

After matching for patient characteristics and level of liver dysfunction, survival in simultaneous LLT was comparable to isolated lung transplantation. Although this population is unique, the clinical picture prompting liver transplant is not clear. National guidelines to better elucidate patient selection are needed.

Assessment of microcirculation in cardiogenic shock

PURPOSE OF REVIEW

Adequate tissue perfusion is of utmost importance to avoid organ failure in patients with cardiogenic shock. Within the recent years, the microcirculation, defined as the perfusion of the smallest vessels, has been identified to play a crucial role. Microcirculatory changes may include capillary flow disturbances as well as changes in the density of perfused vessels. Due to the availability of new technologies to assess the microcirculation, interesting new data came up and it is the purpose of this review to summarize recent studies in the field.

RECENT FINDINGS

Nowadays, an increasing number of studies confirm parameters of the microcirculation, derived by intravital microscopy, to represent strong outcome predictors in cardiogenic shock. In addition, microcirculation as read-out parameter in innovative clinical studies has meanwhile been accepted as serious endpoint. Treatment strategies such as mechanical assist devices, blood pressure regulating agents or fluids use tissue perfusion and microcirculatory network density as targets in addition to clinical perfusion evaluation and decreasing serum lactate levels.

SUMMARY

The parameter most frequently used to detect tissue malperfusion is serum lactate. Novel, noninvasive methods to quantify microvascular perfusion have the potential to guide treatment in terms of optimizing organ perfusion and oxygenation probably paving the way for an individualized therapy.

MELD-XI Score and Coronary Artery Disease Prevalence and Extent Among In-Hospital Patients With End-Stage Liver Failure Awaiting Transplant

OBJECTIVES

Liver transplant is a life-saving procedure for a variety of end-stage liver diseases. Cardiovascular disorders are among the leading cause of death among patients with end-stage liver disease and those undergoing liver transplant procedures. MELD-XI score is a newly developed score for mortality prediction in patients with end-stage liver failure. In this study, we investigated the relationships among MELD-XI score, total in-hospital mortality, and coronary artery disease severity and extent among patients with end-stage liver failure who were awaiting transplant.

MATERIALS AND METHODS

We retrospectively reviewed medical records of 121 patients with end-stage liver failure on transplant wait list. Study patients had undergone coronary angiography as part of pretransplant cardiac evaluation. We determined prevalence of coronary artery disease and Gensini score (which indicates extent of coronary artery disease) using coronary angiography and reviewed MELD-XI score and in-hospital mortality rates. We compared MELD-XI score and Gensini score in deceased and surviving patients and correlated both scores with mortality and with each other.

RESULTS

Of 121 patients, 79 (65.3%) were men; mean age of the study population was 59.6 ± 10.2 years. Twenty-eight patients (23.1%) had coronary artery disease, and 13 (10.7%) had severe coronary artery disease on coronary angiography. Twenty-three patients (19%) died while on the transplant wait list. Gensini score and MELD-XI scores were significantly higher in those who died (P < .05). MELD-XI score, but not Gensini score, was a significant independent predictor of death among patients awaiting liver transplant (hazard ratio = 1.35; 95% confidence interval, 1.04-1.78; P < .05).

CONCLUSIONS

MELD-XI score independently predicted in-hospital death among patients scheduled to undergo liver transplant. These patients also had increased prevalence and extent of coronary artery disease.

Prognostic value of MELD-XI score in patients referring to the emergency department with acute ST elevation myocardial infarction

Objective:

We aimed to evaluate Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score for prediction of 30-day in-hospital mortality in a cohort of patients with ST elevation myocardial infarction.

Methods:

The medical records of a total of 256 patients admitted with ST elevation myocardial infarction to the emergency department between January 2015 and January 2019 were retrospectively reviewed. A total of 111 patients were found eligible for the study. MELD-XI score was analyzed and compared on the basis of survival status.

Results:

A total of 111 patients with a mean age of 62.5 ± 2.55 years were included in the study. In total, 81% (n = 90) of the patients were male and 19% (n = 21) were female. The mean MELD-XI score of the patients was 10.1 ± 1.1. A total of 12 patients (12.9%) died within 30 days after hospitalization. The median MELD-XI score of the patients who died in the hospital was significantly higher than the patients survived (11.0 (10.5–11.6) vs 9.5 (9.4–13.8); p < 0.01). However, Gensini score was not significantly different between the surviving and deceased patients (p > 0.05). MELD-XI score was significantly correlated to left ventricular ejection fraction (r = −232, p < 0.01), and both parameters and age were significant independent predictors of in-hospital mortality (odds ratio: 1.73, 95% confidence interval: 1.25–2.39, p < 0.05; odds ratio: 0.89, 95% confidence interval: 0.81–0.99, p < 0.05; and odds ratio: 1.07, 95% confidence interval: 0.99–1.15, p < 0.05, respectively). A MELD-XI cut-off point of 10 had a sensitivity of 100% and a specificity of 78.8% for in-hospital mortality (area under receiver operating characteristics curve: 0.92, 95% confidence interval: 0.87–0.97, p < 0.05). A survival analysis based on a MELD-XI threshold of 10 revealed that the patients in the high-MELD-XI group had a significantly worse in-hospital survival (log rank test p < 0.001).

Conclusion:

MELD-XI score is a useful tool for in-hospital mortality prediction in patients referring to emergency medicine with acute ST elevation myocardial infarction.

Admission Body Temperature in Critically Ill Patients as an Independent Risk Predictor for Overall Outcome

INTRODUCTION

Body temperature (BT) abnormalities are frequently observed in critically ill patients. We aimed to assess admission BT in a heterogeneous critically ill patient population admitted to an intensive care unit (ICU) as a prognostic parameter for intra-ICU and long-term mortality.

METHODS

A total of 6,514 medical patients (64 ± 15 years) admitted to a German ICU between 2004 and 2009 were included. A follow-up of patients was performed retrospectively. The association of admission BT with both intra-ICU and long-term mortality was investigated by logistic regression.

RESULTS

Patients with hypothermia (<36°C BT) were clinically worse and had more pronounced signs of multi-organ failure. Admission BT was associated with adverse overall outcome, with a 2-fold increase for hyperthermia (mortality 12%; odds ratio [OR] 1.80, 95% confidence interval [CI] 1.43-2.26; p < 0.001), and a 4-fold increase for the risk of hypothermia (mortality 24%; OR 4.05, 95% CI 3.38-4.85; p < 0.001) with respect to intra-ICU and long-term mortality. Moreover, hypothermia was even more harmful than hyperthermia, and both were strongly associated with intra-ICU mortality, especially in patients admitted with acute coronary syndrome (hypothermia: hazard ratio 6.12, 95% CI 4.12-9.11; p < 0.001; hyperthermia: OR 2.70, 95% CI 1.52-4.79; p< 0.001).

CONCLUSION

Admission BT is an independent risk predictor for both overall intra-ICU and long-term mortality in critically ill patients admitted to an ICU. Therefore, BT at admission might not only serve as a parameter for individual risk stratification but can also influence individual therapeutic decision-making.

Easy prognostic assessment of concomitant organ failure in critically ill patients undergoing mechanical ventilation

BACKGROUND

Acute respiratory distress syndrome (ARDS) is a life-threatening disease. We evaluated the prognostic utility of Model for End-stage Liver Disease excluding INR (MELD-XI) score for predicting mortality in a cohort of critically ill patients on mechanical ventilation.

METHODS

In total, 11,091 mechanically ventilated patients were included in our post-hoc retrospective analysis, a subgroup of the VENTILA study (NCT02731898). Evaluation of associations with mortality was done by logistic and Cox regression analysis, an optimal cut-off was calculated using the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points).

RESULTS

Peak-, plateau- and positive end-expiratory pressure were higher in patients with MELD-XI>12. Patients with MELD-XI>12 had higher driving pressures (14 ± 6 cmH2O versus 13 ± 6; p < 0.001). MELD-XI was associated with 28-day mortality after correction for relevant cofounders including SAPS II and ventilation pressures (HR 1.04 95%CI 1.03-1.05; p < 0.001. Patients with MELD-XI>12 evidenced both increased hospital (46% versus 27%; p < 0.001) and 28-day mortality (39% versus 22%).

CONCLUSIONS

MELD-XI is independently associated with mortality and constitutes a useful and easily applicable tool for risk stratification in critically ill patients receiving mechanical ventilation.

TRIAL REGISTRATION

NCT02731898, registered 4 April 2016.

Presentation and outcomes of end stage liver disease patients presenting with septic shock to the emergency department

BACKGROUND

Patients with end stage liver disease (ESLD) are particularly vulnerable to sepsis. ESLD patients are often excluded from controlled sepsis trials and more data are needed to guide the management of this population.

OBJECTIVE

To describe the clinical factors and outcomes of patients with ESLD presenting to the emergency department (ED) with septic shock.

METHODS

We performed a retrospective review of patients registered in our dedicated ED adult septic shock pathway. All patients registered between January 2014 and May 2016 were included. Clinical and treatment variables for ESLD patients were compared with non-ESLD patients. A second analysis assessed ESLD survivors compared to non-survivors.

RESULTS

2,584 septic shock patients were enrolled. ESLD was present in 6.2% (n = 161) of patients. Patients with ESLD had higher mortality compared to patients without ESLD 36.6% vs 21.2% (p < 0.001). ESLD patients were more likely to be younger, female, obese, and have other comorbidities. ESLD patients exhibited lower temperature, higher lactate, and higher incidence of acute kidney injury. There was no difference in antibiotics or fluid resuscitation between groups. ESLD patients received more ED vasopressor support. Among ESLD septic shock patients, maximum lactate and presence of pneumonia were independently associated with death.

CONCLUSIONS

Patients with ESLD comprise a small but important subgroup of patients with ED septic shock that experience high mortality compared to patients without ESLD. Maximum ED lactate and pneumonia as the source of sepsis are independently associated with adverse outcome and may be used for early recognition of high-risk ESLD sepsis patients.

The association of high-normal international-normalized-ratio (INR) with mortality in patients referred for coronary angiography

Aims

The international-normalized-ratio (INR) is typically used to monitor patients on warfarin or related oral anticoagulant therapy. The aim of our study was to investigate the association of the INR with mortality in coronary artery disease (CAD) patients not on oral anticoagulant therapy.

Methods and results

Between 1997 to 2000 the LUdwigshafen RIsk and Cardiovascular Health (LURIC) study enrolled 3316 patients of German ancestry that had been referred for coronary angiography. We excluded patients on coumarin therapy (n = 222) and patients with an INR more than 5 standard deviations (SD) away from the mean (n = 30). During a median follow-up of 9.9 years, 884 patients died, 547 patients from cardiovascular causes. After adjustment for cardiovascular risk factors the INR was associated with all-cause mortality in all patients and the CAD positive group with HRs (95% CI) of 1.14(1.07–1.21) and 1.16(1.09–1.23) per 1-SD increase, respectively. Adjustment for NT-proBNP rendered the association insignificant.

Conclusion

In LURIC, the INR was positively associated with mortality in patients with prevalent CAD not on oral anticoagulant therapy as well as in patients without CAD. Adjustment for NT-proBNP abolished the association suggesting clinical or subclinical heart failure strongly contributing to increased INR and higher mortality.

Prognostic relevance of serum lactate kinetics in critically ill patients

PURPOSE

Changes of lactate concentration over time were reported to be associated with survival in septic patients. We aimed to evaluate delta-lactate (ΔLac) 24 h after admission (Δ24Lac) to an intensive care unit (ICU) in critically ill patients for short- and long-term prognostic relevance.

METHODS

In total, 26,285 lactate measurements of 2191 patients admitted to a German ICU were analyzed. Inclusion criterion was a lactate concentration at admission above 2.0 mmol/L. Maximum lactate concentrations of day 1 and day 2 were used to calculate Δ24Lac. Follow-up of patients was performed retrospectively. Association of Δ24Lac and both in-hospital and long-term mortality were investigated. An optimal cut-off was calculated by means of the Youden index.

RESULTS

Patients with lower Δ24Lac were of similar age, but clinically sicker. As continuous variable, higher Δ24Lac was associated with decreased in-hospital mortality (per 1% Δ24Lac; HR 0.987 95%CI 0.985-0.990; p < 0.001) and an optimal Δ24Lac cut-off was calculated at 19%. Δ24Lac ≤ 19% was associated with both increased in-hospital (15% vs 43%; OR 4.11; 95%CI 3.23-5.21; p < 0.001) and long-term mortality (HR 1.54 95%CI 1.28-1.87; p < 0.001), even after correction for APACHE II, need for catecholamines and intubation. We matched 256 patients with Δ24Lac ≤ 19% to case-controls > 19% corrected for APACHE II scores, baseline lactate level and sex: Δ24Lac ≤ 19% remained associated with lower in-hospital and long-term survival.

CONCLUSIONS

Lower Δ24Lac was robustly associated with adverse outcome in critically ill patients, even after correction for confounders. Δ24Lac might constitute an independent, easily available and important parameter for risk stratification in the critically ill.

Model for End-Stage Liver Disease Excluding INR (MELD-XI) score is associated with hemodynamic impairment and predicts mortality in critically ill patients

PURPOSE

We aimed (i) to evaluate Model for End-stage Liver Disease excluding INR (MELD-XI) score for prediction of mortality in a cohort of critically ill patients and (ii) to investigate associations of MELD-XI with microcirculation and (iii) to evaluate microcirculation for prediction of mortality in high-risk patients, e.g., with high MELD-XI scores.

METHODS

308 patients were included in our retrospective analysis, a subgroup of the multicenter micro-SOAP-study. Microcirculation was evaluated by Sidestream Dark Field (SDF) imaging. Evaluation of associations with mortality was done by logistic regression analysis, an optimal cut-off was calculated by means of the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points).

RESULTS

Patients with a MELD-XI > 12 points were of similar age (60 ± 1 years vs 62 ± 2 years; p = 0.32), but clinically sicker as mirrored by higher APACHE II scores (20 ± 1 vs 16 ± 1; p < 0.001). In the MELD-XI > 12 cohort in-hospital mortality was significantly higher compared to the MELD ≤ 12 group (48% vs 24%%; HR 2.98 95%CI 1.76-5.04; p = 0.003) and MELD-XI score was associated with mortality even after correction for relevant clinical confounders (HR 1.04 95%CI 1.01-1.07; p = 0.004) There were no associations between MELD-XI and parameters of microvascular perfusion.

CONCLUSIONS

MELD-XI is associated with in-hospital mortality and constitutes a useful tool for risk stratification in intensive care medicine. Interestingly, there were no associations between MELD-XI and microcirculation. Possibly parameters of the microcirculation present an online tool of hemodynamic assessment while MELD-XI presents an assessment of already established organ failure.

MELD-Na score predicts incident major cardiovascular events, in patients with nonalcoholic fatty liver disease (NAFLD)

Cardiovascular disease (CVD) is the leading cause of mortality among adults with nonalcoholic fatty liver disease (NAFLD); however, accurate tools for identifying NAFLD patients at highest CVD risk are lacking. Using a validated algorithm, we identified a retrospective cohort of 914 NAFLD patients without known CVD. Fibrosis severity was estimated using the fibrosis‐4 index. Patients were followed for 5 years for the development of a major adverse cardiovascular event (MACE); a composite of cardiovascular death, myocardial infarction, or unstable angina; urgent coronary revascularization; or stroke. Using an adjusted Cox proportional hazard regression model, NAFLD‐specific biomarkers of CVD risk were identified. Discrimination was compared to that of the Framingham Risk Score (FRS) using the area under the receiver operating characteristic curve. Among 914 patients, the mean age was 53.4 years and 60.6% were female. Over 5 years, 288 (31.5%) experienced MACE. After adjustment for traditional cardiometabolic risk factors and underlying FIB‐4 index score, each 1‐point increase in the model for end‐stage liver disease integrating sodium (MELD‐Na) was associated with a 4.2% increased risk of MACE (hazard ratio, 1.042; 95% confidence interval, 1.009‐1.075; P = 0.011). Compared to patients in the lowest MELD‐Na quartile (<7.5), those in the highest quartile (≥13.2) had a 2.2‐fold increased risk of MACE (adjusted hazard ratio, 2.21; 95% confidence interval, 1.11‐4.40; P = 0.024; P trend = 0.004). Incorporating MELD‐Na with the FRS significantly improved discrimination of future CVD risk (combined C‐statistic 0.703 versus 0.660 for the FRS alone; P = 0.040). Conclusion: Among patients with NAFLD, the MELD‐Na score accurately stratifies the risk for patients according to future CVD event risk. The addition of the MELD‐Na score to the FRS may further improve discrimination of NAFLD‐related CVD risk. (Hepatology Communications 2017;1:429–438)