Change In Model For End-Stage Liver Disease Score Research Articles

Identifying the early predictors of non-response to steroids in patients with flare of autoimmune hepatitis causing acute-on-chronic liver failure.

Early identification of non-response to steroids is critical in patients with autoimmune hepatitis (AIH) causing acute-on-chronic liver failure (ACLF). We assessed if this non-response can be accurately identified within first few days of treatment. Patients with AIH-ACLF without baseline infection/hepatic encephalopathy were identified from APASL ACLF research consortium (AARC) database. Diagnosis of AIH-ACLF was based mainly on histology. Those treated with steroids were assessed for non-response (defined as death or liver transplant at 90days for present study). Laboratory parameters, AARC, and model for end-stage liver disease (MELD) scores were assessed at baseline and day 3 to identify early non-response. Utility of dynamic SURFASA score [-6.80 + 1.92*(D0-INR) + 1.94*(∆%3-INR) + 1.64*(∆%3-bilirubin)] was also evaluated. The performance of early predictors was compared with changes in MELD score at 2weeks. Fifty-five out of one hundred and sixty-five patients (age-38.2 ± 15.0years, 67.2% females) with AIH-ACLF [median MELD 24 (IQR: 22-27); median AARC score 7 (6-9)] given oral prednisolone 40 (20-40) mg per day were analyzed. The 90day transplant-free survival in this cohort was 45.7% with worse outcomes in those with incident infections (56% vs 28.0%, p = 0.03). The AUROC of pre-therapy AARC score [0.842 (95% CI 0.754-0.93)], MELD [0.837 (95% CI 0.733-0.94)] score and SURFASA score [0.795 (95% CI 0.678-0.911)] were as accurate as ∆MELD at 2weeks [0.770 (95% CI 0.687-0.845), p = 0.526] and better than ∆MELD at 3days [0.541 (95% CI 0.395, 0.687), p < 0.001] to predict non-response. Combination of AARC score > 6, MELD score > 24 with SURFASA score ≥ -1.2, could identify non-responders at day 3 (concomitant- 75% vs either -42%, p < 0.001). Baseline AARC score, MELD score, and the dynamic SURFASA score on day 3 can accurately identify early non-response to steroids in AIH-ACLF.

4:12 PM Abstract No. 290 Changes in kidney function and model of end-stage liver disease score in diabetic patients undergoing the transjugular intrahepatic portosystemic shunt procedure

Diabetes is an important comorbidity present in up to 30% of patients with liver cirrhosis. The purpose of our study was to determine the impact of diabetes on the renal function and survival after transjugular intrahepatic portosystemic shunt (TIPS) procedure. We reviewed the medical records of 387 patients who had successful TIPS between September 2004 and September 2016. The patients were divided into two groups; group A (diabetics, n = 186) and group B (non-diabetics, n = 201). The glomerular filtration rate (GFR) and model for end-stage liver disease (MELD) score before and within 1 month after TIPS placement were recorded in each group. A threshold GFR and MELD score associated with mortality was estimated in each group. The study included 261 (62%) males, 373 (88%) whites, and 186 (45%) diabetics, with an average age of 59 (SD = 9.7) for diabetics and 54.7 (SD = 9.6) for non-diabetics. Before TIPS, there was a statistically significant difference between diabetics and non-diabetics in mean GFR (63.3 versus 80.9 respectively, p<0.0001) and in MELD score (13.3 versus 12.3 respectively, p = 0.0123). In spite of the significant change in MELD score after TIPS in diabetics and non-diabetics (p<0.0001), there was no significant change in the GFR after TIPS in either diabetics (p = 0.3345) or non-diabetics (p = 0.5065). Lower pre-TIPS GFR was significantly associated with mortality in diabetics [HR = 0.989,CI (0.98-0.99),p = 0.039), while higher pre-TIPS MELD score was associated with mortality in both diabetics [HR = 1.07,CI (1.00-1.14),p = 0.0398] and non-diabetics [HR = 1.08,CI (1.03-1.14),p = 0.001]. The threshold of pre-TIPS GFR and MELD score in discriminating survival in diabetics was 54 (p = 0.039) and 12 (p = 0.0398). Non-diabetic status was a significant contributor to survival [HR = 0.74,CI (0.55-0.99),p = 0.043]. TIPS does not significantly change the GFR in diabetics. However, pre-TIPS lower GFR and higher MELD score were associated with mortality after TIPS in diabetic patients. The best survival outcome was seen in patients with GFR > 54 and MELD < 12, and the absence of diabetes was a significant contributor to survival in cirrhotic patients undergoing TIPS.

New organ allocation policy in liver transplantation in the United States.

New organ allocation policy in liver transplantation in the United States.

Association of Model for End-Stage Liver Disease Score and Mortality in Trauma Patients With Chronic Liver Disease.

The Model for End-Stage Liver Disease (MELD) score is predictive of trauma outcomes. To determine whether a decrease in MELD score is associated with improved mortality in critically ill trauma patients. We performed a retrospective registry study of critically ill trauma patients 18 years or older with chronic liver disease treated between August 3, 1998, and January 5, 2012, at 2 level I trauma centers in Boston, Massachusetts. The consecutive sample included 525 patients (male, 373 [71.0%]; white, 399 [76.0%]; mean [SD] age, 55.0 [12.4] years). Change in MELD score from intensive care unit (ICU) admission to 48 to 72 hours later. Thirty-day all-cause mortality. The mean (SD) MELD score at ICU admission was 19.3 (9.7). The 30-day mortality was 21.9%. The odds of 30-day mortality with a change in MELD score of less than -2, -2 to -1, +1 to +4, and greater than +4 were 0.23 (95% CI, 0.10-0.51), 0.30 (95% CI, 0.10-0.85), 0.57 (95% CI, 0.27-1.20), and 1.31 (95% CI, 0.58-2.96), respectively, relative to a change in MELD score of 0 and adjusted for age, sex, race, Charlson/Deyo Index, sepsis, number of acute organ failures, International Classification of Diseases, Ninth Revision-based injury severity score, and ICU admission MELD score. A decrease in MELD score within 72 hours of ICU admission is associated with improved mortality.

Prognostic Value of Model for End-Stage Liver Disease Score Measurements on a Daily Basis in Critically Ill Patients With Cirrhosis

ObjectiveTo determine whether daily measurement of Model for End-Stage Liver Disease (MELD) score adds prognostic value to the initial MELD score in predicting mortality among patients with cirrhosis admitted to the intensive care unit (ICU). MethodsWe included 830 consecutive patients with cirrhosis admitted to a tertiary care ICU from January 1, 2003, through December 31, 2013, who had MELD scores on admission day 1 (MELD-D1). Daily MELD score during the first 7 days of ICU admission were retrospectively abstracted. The performances of MELD-D1 to MELD-D7 and changes in MELD score on consecutive days (Δ-MELD) in predicting 90-day mortality were determined using logistic regression. ResultsMELD-D1 was an independent predictor of mortality (adjusted odds ratio, 1.07; 95% CI, 1.05-1.10; P<.001), with an area under the receiver operating characteristic curve (AUC) of 0.72. MELD-D2 to MELD-D7 yielded comparable performance to MELD-D1 with an approximately 10% increase in risk of death per each incremental unit of MELD score (odds ratios, 1.09-1.11; P<.001; AUCs, 0.68-0.72). Δ-MELD-D2 to Δ-MELD-D7 were not independently associated with mortality (P=.69, P=.42, P=.81, P=.94, P=.83 and P=.28, respectively) and did not increase the predictive performance (AUCs) when combined with MELD-D2 to MELD-D7. ConclusionRepeating MELD score assessment during the first 7 days after ICU admission does not improve the ability of the initial MELD score for predicting 90-day mortality among patients with cirrhosis. Our finding does not support the practice of routine daily measurement of the MELD score.

Association between dental infections and the clinical course of chronic liver disease

Dental infections are implicated in several systemic diseases due to bacteremia and pro-inflammatory effects, but their possible role in liver disease is unclear. We retrospectively analyzed the clinical course of liver disease in relation to dental health among 116 patients with liver cirrhosis who underwent dental examination before liver transplantation. The need for multiple tooth extractions, a surrogate marker of dental infections, was associated with reduced time from diagnosis of liver disease to the need for liver transplantation (P = 0.02). The association was independent of age, sex, liver disease etiology and Model for End-Stage Liver Disease (MELD) score (P = 0.04). Among 38 patients with accurate laboratory follow-up data, the number of tooth extractions correlated with the change in MELD score during the year preceding dental examination (r = 0.43, P = 0.03). Spontaneous bacterial peritonitis caused by Streptococcus viridans occurred only among patients with multiple dental infections. Dental infections may influence the clinical course of liver disease, but prospective studies are needed.

MELD-good for many, not as good for others … at least for now.

Since its introduction in early 2002 as the prioritization system utilized by the United Network for Organ Sharing (UNOS) for patients on liver transplant waiting lists in the United States, the model for end stage liver disease (MELD) [1–3] has been extensively validated over time as a very sensitive predictor of pre-transplant mortality. Part of the success of the MELD system has been the foresight of UNOS to continuously reexamine MELD and be open to modifying it, so as to address inequities that might favor or prejudice certain patient groups. This is in fulfillment of the ‘‘final rule’’ of the organ procurement and transplantation network (OPTN) ensuring that all patients have as equal access to transplantation as possible [4]. For instance, in the early days of MELD, patients with small hepatocellular carcinoma (HCC) were given priority on the transplant waiting list (T1 lesions) and patients meeting the current T2 criteria were given higher priority than they currently have. T1 listing was done away with and patients with T2 criteria were assigned lower MELD scores when analysis suggested that patients with HCC were being given too much priority on the list and that non-HCC patients might be suffering the consequences of less access to organs and higher death rates on the waiting list [5, 6]. There are now specific disease states that allow patients to receive additional MELD priority scores, such as hepatopulmonary syndrome, portopulmonary hypertension, and familial amyloidosis [7]. Realization that patients with low MELD scores having hyponatremia are more likely to die on the waiting list has spurred ongoing research to assess whether an adjusted MELD score in this setting would be warranted [8]. Even patients having certain cholangiocarcinomas are now given priority in the waiting list because research has demonstrated appreciable survival with aggressive treatment protocols [9]. The success of MELD has captured the interest of the transplant community outside of the United States, and it has now been adopted by many other countries [10–13]. MELD has also been shown to have utility in predicting outcome in patients suffering from acute liver failure, alcoholic hepatitis, and in patients with chronic liver disease undergoing surgery or experiencing traumatic injury [14–18]. To date, however, it has not been shown to reliably predict post-liver transplant mortality. In listed patients with small changes in MELD score (delta MELD), there can be appreciable changes in pre-transplant mortality, although studies do not convincingly show this to be a strong predictor for having a bad outcome [19, 20]. In the issue of Hepatology International, Badr Al-Freah and colleagues [21] reviewed the results of an analysis of patients listed between 1998 and 2005 at the New Zealand Liver Transplant Unit with retrospective calculation of the MELD score at the time of listing and subsequently at the time of transplantation. They took into account prioritization points for HCC and studied 264 patients. Typically, patients in Australia and New Zealand are prioritized to transplantation when they are Child’s Class C and have had complications of portal hypertension, with hospitalized patients being further prioritized. The investigators found that MELD scores at transplant as well as delta MELD scores did not correlate with 3and 12-month post-transplant mortality. The authors concluded that the MELD allocation system would not be helpful in New Zealand, which has a single transplant center and organ procurement organization, and I am in agreement with this. Their results are not surprising in light of the fact that median waiting time prior to transplantation was 72 days and the MELD T. Schiano (&) Mount Sinai School of Medicine, New York, NY, USA e-mail: Thomas.Schiano@mountsinai.org

The value of model for end‐stage liver disease and Child–Turcotte–Pugh scores over time in evaluating the prognosis of patients with decompensated cirrhosis: experience in the Chinese mainland

In addition to the model for end-stage liver disease (MELD) and Child-Turcotte-Pugh (CTP) score, the change in MELD score (DeltaMELD) and CTP (DeltaCTP) over time, as well as the modified CTP score, have been proposed as predictive factors for patients with advanced liver cirrhosis. We investigated the ability of the above scoring systems to predict the outcome of decompensated cirrhosis in the Chinese mainland. A cohort of 160 patients with advanced liver cirrhosis who were followed up were studied prospectively. Kaplan-Meier survival analysis was used to evaluate 3-month survival in categories ranked by MELD and DeltaMELD, CTP, DeltaCTP and modified CTP score respectively. The area under receiver operator characteristics curve (AUC) was used to determine the predictive abilities of these models for 3-month mortality. A multivariate logistic regression method was used to determine the factors associated with mortality. Forty-five patients (28%) died within 3 months. The AUC of the DeltaMELD (0.901) was significantly higher than that of the MELD score (0.828) and the CTP score (0.605) (P < 0.01). The differences remained significant between the AUC of the DeltaCTP and CTP score, modified CTP and CTP (P < 0.01). The AUC of DeltaCTP, modified CTP and MELD were not different from each other (P > 0.05). In multivariate analysis, MELD, CTP scores, DeltaMELD, DeltaCTP and modified CTP were independent predictors of 3-month mortality. DeltaMELD, DeltaCTP and modified CTP were clinically useful parameters for short-term prognostication of patients with decompensated cirrhosis.

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.

Change in model for end-stage liver disease score on the transplant waiting list predicts survival in patients undergoing liver transplantation

Allocation of donor livers through the model for end-stage liver disease (MELD) score has resulted in a fall in waiting list deaths in the United States. Change in MELD score (DeltaMELD) whilst awaiting transplant has been suggested as a method of refining organ allocation. Our aims were to analyse the effect of DeltaMELD between listing and transplant, and examine its impact on patient survival, intensive care stay and hospital stay in 402 patients transplanted for chronic liver disease at a single centre. Patients who had a DeltaMELD score of >+1 point were more likely to die in hospital following transplant (P < 0.05) and had a significantly worse 12- and 36-month survival post transplant (P < 0.0001) when compared with patients with DeltaMELD <or=+1 (77.8% vs. 91.9% at 12 months; 72.1% vs. 83.6% at 36 months). This difference persisted even when in-hospital deaths were excluded (P = 0.0148). In a Cox-proportional hazards model, factors associated with reduced survival were DeltaMELD (P = 0.008), and transplant from intensive care (P < 0.001). In conclusion, change in MELD score whilst on the transplant waiting list has a significant effect on survival post-transplant although MELD score at the time of transplant appears to have the most significant effect on resource utilization.

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.

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

The model for end-stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. The change in MELD score over time (DeltaMELD) may have additional prognostic value. We investigated the ability of DeltaMELD to predict the outcome of advanced cirrhosis and prospectively assessed the factors associated with increasing DeltaMELD. Risk factors were determined in 58 prospectively followed-up patients. The predictive power of DeltaMELD, initial MELD and Child-Turcotte-Pugh (CTP) score was compared by using c-statistic in 351 patients. Ascites (P=0.020) and hepatic encephalopathy (P=0.023) were significantly associated with increasing MELD score at 3 months. The area under receiver operating characteristic (ROC) curve for DeltaMELD/month was 0.779 compared with 0.718 for MELD (P=0.130) and 0.528 for CTP score (P<0.001) at 6 months; the area was 0.822, 0.744 and 0.528, respectively (P=0.018 and <0.001, respectively) at 12 months. DeltaMELD/month >2.5 was the only significant prognostic predictor at 6 (odds ratio: 9.8, P<0.001) and 12 months (odds ratio: 16.3, P<0.001) in multivariate logistic analysis. Increasing MELD score is associated with the onset of ascites and encephalopathy. DeltaMELD is superior to initial MELD and CTP scores to predict intermediate term outcome in patients with advanced cirrhosis.

Model for end stage liver disease (MELD): dynamic changes in MELD score is important in predicting mortality for patients awaiting liver transplantation (LTX): Mahmoud M Yousfi, David D Douglas, M Edwyn Harrison, Hugo E Vargas, David C Mulligan, Adyr A Moss, Mayo Clinic Arizona, Phoenix, AZ; Michael Malinchoc, Russell H Wiesner, Mayo Clinic Rochester, Rochester, MN; Jorge Rakela, Vijayan Balan,

Model for end stage liver disease (MELD): dynamic changes in MELD score is important in predicting mortality for patients awaiting liver transplantation (LTX): Mahmoud M Yousfi, David D Douglas, M Edwyn Harrison, Hugo E Vargas, David C Mulligan, Adyr A Moss, Mayo Clinic Arizona, Phoenix, AZ; Michael Malinchoc, Russell H Wiesner, Mayo Clinic Rochester, Rochester, MN; Jorge Rakela, Vijayan Balan,

Preoperative Delta-MELD Score Does Not Independently Predict Mortality After Liver Transplantation

Changes in model for end-stage liver disease (MELD) score of ≥5 points over 30 days (delta-MELD) is an independent predictor for death in patients awaiting liver transplantation. The aim of the current study was to determine if a positive change in MELD score occurring over the 30 days immediately prior to liver transplantation was predictive of posttransplant mortality. MELD scores from the day of transplantation and 30 days prior to transplantation were calculated for 1510 UNOS patients and used to compute a delta-MELD score. Multivariate modeling determined predictors of posttransplant mortality. Patients with a preoperative delta-MELD ≥ 5 had higher absolute MELD scores at transplant, shorter mean posttransplant survival and higher mortality. However, multivariate analysis showed that none of the excess mortality was attributable to the high delta-MELD score (p = 0.43 for delta-MELD ≥ 5) and the majority of the excess risk was attributable to absolute MELD score (p < 0.001) at the time of transplantation. Mortality of patients with rapidly worsening chronic liver disease who undergo transplantation depends substantially on absolute MELD score at the time of transplantation but not the rate of change immediately preceding transplant. Allocation policymakers should consider that a high delta-MELD in the immediate pretransplant period does not indicate greater posttransplant mortality.

Longitudinal assessment of mortality risk among candidates for liver transplantation.

Liver allocation policy recently was modified to use the Model for End-Stage Liver Disease (MELD) for patients with chronic liver disease to stratify potential recipients according to risk for waitlist death. In this study, a retrospective cohort of 760 adult patients with chronic liver disease placed on the liver transplant waitlist between January 1995 and March 2001 and followed up for up to 74 months was studied to assess the ability of the MELD to predict mortality among waitlisted candidates and evaluate the prognostic importance of changes in MELD score over time. Serial MELD scores predicted waitlist mortality significantly better than baseline MELD scores or medical urgency status. Each unit of the 40-point MELD score was associated with a 22% increased risk for waitlist death (P <.001), whereas medical urgency status was not a significant independent predictor. For any given MELD score, the magnitude and direction of change in MELD score during the previous 30 days (DeltaMELD) was a significant independent mortality predictor. Patients with MELD score increases greater than 5 points over 30 days had a threefold greater waitlist mortality risk than those for whom MELD scores increased more gradually (P <.0001). We conclude that mortality risk on the liver transplant waitlist is predicted more accurately by serial MELD score determinations than by medical urgency status or single MELD measurements. DeltaMELD score over time reflects progression of liver disease and conveys important additional prognostic information that should be considered in the further evolution of national liver allocation policy.