New Model for End Stage Liver Disease Improves Prognostic Capability After Transjugular Intrahepatic Portosystemic Shunt

Abstract

Cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites or recurrent variceal bleeding are at risk for decompensation and death. This study examined whether a new model for end stage liver disease (MELD), which incorporates serum sodium (MELDNa), is a better predictor of death or transplant after TIPS than the original MELD. One hundred forty-eight consecutive patients undergoing nonemergent TIPS for refractory ascites or recurrent variceal bleeding from 1997 to 2006 at a single center were evaluated retrospectively. Cox model analysis was performed with death or transplant within 6 months as the end point. The models were compared using the Harrell's C index. Recursive partitioning determined the optimal MELDNa cutoff to maximize the risk:benefit ratio of TIPS. The predictive ability of MELDNa was superior to MELD, particularly in patients with low MELD scores. The C indices (95% confidence interval [CI]) for MELDNa and MELD were 0.65 (95% CI, 0.55-0.71) and 0.58 (95% CI, 0.51-0.67) using a cut-off score of 18, and 0.72 (95% CI, 0.60-0.85) and 0.62 (95% CI, 0.49-0.74) using a cut-off score of 15. Using a MELDNa >15, 22% of patients were reclassified to a higher risk with an event rate of 44% compared with 10% when the score was <or=15. MELDNa performed better than MELD in predicting death or transplant after non-emergent TIPS, especially in patients with low MELD scores. A MELD score <or=18 can provide a false positive prognosis; a MELDNa score <or=15 provides a more accurate risk prediction.