End-Stage Liver Disease Excluding INR Research Articles

Effect of change in hepato-renal function and cardiac rehabilitation on mortality in patients with heart failure

BackgroundPatients with heart failure (HF) often suffer from hepato-renal dysfunction. The associations between hepato-renal function changes and mortality remain unclear. Further, the effect of cardiac rehabilitation (CR) on mortality and motor functions in patients with HF and hepato-renal dysfunction requires investigation. MethodsWe reviewed 2522 patients with HF (63.2 % male; median age: 74 years). The association between changes in hepato-renal function assessed by the Model for End-stage Liver Disease eXcluding INR (MELD-XI) score at discharge and after 150 days at follow-up and mortality was examined. The association of CR participation with mortality and physical functions was investigated in patients with HF and hepato-renal dysfunction. ResultsDuring the follow-up period, 519 (20.6 %) patients died. Worsened MELD-XI score was independently associated with all-cause death [adjusted hazard ratio (aHR): 1.009; 95 % confidence interval (CI): 1.061–1.138; p < 0.001]. CR participation was associated with low mortality, even in the increased MELD-XI score group (aHR: 0.498; 95 % CI: 0.333–0.745; p < 0.001). Trajectory of the MELD-XI score was not associated with physical function changes and did not have the interaction with time effect in handgrip strength (p = 0.084), leg strength (p = 0.082), walking speed (p = 0.583), and 6-min walking distance (p = 0.833) in patients participating in outpatient CR. ConclusionsHepato-renal dysfunction predicts high mortality. CR participation may be helpful for a better prognosis of patients with HF and hepato-renal dysfunction.

Mechanical support for the failing single ventricle after Fontan

Mechanical support for the failing single ventricle after Fontan

Significance of pre and post-implant MELD-XI score on survival in children undergoing VAD implantation

Derangements in liver and renal function often accompany end-stage heart failure. We sought to assess the utility of an objective risk assessment tool, the Model for End-stage Liver Disease eXcluding INR (MELD-XI), to identify pediatric patients at increased risk for adverse outcomes post-ventricular assist device (VAD) implantation. The Pedimacs database was queried for all pediatric patients who underwent VAD implantation from September 19, 2012 to December 31, 2019. Pre-implant and early (1-week) post-implant MELD-XI scores were used to stratify patients into low, intermediate and high score cohorts. Comparison of pre-implant characteristics and post-implant outcomes were conducted across groups. Multiphase parametric hazard modeling was utilized to identify independent predictors of post-implant mortality. A total of 742 patients had a calculable MELD-XI score pre-implant. When stratified by MELD-XI scores pre-implant, patients in the high MELD-XI score cohort (score >13.6) had inferior survival and increased bleeding, renal dysfunction and respiratory failure post-implant compared to intermediate and low score cohorts. Risk factors for mortality post-VAD implantation were: increasing MELD-XI scores (HR 1.1 per 1 unit rise), Pedimacs profile 1 (HR 1.6), congenital heart disease (HR 2.3) and being on a percutaneous VAD (HR 2.7). Importantly, MELD-XI score was a better predictor of post-VAD implant mortality than bilirubin or creatinine alone, neither of which were significant in the final model. Patients with increasing or continued high MELD-XI scores early post-implant had the worst survival. The MELD-XI is an easily calculated score that serves as a promising risk assessment tool in identifying children at risk for poor outcomes post VAD implantation.

Hepatorenal dysfunction assessment with the Model for End-Stage Liver Disease Excluding INR score predicts worse survival after heart transplant in pediatric Fontan patients

BackgroundFontan physiology results in multiorgan dysfunction, most notably affecting the liver and kidney. We evaluated the utility of Model for End-Stage Liver Disease Excluding INR (MELD-XI) score, a score evaluating the function of both liver and kidney to identify Fontan patients at increased risk for morbidity and mortality post–heart transplant. MethodsThe Pediatric Heart Transplant Society database was queried to identify Fontan patients listed for heart transplant between January 2005 and December 2018. MELD-XI scores were calculated at listing and heart transplant. A multivariable analysis was conducted to identify risk factors for post–heart transplant mortality. Demographic, clinical characteristics, and survival differences were evaluated and compared between the high and low MELD-XI score cohorts. The impact of changing MELD-XI scores during the waitlist period on post–heart transplant outcomes was also evaluated. ResultsOf 565 Fontan patients who underwent transplantation, 524 (93%) had calculable MELD-XI scores at the time of heart transplant: 421 calculable at listing and 392 calculable at listing and at heart transplant. On multivariable analysis, only MELD-XI score (squared) (hazard ratio, 1.007), history of protein-losing enteropathy (hazard ratio, 2.1), and ventricular assist device use at transplant (hazard ratio, 3.4) were risk factors for early phase post–heart transplant mortality. Patients with high MELD-XI scores at heart transplant had inferior survival post–heart transplant (P = .02); those in the high MELD-XI score cohort at wait listing and heart transplant tend to have the worst post–heart transplant survival; however, this was not significant (P = .42). ConclusionsThe MELD-XI, an easily calculated score, serves as a valuable aid in identifying pediatric Fontan patients at increased risk for post–heart transplant mortality.

Abstract 12917: Prognostic Value of the Combination of Model for End-stage Liver Disease Excluding Inr Score and Non-alcoholic Fatty Liver Disease Fibrosis Score in Patients Admitted for Acute Heart Failure

Background: Cardiohepatic interactions have been a focus of attention in heart failure(HF), and the model for end-stage liver disease excluding INR (MELD-XI) has been shown to be useful for prediction of poor outcome in patients (pts) with acute decompensated heart failure (ADHF). Furthermore, it has been reported that liver stiffness predicts adverse prognosis in pts with HF. Liver fibrosis is assessed by non-invasive fibrosis markers such as Fibrosis-4 (FIB4) index, non-alcoholic fatty liver disease fibrosis score (NFS) and aminotransferase to platelet ratio index (APRI). Recently, a new group of HF pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). However, there is little information available on the comparison of prognostic significance of MELD-XI and liver fibrosis scores in ADHF pts, relating to LVEF. Methods: We prospectively studied 466 consecutive ADHF pts (HFrEF (LVEF≦40%): n=164, HFmrEF (40&lt;LVEF&lt;50): n=104 and HFpEF (LVEF≧50%): n=198). At the discharge, we calculated MELD-XI, FIB4 index , NFS, and APRI. The endpoint was all cause death (ACD). Results: During a follow-up period of 2.8±1.5 years, 143 pts had ACD. At multivariate Cox analysis, MELD-XI and FIB4 index was independently associated with ACD irrespective of LVEF. The pts with both greater MELD-XI ([HFrEF]≥25.8, [HFmrEF]≥33.2, [HFpEF]≥30.1) and greater FIB4 index ([HFrEF]≥2.58, [HFmrEF]≥2.58, [HFpEF]≥2.22) had a significantly increased risk of ACD than those with either and none of them in all three groups. Conclusions: The combination of MELD-XI and FIB4 index might be useful for stratifying pts at risk for ACD in ADHF pts with irrespective of LVEF.

Does liver biopsy accurately measure fibrosis in Fontan-associated liver disease? A comparison of liver biopsy pre-combined heart and liver transplant and liver explant post-transplant.

The accuracy of liver biopsy to stage fibrosis due to Fontan-associated liver disease (FALD) remains unclear. We compared the results of biopsy pre-combined heart and liver transplantation (CHLT) to the results of whole liver explant. Liver biopsy and explants from 15 Fontan patients (ages 16-49, median 28years) were retrospectively reviewed. Staging was as follows: stage 0: no fibrosis, stage 1: pericellular fibrosis, stage 2: bridging fibrosis, and stage 3: regenerative nodules. There is no stage 4. Clinical characteristics including Model of End-stage Liver Disease eXcluding INR and Varices, Ascites, Splenomegaly, and Thrombocytopenia (VAST) scores were collected, and descriptive statistics and Mann-Whitney U tests were used to analyze the data. All patients had biopsies with at least bridging fibrosis, and all had nodularity on explant; transjugular biopsy never overestimated fibrosis. Explant showed higher-grade fibrosis (stage 3) than pre-CHLT biopsy (stage 2) in 6 of 15 patients and equal grade of fibrosis (stage 3) in 9 of 15 patients. Though clinical characteristics varied significantly, VAST score was ≥2 in all but two patients. Transjugular liver biopsy does not overestimate and can underestimate fibrosis in Fontan patients undergoing CHLT, likely due to the patchy nature of fibrosis in FALD.

Trends in MELD-XI between Listing and Transplant are Associated with Poor Outcomes in Heart Transplant Recipients with Stage 3 Chronic Kidney Disease

Non-dialysis dependent patients with renal impairment undergoing heart transplantation (HT) alone are at significantly higher risk of mortality and poor renal outcomes compared with those undergoing heart-kidney transplantation (HKT). It remains unclear what parameters might identify patients who may benefit from HKT compared to HT alone. The Model for End-Stage Liver Disease Excluding INR (MELD-XI) score at the time of HT has been shown to predict early post-HT mortality. We investigated whether trends in the MELD-XI score between listing and transplant among those with stage 3 chronic kidney disease (CKD) (estimated glomerular filtration rate (eGFR) between 30 and 59 ml/min/1.73 m2) are associated with higher risk of post-HT death or dialysis. We identified 159 patients undergoing HT at our institution between 1/2009 and 2/2018. The following groups were created: Group 1 - MELD-XI ≤ 16 at listing and HT, Group 2 - MELD-XI ≤ 16 at listing and > 16 at HT, Group 3 - MELD-XI > 16 at listing and ≤ 16 at HT, Group 4 - MELD-XI > 16 at listing and HT. A cutoff of 16 was chosen based on the 75th percentile in a normal distribution among those without a composite outcome of post-HT death or dialysis at 1 year. Cox-proportional regression and survival analyses were performed to assess risk of this outcome. Average MELD-XI at listing was 14.0 ± 4.9 and at HT was 12.8 ± 4.5 (p < 0.01); MELD-XI >16 was present in 51 (32.1%) at listing and 38 (23.9%) at HT. Group 4 incurred highest risk of composite outcome relative to Group 1 (adjusted hazard ratio 3.67 (95% confidence interval: 1.38-9.76, p < 0.01); see figure). Notably, Groups 2 and 3 had a statistically nonsignificant trend toward higher risk of the composite outcome compared to Group 1. Changes in MELD-XI between listing and transplantation offer additional risk stratification beyond absolute MELD-XI at time of transplant for death or dialysis at 1 year in patients with stage 3 CKD.

Model for End-Stage Liver Disease Excluding INR (MELD-XI) Score Predicts Outcomes in Pediatric Patients Supported with Ventricular Assist Device: An Analysis of the PediMACS Registry

Our study aims to identify the utility of pre-implant MELD-XI score in identifying pediatric patients at higher risk for morbidity and mortality post-VAD implant. We reviewed all patients listed in the PediMACS database from 9/19/12 to 3/31/19. Patients missing bilirubin or creatinine that precluded calculation of MELD-XI score (n=89) were excluded. Patients were divided into three cohorts based on MELD-XI score pre-implant - low (minimum score 9.4, < 25%-tile), intermediate (scores 9.4-13.6, 25-75%-tile), and high (scores >13.6, 75-100%-tile). Baseline clinical and hemodynamic data were compared; outcomes data on morbidity and mortality were compared across groups. Of 596 patients included, 42.5% were in the low, 29.2% in the intermediate and 28.3% in the high MELD-XI cohort. Compared to the low and intermediate cohorts, patients in the high MELD-XI cohort were significantly older (p<0.01); more likely had congenital heart disease (17.8 vs. 24.7 vs. 30.2%, p<0.01); elevated NT-pro BNP, elevated AST and ALT (p<0.05). They were more likely to be mechanically ventilated, on ECMO and INTERMACS 1 (p<0.01) pre-implant. Compared to the low-MELD-XI cohort, patients in the high MELD-XI cohort had an increased risk of death [14.7 vs. 29.5%, p<0.01] (Figure) and a lower probability of transplant [69.4 vs. 50.1, p<0.01] at 12 months post-VAD implant. On multivariable analysis, a high MELD-XI score persisted as highly significant risk factor for early mortality (HR 1.7, p<0.01) (Table). Pediatric patients with an elevated MELD-XI score have higher acuity of illness pre-implant. This easily calculated score based on routinely collected lab values serves as a promising risk assessment tool in identifying pediatric VAD recipients at increased risk for mortality post VAD implant. Trending the MELD-XI score in patients with advanced heart failure may aid clinicians in timing of VAD implantation.

Prognostic value of the model for end-stage liver disease excluding INR score (MELD-XI) in patients with adult congenital heart disease.

Patients with adult congenital heart disease (ACHD) are at increased risk of developing late cardiovascular complication. However, little is known about the predictive factors for long-term outcome. The Model for End-Stage Liver Disease eXcluding INR (MELD-XI) score was originally developed to assess cirrhotic patients and has the prognostic value for heart failure (HF) patients. In the present study, we examined whether the score also has the prognostic value in this population. We retrospectively examined 637 ACHD patients (mean age 31.0 years) who visited our Tohoku University hospital from 1995 to 2015. MELD-XI score was calculated as follows; 11.76 x ln(serum creatinine) + 5.11 x ln(serum total bilirubin) + 9.44. We compared the long-term outcomes between the high (≥10.4) and the low (<10.4) score groups. The cutoff value of MELD-XI score was determined based on the survival classification and regression tree (CART) analysis. The major adverse cardiac event (MACE) was defined as a composite of cardiac death, HF hospitalization, and lethal ventricular arrhythmias. During a mean follow-up period of 8.6 years (interquartile range 4.4–11.4 years), MACE was noted in 51 patients, including HF hospitalization in 37, cardiac death in 8, and lethal ventricular arrhythmias in 6. In Kaplan-Meier analysis, the high score group had significantly worse MACE-free survival compared with the low score group (log-rank, P<0.001). Multivariable Cox regression analysis showed that the MELD-XI score remained a significant predictor of MACE (hazard ratio 1.36, confidence interval 1.17–1.58, P<0.001) even after adjusting for patient characteristics, such as sex, functional status, estimated glomerular filtration rate, and cardiac function. Furthermore, CART analysis revealed that the MELD-XI score was the most important variable for predicting MACE. These results demonstrate that the MELD-XI score can effectively predict MACE in ACHD patients, indicating that ACHD patients with high MELD-XI score need to be closely followed.

OC31 HOW TO IDENTIFY THE APPROPRIATE LEFT VENTRICULAR ASSIST DEVICE CANDIDATE AMONG PATIENTS ON EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT

Background and Aim: Implantation of long-term left ventricular assist devices (LVADs) in patients on veno-arterial membrane oxygenation (VA-ECMO) support is controversial. Aim of this study has been to report the experience of seven LVAD centers. Methods: Data of LVAD patients (2010–2017) at seven European institutions were reviewed. The only inclusion criteria was VA-ECMO before LVAD placement. Patients’ characteristics, intraoperative variables and postoperative course were analyzed thus eventually identifying predictors of mortality. Results: A total of 154 continuous flow LVAD patients (mean age 53.1 ± 12 years; 84% male) were identified. The VA-ECMO cannulation was peripheral in 92% of patients and 37% had received cardiopulmonary resuscitation prior to VA-ECMO implantation. Mean VA-ECMO duration prior to LVAD implantation was 7.1 ± 7 days. Cardiopulmonary bypass was adopted in 64% of patients for LVAD implantation. Major postoperative complications included right heart failure requiring temporary right ventricular device (RVAD) support (47%), bleeding requiring rethoracotomy (20%), respiratory failure (54%), renal failure (50%) and hepatic failure (31%). Thirty-day and 1-year survival was 84 and 62%, respectively. At univariate analysis age, lactate level, pH, white blood cells (WBC) count, pre-LVAD dialysis and Model for End-stage Liver Disease eXcluding INR (MELD-XI) score before implant were significant. Multivariate regression analysis identified pre-LVAD MELD-XI (OR 1,250, 95% CI 1,038–1,505; p = 0.019) as the only significant predictor of mortality. Conclusions: The outcome of LVAD patients on VA-ECMO support is limited by the high rate of major adverse events. Preoperative LVAD MELD-XI score seems to identify patients that will clearly not benefit from LVAD implantation.

Calculation of the ALMA Risk of Right Ventricular Failure After Left Ventricular Assist Device Implantation.

Right ventricular failure after continuous-flow left ventricular assist device (LVAD) implantation is still an unsolved issue and remains a life-threatening event for patients. We undertook this study to determine predictors of the patients who are candidates for isolated LVAD therapy as opposed to biventricular support (BVAD). We reviewed demographic, echocardiographic, hemodynamic, and laboratory variables for 258 patients who underwent both isolated LVAD implantation and unplanned BVAD because of early right ventricular failure after LVAD insertion, between 2006 and 2017 (LVAD = 170 and BVAD = 88). The final study patients were randomly divided into derivation (79.8%, n = 206) and validation (20.1%, n = 52) cohorts. Fifty-seven preoperative risk factors were compared between patients who were successfully managed with an LVAD and those who required a BVAD. Nineteen variables demonstrated statistical significance on univariable analysis. Multivariable logistic regression analysis identified destination therapy (odds ratio [OR] 2.0 [1.7-3.9], p = 0.003), a pulmonary artery pulsatility index <2 (OR 3.3 [1.7-6.1], p = 0.001), a right ventricle/left ventricle end-diastolic diameter ratio >0.75 (OR 2.7 [1.5-5.5], p = 0.001), an right ventricle stroke work index <300 mm Hg/ml/m (OR 4.3 [2.5-7.3], p < 0.001), and a United Network for Organ Sharing modified Model for End-Stage Liver Disease Excluding INR score >17 (OR 3.5 [1.9-6.9], p < 0.001) as the major predictors of the need for BVAD. Using these data, we propose a simple risk calculator to determine the suitability of patients for isolated LVAD support in the era of continuous-flow mechanical circulatory support devices.

Prognostic utility of MELD-XI in adult congenital heart disease patients undergoing cardiac transplantation.

Model of End-Stage Liver Disease eXcluding INR (MELD-XI) at cardiac transplant has demonstrated prognostic survival utility, but has not been specifically validated in adult congenital heart disease (ACHD) in a registry study. Adults undergoing first-time orthotopic heart transplant from 2005 to 2015 in the United Network for Organ Sharing (UNOS) registry were examined in parallel: ACHD (n=543), ischemic-dilated cardiomyopathy (IDCM, n=6954) and valvular heart disease (VHD, n=355). Our primary endpoint was a composite of death, graft failure, and retransplantation assessed at 3months (early), and those with freedom from early endpoint were reassessed at 5years (late). Interactions between hepatorenal indices and waitlist time were examined. Secondary outcomes relating to long-term morbidity were assessed at late endpoint. Freedom from endpoint analysis in ACHD at clinically relevant endpoints was also conducted. Model of End-Stage Liver Disease eXcluding INR score at transplant associated with an increased risk of early endpoint in all cohorts. At late endpoint, bilirubin level associated with increased risk uniquely in ACHD. Model of End-Stage Liver Disease eXcluding INR holds prognostic application to ACHD in early time points and demonstrates unique waitlist interactions. Transplant bilirubin level may hold significance in long-term risk stratification of the ACHD population. Time on waitlist is an important consideration to contextualize these values.

Prognostic value of selected risk scales in patients with end-stage heart failure

Due to the increasing number of patients placed on waiting lists for orthotopic heart transplantation (OHT), the selection of patients with the highest risk of death has become paramount. This study aimed to evaluate the predictive value of the Model for End-stage Liver Disease eXcluding INR (MELD-XI) and Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) scales in ambulatory patients awaiting OHT and compare them to the Heart Failure Survival Score (HFSS). The study was a retrospective review of 370 adult ambulatory patients with end-stage heart failure, who were added to the OHT waiting list at our institution between 2012 and 2016. The median age of the patients was 54.0 (46.0-60.0) years, and 324 (87.6%) of them were male. The overall one-year mortality was 27.6%. The areas under the curve (AUCs) for the MAGGIC and HFSS scales were comparable: 0.771 (95% confidence interval [CI] 0.720-0.823); sensitivity 77%, specificity 68% vs. 0.781 (95% CI 0.732-0.829); sensitivity 90%, specificity 58%, respectively. The AUC for the MELD-XI scale was higher than that for the HFSS scale: 0.812 (95% CI 0.769-0.856); sensitivity 91%, specificity 63% vs. 0.781 (95% CI 0.732-0.829) sensitivity 90%, specificity 58%, respectively. Our study demonstrated that elevated MELD-XI and MAGGIC scores and lowered HFSS scores were associated with an increased risk of death during one-year follow-up. The prognostic utility of the MELD-XI scoring system was better than that of the HFSS scale, while the MAGGIC scale was comparable to the HFSS.

A New Combined Model for End-Stage Liver Disease Excluding INR (CMELD-XI) Score Better Predicts Pediatric Heart Transplant Outcomes

The Model for end-stage liver disease (MELD) score, derived based on serum creatinine, bilirubin, and INR, was developed to accurately predict the probability of waitlist mortality in patients awaiting a liver transplant. Subsequently, a MELD excluding INR (MELD-XI) score was adapted to predict mortality after heart transplant (HT). Our objective was to devise a new combined scoring model (defined as CMELD-XI, derived by adding the MELD-XI score with independent predictors of 1-year mortality) to accurately predict mortality after pediatric HT (PHT).

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

PurposeWe 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. Methods308 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). ResultsPatients 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. ConclusionsMELD-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.

Abstract 13894: Prediction of Mode of Death by Model of End-Stage Liver Disease Excluding INR (MELD-XI) Scoring System in Patients Admitted for Acute Decompensated Heart Failure With Preserved and Reduced Ejection Fraction; a Comparison With Nonalcoholic Fatty Liver Disease Fibrosis Score

Backgrounds: Cardiohepatic interactions have been a focus of attention among heart failure. A model of end-stage liver disease excluding INR (MELD-XI), a robust scoring system of liver dysfunction, has been shown to provide prognostic information in heart failure patients (pts). Furthermore, it was reported that nonalcoholic fatty liver disease (NAFLD) is a risk factor for cardiovascular disease. There is a difference in mode of death (cardiac vs non-cardiac death) between heart failure with preserved (HFpEF) and reduced ejection fraction (HFrEF). We sought to investigate the prognostic significance of MELD-XI and NAFLD in the prediction of mode of death in pts admitted for acute decompensated heart failure (ADHF), relating to HFpEF and HFrEF. Methods and Results: We studied 303 consecutive ADHF pts (HFrEF[LVEF&lt;50%]; n=163, HFpEF[LVEF≥50%];n=140). MELD-XI score was calculated by the formula: 5.11х ln(bilirubin)+11.79х ln(creatinine)+9.44. NAFLD fibrosis score (NFS) was obtained by the formula: -1.675 + 0.037 х age + 0.094 х BMI + 1.13 х hyperglycemia or diabetes (yes = 1, no = 0) + 0.99 х AST/ALT - 0.013 х platelet ( х 10 9 /L) - 0.66 х albumin. During a follow-up period of 5.1±4.3 yrs, 65 pts had cardiac death and 56 pts had non-cardiac death. At multivariate Cox analysis, MELD-XI score, but not NFS, was significantly associated with cardiac death independently of prior heart failure hospitalization, BMI, systolic blood pressure and serum sodium level, while neither MELD-XI score nor NFS showed the association with non-cardiac death. MELD-XI of 13 was a fair discriminator for cardiac death (AUC 0.737[0.670-0.805]). In both groups with HFrEF and HFpEF, pts with higher MELD-XI score had a significantly higher risk of cardiac death than those with lower MELD-XI score. Conclusion: A MELD-XI scoring system might predict cardiac death but not non-cardiac death in ADHF pts, regardless of HFrEF or HFpEF, although NAFLD fibrosis score did not.

(1160) - Modified Model for End-Stage Liver Disease eXcluding INR (MELD XI) Score Predicts Post-Heart Transplant Mortality Among Children with Congenital Heart Disease

(1160) - Modified Model for End-Stage Liver Disease eXcluding INR (MELD XI) Score Predicts Post-Heart Transplant Mortality Among Children with Congenital Heart Disease

Abstract 12917: Model of End-stage Liver Disease Excluding INR (MELD-XI) Scoring System Provides the Additional Long-Term Prognostic Information to Malnutrition in Patients Admitted With Acute Decompensated Heart Failure

Backgrounds: Hospitalization for acute decompensated heart failure (ADHF) is associated with a high mortality after discharge. Liver dysfunction has a prognostic impact on the outcome of patients with advanced heart failure. A model of end-stage liver disease excluding INR (MELD-XI), a robust scoring system of liver dysfunction, has been shown to provide prognostic information in heart failure patients. Malnutrition is also associated with poor outcome in ADHF pts. However, there is no information available on the long-term prognostic significance of MELD-XI score in patients admitted with acute decompensated heart failure (ADHF), relating to malnutrition. Methods and Results: We studied 303 consecutive ADHF patients discharged with survival. MELD-XI score was calculated by the following formula: 5.11·ln(bilirubin)+11.79·ln(creatinine)+9.44. Nutritional status was evaluated by Geriatric Nutritional Risk Index (GNRI) calculated as follows: 14.89·serumalbumin (g/dl) + 41.7·BMI/22. During a follow-up period of 5.0±4.3 yrs, 75 patients had cardiovascular death (CVD). At multivariate Cox analysis, MELD-XI score (p=0.0025) and GNRI (p=0.0025) were significantly independently associated with CVD, independently of systolic blood pressure, serum sodium level and prior heart failure hospitalization. ROC analysis revealed that MELD-XI score of 12 was a fair discriminator for CVD (AUC 0.70 [0.64-0.77]). In group with malnutrition (GNRI&lt;96.5: median value), patients with high MELD-XI score (≥12) had a higher risk of CVD than those with low MELD score (43% vs 25%, p=0.02, HR 1.9 [1.1-3.3]). In group without hyponatremia (GNRI≥96.5), patients with high MELD-XI score also had a higher risk of CVD (38% vs 11%, p&lt;0.0001, HR 4.4 [2.0-10.0]). Conclusion: A MELD-XI scoring system could provide the additional long-term prognostic information to malnutrition in ADHF patients.

MELD-XI Score Predicts Early Mortality in Patients After Heart Transplantation

The aim of this study was to determine the utility of the Model for End-Stage Liver Disease Excluding INR (MELD-XI) in predicting early outcomes (30 days and 1 year) and late outcomes (5 years) in patients after orthotopic heart transplantation (OHT). The United Network for Organ Sharing database was queried for all adult patients (aged ≥ 18 years) undergoing OHT from 2000 to 2012. A MELD-XI was calculated and the population stratified into score quartiles. Early and late survivals were compared among the MELD-XI cohorts. Multivariable Cox proportional hazards models were constructed to determine the capacity of MELD-XI (when modeled both as a categoric and a continuous variable) to predict 30-day, 1-year, and 5-year mortality. Conditional models were also designed to determine the effect of early mortality on long-term survival. A total of 22,597 patients were included for analysis. The MELD-XI cutoff scores were established as follows: low (≤ 10.5), low-intermediate (10.6 to 12.6), intermediate-high (12.7 to 16.4), and high (>16.4). The high MELD-XI cohort experienced statistically worse 30-day, 1-year, and 5-year unconditional survivals when compared with patients with low scores (p < 0.001). Similarly, a high MELD-XI score was also predictive of early and late mortality (p < 0.001) after risk adjustment. There was, however, no difference in 5-year survival between the high score and low score cohorts after accounting for 1-year deaths. Subanalysis of patients bridged to transplant with a continuous-flow left ventricular assist device demonstrated similar findings. This is the first known study to examine the relationship between a high MELD-XI score and outcomes in patients after OHT. Patients with hepatic or renal dysfunction before OHT should be closely monitored and aggressively optimized as early mortality appears to drive long-term outcomes.

Modified Model for End-Stage Liver Disease eXcluding INR (MELD-XI) Score Predicts Early Death After Pediatric Heart Transplantation

We sought to determine the ability of the Model for End-Stage Liver Disease eXcluding INR (MELD-XI) to predict short-term and long-term outcomes in pediatric patients undergoing orthotopic heart transplant. The United Network for Organ Sharing Database was queried for all pediatric patients (aged 1 to 18 years) undergoing orthotopic heart transplant from 2000 to 2012. The logarithmic relationship between the serum creatinine and bilirubin was used to calculate the MELD-XI score. Lowess smoothing plots were referenced, and a score threshold of 12.2 was used to stratify patients into low (75%) and high (25%) MELD-XI cohorts. Patient-specific characteristics, intraoperative variables, and postoperative outcomes were compared between the two cohorts. Differences in survival at 30 days, 1 year, and 5 years between the MELD-XI cohorts were estimated by the Kaplan-Meier method. Cox proportional hazards modeling was used to determine the risk-adjusted effect of a high MELD-XI score on death. After patients with missing MELD-XI scores were excluded, 2,939 patients met the inclusion criteria. Unconditional 30-day (93.1% vs 98.0%, p < 0.001), 1-year (85.9% vs 92.9%, p < 0.001), and 5-year (71.2% vs 79.5%, p < 0.001) survivals were significantly worse in the high-score cohort. However, 1-year survival excluding 90-day deaths (94.9% vs 95.8%, p= 0.29) and 5-year survival excluding 1-year deaths (82.8% vs 85.6%, p= 0.09) were statistically equivalent. When modeled as a categoric variable, a high MELD-XI score was an independent predictor of death at 30 days (hazard ratio, 2.86; 95% confidence interval, 1.84 to 4.45; p < 0.001), 1 year (hazard ratio, 1.88; 95% confidence interval, 1.42 to 2.48, p < 0.001), and 5 years (hazard ratio, 1.41; 95% confidence interval, 1.19 to 1.77; p < 0.001). For every 1-point increase in the MELD-XI score, mortality increased 11% at 30 days, 7% at 1 year, and 4% at 5 years (p < 0.001). The MELD-XI was not predictive of conditional mortality at 1 year or 5 years. The MELD-XI scoring system can be used in pediatric orthotopic heart transplant to identify patients at risk for poor outcomes. Because long-term survival is largely driven by early death, renal insufficiency and congestive hepatopathy should be optimized before transplant.