Low Model For End-Stage Liver Disease Scores Research Articles

Differential Effects of Ascites and Hepatic Encephalopathy on Waitlist Mortality in Liver Transplantation by MELD 3.0.

MELD 3.0 introduces changes to address waitlist disparities for liver transplant (LT) candidates. Ascites and hepatic encephalopathy (HE) are important milestones in the natural history of cirrhosis regardless of the Model for End-Stage Liver Disease (MELD) score. We aim to assess the impact of ascites and HE and its interaction with MELD 3.0 on waitlist mortality. This is a retrospective study of patients listed for LT in the Organ Procurement and Transplantation Network database from 2016 to 2021. The primary outcome was waitlist mortality (death/delisting for too sick to LT). Ascites/HE were classified as moderate ascites without moderate HE (mAscites), moderate HE without moderate ascites (mHE), both moderate ascites/HE (mBoth), and neither. MELD 3.0 scores were categorized as <20, 20-29, 30-39, and ≥40. Of 39 025 candidates, 29% had mAscites, 3% mHE, and 8% mBoth. One-year waitlist mortality was 30%, 38%, and 47%, respectively, compared with 17% (all P < 0.001) for those with neither. In multivariable Cox regression, the adjusted risk of waitlist mortality associated with mAscites (versus neither) was a hazard ratio (HR) of 1.76 (95% confidence interval [CI], 1.55-2.00) when the MELD 3.0 score was <20, significantly higher than when the MELD 3.0 score was 20-29 (HR 1.40; 95% CI, 1.27-1.54), 30-39 (HR 1.19; 95% CI, 1.04-1.35), and ≥40 (HR 1.14; 95% CI, 0.91-1.43, interaction P < 0.05 for all). A similar pattern was observed by MELD 3.0 for both moderate ascites/HE. The presence of moderate ascites alone, or combined with moderate HE, not only increases the risk of waitlist mortality but also has a differential effect by MELD 3.0, especially at lower MELD scores. Earlier strategies addressing this group and improving treatment plans or access to LT regardless of MELD remain needed.

Natural history of NASH cirrhosis in liver transplant waitlist registrants

Non-alcoholic steatohepatitis (NASH) cirrhosis is rapidly growing as an indication for liver transplant(ation) (LT). However, the natural history of NASH cirrhosis among LT waitlist registrants has not been established. The present study aimed to define the natural history of NASH cirrhosis using the Scientific Registry of Transplant Recipients database. The study cohort comprised patients registered on the LT waitlist between 1/1/2016 to 12/31/2021. The primary outcomes included probability of LT and waitlist mortality, comparing NASH (n= 8,120) vs. non-NASH (n= 21,409) cirrhosis. Patients with NASH cirrhosis were listed with lower model for end-stage liver disease (MELD) scores despite bearing a greater burden of portal hypertension, especially at lower MELD scores. The overall transplant probability in LT waitlist registrants with NASH [vs. non-NASH] cirrhosis was significantly lower at 90 days (HR 0.873, p <0.001) and 1 year (HR 0.867, p <0.001); this was even more pronounced in patients with MELD scores >30 (HR 0.705at 90 days and HR 0.672at 1 year, p <0.001 for both). Serum creatinine was the key contributor to MELD score increases leading to LT among LT waitlist registrants with NASH cirrhosis, while bilirubin was in patients with non-NASH cirrhosis. Finally, waitlist mortality at 90 days (HR 1.15, p <0.001) and 1 year (1.25, p <0.001) was significantly higher in patients with NASH cirrhosis compared to those with non-NASH cirrhosis. These differences were more pronounced in patients with lower MELD scores at the time of LT waitlist registration. LT waitlist registrants with NASH cirrhosis are less likely to receive a transplant compared to patients with non-NASH cirrhosis. Serum creatinine was the major contributor to MELD score increases leading to LT in patients with NASH cirrhosis. This study provides important insights into the distinct natural history of non-alcoholic steatohepatitis (NASH) cirrhosis among liver transplant (LT) waitlist registrants, revealing that patients with NASH cirrhosis face lower odds of transplantation and higher waitlist mortality than those with non-NASH cirrhosis. Our study underscores the significance of serum creatinine as a crucial contributor to model for end-stage liver disease (MELD) score in patients with NASH cirrhosis. These findings have substantial implications, emphasizing the need for ongoing evaluation and refinement of the MELD score to more accurately capture mortality risk in patients with NASH cirrhosis on the LT waitlist. Moreover, the study highlights the importance of further research investigating the impact of the implementation of MELD 3.0 across the US on the natural history of NASH cirrhosis.

Health-related Quality of Life After Liver Transplantation-An Important Goal, but One Definition (or Size) Does Not Fit All.

Health-related Quality of Life After Liver Transplantation-An Important Goal, but One Definition (or Size) Does Not Fit All.

Factors predicting early re-bleeding and in-hospital mortality after acute variceal hemorrhage in patients with cirrhosis

Introduction: Risk factors for early re-bleeding and in-hospital mortality following acute variceal hemorrhage (AVH) are incompletely understood. The aim of this study was to find out the risk factors for early re-bleeding within 5 days and in-hospital mortality after AVH in patients with cirrhosis.&#x0D; Method: This was an analytical cross-sectional study conducted in Department of Medicine, Patan Hospital, Patan Academy of Health Sciences (PAHS), Nepal from July 2021 to June 2022. The ethical clearance was obtained from the Institutional Review Committee-PAHS. Informed consent was taken from the patients. Patients aged &gt;18 y with diagnosed case of liver cirrhosis and endoscopy confirmed variceal bleeding were enrolled. All cases of early re-bleeding within 5 days and in-hospital outcome were recorded.&#x0D; Result: In this study total 72 patients were enrolled. The mean age of our patients was 51.68 y. Sixty seven (93%) of the patients improved, 3(4.16%) had early re-bleeding and 5(6.9%) died during the same hospital admission. Univariate analysis showed that early re-bleeding was significantly associated with the high PT/INR (p&lt;0.001) and high Child-Turcotte Pugh (CTP) score (p=0.032), whereas in-hospital mortality of patients was significantly associated with low Protein (p=0.044), high CTP score (p=0.041), high Model for End stage Liver Disease (MELD) score (p=0.002) and presence of gastric varices (p=0.008).&#x0D; Conclusion: High PT/INR and high CTP score are the risk factors of early re-bleeding after AVH in cirrhotic patients. Low Protein, high CTP and MELD scores, and presence of gastric varices are the factors associated with in-hospital mortality in these patients.

Outcomes of liver transplant recipients with high MELD scores: an experience from a Canadian centre.

Background:The frequency with which patients with high Model for End-Stage Liver Disease (MELD) scores undergo liver transplantation has been increasing. Canadian literature regarding the outcomes of liver transplantation in recipients with high MELD scores is limited. The primary objective of this study was to assess patient and graft survival among recipients with high (> 35) and low (≤ 35) MELD scores. Secondary objectives were to potentially identify independent predictors of graft failure and patient mortality.Methods:We conducted a retrospective chart review of patients undergoing liver transplantation at a single Canadian centre from 2012 to 2017.Results:A total of 332 patients were included in the study: 280 patients had a MELD score of 35 or lower, and 52 had a MELD score above 35. Patients with high MELD scores had higher rates of pretransplant acute kidney injury and dialysis (p < 0.001), admission to the intensive care unit (ICU) or intubation (p < 0.001), intraoperative blood product transfusions (p < 0.001) and post-transplantation acute kidney injury and dialysis (p < 0.001), as well as longer ICU (p < 0.001) and hospital stays (p = 0.002). One- and 3-year patient survival in recipients with MELD scores of 35 or lower was 93.1% and 84.9% versus 85.0% and 80.0% in recipients with MELD scores above 35 (p = 0.37). One- and 3-year graft survival in recipients with MELD scores of 35 or lower was 91.7% and 90.9% versus 77.2% and 72.8% in recipients with MELD scores above 35 (p < 0.001). Prior liver transplant was an independent predictor of patient mortality, and no independent predictors of graft failure were identified. When MELD was replaced with D-MELD (donor age × recipient MELD), it predicted graft failure but not patient survival.Conclusion:No difference in patient mortality was found between MELD groups. Graft survival was significantly lower in recipients with MELD scores above 35. D-MELD may potentially be used as an adjunct in determining risk of graft failure in recipients with high MELD scores.

Quality of Life and Its Determinants in Liver Transplantation Candidates: A Missed Link in Liver Care Program during the Waiting Time for Liver Transplantation.

Background: The health-related quality of life (HRQOL) in the before liver transplantation (LT) stage has not been studied as much as that after the LT stage. We aimed to assess HRQOL and its determinants before the LT stage.Methods: As a cross-sectional study, HRQOL of all adult patients (n=632) referred to the LT center of Shiraz, Iran in 2018-2019 were assessed. Demographic, socioeconomic, medical, and paraclinical data were requested. Physical (PCS) and mental (MCS) aspects of HRQOL were assessed using the SF36 questionnaire. Univariable, multivariable (linear regression), and confirmatory factor analysis were performed utilizing SPSS 20 and Mplus 6.1 software. P<0.05 was considered to be significant.Results: The mean age of the patients was 47.6±12.3 years, while 414 (65.6%) were men, and the mean, score of the model for end-stage liver disease (MELD) was 18.36±5.58. The mean score of QOL, PCS, and MCS was 50.01±21.73, 46.23±23.23, and 53.78±23.91 (out of 100), respectively. Vitality had the most association with HRQOL, while role limitations had the lowest. The multivariable analysis revealed that unemployment (P<0.001), anemia (P=0.005), weight loss (P=0.005), diabetes mellitus (DM) (P=0.009), low MELD score (P=0.027), and drug use (P=0.03) were the significant determinants of HRQOL, respectively.Conclusion: The present study showed that HRQOL in the LT candidates was at the intermediate level, while their PCS and MCS are at the low and moderate levels, respectively. Furthermore, physical performance, job status, anemia, weight loss, MELD score, DM, and drug use should be considered as the significant determinants of HRQOL in the LT candidates.

Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score

ObjectiveIsolated tricuspid valve surgery is perceived as high-risk. This perception is nurtured by patients who often present with substantial liver dysfunction, which is inappropriately reflected in current surgical risk scores (eg, the Society of Thoracic Surgeons [STS] score has no specific tricuspid model). The Model for End-Stage Liver Disease (MELD) has was developed as a measure for the severity of liver dysfunction. We report scores and outcomes for our patient population. MethodsWe calculated STS, European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (ESII), and MELD scores for all of our patients who received isolated tricuspid valve surgery between 2011 and 2020 (n = 157). We determined the MELD score, stratified patients into 3 groups (MELD <10: low, n = 53; 10 to <20: intermediate, n = 78; ≥20: high, n = 26) and describe associated outcomes. ResultsPatients were 72 ± 10 years old and 43% were male. Mean STS score was 4.9 ± 3.5% and ESII was 7.2 ± 6.6%. Mortality was 8.9% at 30 days and 65% at latest follow-up (95% CI, 51%-76%). Median follow-up was 4.4 years (range, 0-9.7 years). Although ESII and STS score accurately predicted 30-day mortality at low MELD scores (observed to expected [O/E] for ESII score = 0.8 and O/E for STS score = 1.0) and intermediate MELD (O/E for ESII score = 0.7, O/E for STS score = 1.0), mortality was underestimated at high MELD (O/E for ESII score = 3.0, O/E for STS score = 4.7). This subgroup also had higher incidence of new-onset hemodialysis. Besides MELD category, recent congestive heart failure, endocarditis, and hemodialysis were also associated with 30-day mortality. ConclusionsFor isolated tricuspid valve regurgitation, classic surgical risk stratification with STS or ESII scores failed to predict perioperative mortality if there was evidence of severe liver dysfunction. Preoperative MELD assessment might be useful to assist in proper risk assessment for isolated tricuspid valve surgery.

Living donor liver transplantation versus donation after brain death and donation after circulatory death liver transplantation in the US

While previous research has compared outcomes between living donor liver transplantation (LDLT) and deceased donor liver transplantation, evidence is lacking regarding how donation after circulatory death (DCD) vs donation after brain death (DBD) affects this comparison. Using data from the Scientific Registry of Transplant Recipients for adults listed for liver transplant from 2012 to 2018, we compared 5-year patient and graft survival, readmissions, posttransplant chronic kidney disease (CKD), and return to work for 25,151 patients who underwent LDLT (1223 [4.9%]), DCD-LT (1431 [6.4%]), and DBD-LT (22,497 [89.4%]). LDLT recipients were significantly more likely to have a Model for End-Stage Liver Disease (MELD) score < 15 and to be working prior to transplant (P < 0.001 for both). At 5 years posttransplant, LDLT recipients had significantly more readmissions, but significantly less CKD and better survival than DBD-LT and DCD-LT recipients, as well as significantly better graft survival than DCD-LT recipients (P ≤ 0.01 for all). Significantly more LDLT recipients also returned to work for income (P < 0.01). This study shows a clear advantage of LDLT vs DCD-LT. This information should be weighed in transplantation decisions for patients such as those with low MELD scores who will realistically only be considered for DCD-LT.

Clinical Analysis of Factors Affecting Hospital Mortality After Liver Transplant in Patients With High Model for End-Stage Liver Disease Score

This study was undertaken to identify poor prognostic factors in patients with high Model for End-Stage Liver Disease (MELD) scores. From September 2001 to December 2017, living donor liver transplant and deceased donor liver transplant were performed in 851 (84.4%) and 157 patients (15.6%), respectively, in our center. Eighty-one patients (8.0%) with MELD scores ≥ 35 were classified as patients with high MELD scores. The overall survival rates in patients with high MELD scores were significantly worse than those in patients with low MELD scores (P=.005). However, no significant difference in survival was found between the 2 groups when in-hospital mortality was excluded. In-hospital mortality occurred in 18 patients (22.2%), and the main cause of death was sepsis (n=14, 77.8%). On univariate analysis, the risk factors for in-hospital mortality were mean age (P=.028), mean MELD score (P=.045), intubation status (P < .001), culture positivity (P=.042), and encephalopathy grade 3 or 4 (P=.014). On multivariate analysis, age (P=.006), intubation status (P=.042), and culture positivity (P=.036) were significant. The main cause of in-hospital mortality was sepsis, and the risk factors for in-hospital mortality of patients with high MELD score were older age, preoperative intubation, and culture positivity. Special attention should be paid to the prevention and treatment of infection in the liver transplant of patient with high MELD scores.

Preoperative MELD score predicts mortality and adverse outcomes following radical cystectomy: analysis of American College of Surgeons National Surgical Quality Improvement Program.

The model for end-stage liver disease (MELD) has been widely used to predict the mortality and morbidity of various surgical procedures. We aimed to correlate a high preoperative MELD score with adverse 30-day postoperative complications following radical cystectomy. Patients who underwent elective, non-emergency radical cystectomy were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2017. Patients were categorized according to a calculated MELD score. The primary outcomes of this study were 30-day postoperative mortality, morbidity, and length of hospital stay following radical cystectomy. For further sensitivity analysis, propensity score matching was used to yield a total of 1387 matched pairs and primary outcomes were also assessed in the matched cohort. Compared with patients with a MELD < 10, those with MELD ⩾ 10 had significantly higher rates of mortality [odds ratio (OR) = 1.71, p = 0.004], major complications (OR = 1.42, p < 0.001), and prolonged hospital stay (OR = 1.29, p < 0.001) on multivariate analysis. Following risk-adjustment for race, propensity-matched groups revealed that patients with MELD score ⩾ 10 were significantly associated with higher mortality (OR = 1.85, p = 0.008), major complications (OR = 1.34, p < 0.001), yet similar length of hospital stay (OR = 1.17, p = 0.072). MELD score ⩾ 10 is associated with higher mortality and morbidity in patients undergoing radical cystectomy compared with lower MELD scores. Risk-stratification using MELD score may assist clinicians in identifying high-risk patients to provide adequate preoperative counseling, optimize perioperative conditions, and even consider nonsurgical alternatives.

Low preoperative prealbumin predicts the prevalence of complications following liver transplantation

BackgroundAs a nutritional index, preoperative serum prealbumin highly correlates with surgical complications. However, the correlation between preoperative prealbumin and postoperative complications remains unclear in liver transplantation (LT).MethodsA total of 191 patients who underwent LT between 2015 and 2019 were included in the retrospective analysis. According to a cut-off value calculated from a receiver operating characteristic (ROC) curve, the patients were divided into normal and low preoperative prealbumin groups. Univariable and multivariable logistic regression analyses were used to identify independent risk factors for postoperative complications. In addition, patients were divided into subgroups by Model for End-stage Liver Disease (MELD) score, and the association between preoperative prealbumin and postoperative complications was also assessed in each group.ResultsA total of 111 (58.1%) patients were included in the low prealbumin group based on a cut-off value of 120 mg/L. The area under the ROC curve (AUC) was 0.754 (95% confidence interval [CI] 0.678–0.832). Low prealbumin (95% CI 1.51–12.8, P = 0.007) was identified as a predictor for postoperative complications based on multivariable regression. In the low and normal prealbumin groups, the prevalence rates of postoperative complications were 27.5% and 8.0% (P = 0.003) in the MELD score ≤ 15 subgroup and 53.3% and 20.0% (P = 0.197) in the MELD score > 15 subgroup, respectively.ConclusionsPreoperative prealbumin was associated with postoperative complications in LT, and preoperative nutritional support benefitted postoperative recovery, especially for patients with low MELD scores.

A notable proportion of liver transplant candidates with alcohol-related cirrhosis can be delisted because of clinical improvement

To what extent patients with alcohol-related decompensated cirrhosis can improve until recovery from decompensation remains unclear. We aimed to investigate the probability of recovery and delisting due to improvement in patients with alcohol-related decompensated cirrhosis on the waiting list (WL) for liver transplantation (LT). We conducted a registry-based, multicenter, retrospective study including all patients admitted to the LT WL in Catalonia (Spain) with the indication of alcohol-, HCV-, cholestasis- or non-alcoholic steatohepatitis-related decompensated cirrhosis between January 2007 and December 2018. Competing-risk analysis was used to investigate variables associated with delisting due to improvement in patients with alcohol-related decompensated cirrhosis. Criteria for delisting after improvement were not predefined. Outcomes of patients after delisting were also studied. One-thousand and one patients were included, 420 (37%) with alcohol-related decompensated cirrhosis. Thirty-six (8.6%) patients with alcohol-related decompensated cirrhosis were delisted after improvement at a median time of 29 months after WL admission. Lower model for end-stage liver disease (MELD) score, higher platelets and either female sex or lower height were independently associated with delisting due to improvement, while time of abstinence did not reach statistical significance in multivariate analysis (p= 0.055). Five years after delisting, the cumulative probability of remaining free from liver-related death or LT was 76%, similar to patients with HCV-related decompensated cirrhosis delisted after improvement. A significant proportion of LT candidates with alcohol-related cirrhosis can be delisted due to improvement, which is predicted by low MELD score and higher platelet count at WL admission. Women also have a higher probability of being delisted after improvement, partially due to reduced early access to LT for height discrepancies. Early identification of patients with potential for improvement may avoid unnecessary transplants. Patients with alcohol-related cirrhosis can improve until being delisted in approximately 9% of cases. Low model for end-stage liver disease score and high platelet levels at admission predict delisting after improvement, and women have higher probabilities of being delisted due to improvement. Long-term outcomes after delisting are generally favorable.

Predictors of Complete Response in Patients with Hepatocellular Carcinoma Treated with Trans-Arterial Radioembolization.

Background: Trans-arterial radioembolization (TARE) has shown promising results in treating hepatocellular carcinoma (HCC). We identified independent predictors of radiological complete response (CR) in patients with intrahepatic HCC who were treated with TARE. Methods: Patients with intrahepatic HCC treated with TARE between 2011 and 2017 were recruited. CR was defined according to the modified Response Evaluation Criteria in Solid Tumors. Cox regression analysis was used to determine independent predictors of CR. Results: The median age of study participants (83 men and 19 women) was 64.3 years. The mean survival after TARE was 55.5 months, and 21 (20.6%) patients died during the study period. Patients who achieved CR (14 patients, 13.7%) had significantly higher serum albumin level (median 4.1 vs. 3.9 g/dL), lower total bilirubin level (median 0.6 vs. 0.7 mg/dL), lower aspartate aminotransferase level (median 30.0 vs. 43.0 IU/L), lower alkaline phosphatase level (median 79.0 vs. 103.0 IU/L), lower alpha-fetoprotein level (median 12.7 vs. 39.9 ng/mL), lower des-gamma-carboxyprothrombin level (median 575.5 vs. 2772.0 mAU/mL), lower model for end-stage liver disease (MELD) score (median 6.0 vs. 7.0), and smaller maximal tumor diameter (median 6.3 vs. 9.0 cm) compared to those who did not achieve CR (all p < 0.005). Multivariate Cox regression analysis showed that lower MELD score (hazard ratio (HR) = 0.436, p = 0.015) and maximal tumor size < 9 cm (HR = 11.180, p = 0.020) were independent predictors of an increased probability of radiological CR after TARE. Conclusions: Low MELD score and small maximal tumor size were independently associated with an increased probability of CR after TARE in patients with intrahepatic HCC.

Validating a novel score based on interaction between ACLF grade and MELD score to predict waitlist mortality

Among candidates listed for liver transplant (LT), the model for end-stage liver disease (MELD) score may not capture acute-on-chronic liver failure (ACLF) severity. Data on the interaction between ACLF and MELD score in predicting waitlist mortality are scarce. We analyzed the UNOS database (01/2002 to 06/2018) for LT listings in adults with cirrhosis and ACLF (without hepatocellular carcinoma). ACLF grades 1, 2, 3a, and 3b- were defined using the modified EASL-CLIF criteria. Of 18,416 candidates with ACLF at listing (mean age 54 years, 69% males, 63% Caucasians), 90-day waitlist mortality (patient death or being too sick for LT) was 21.6% (18%, 20%, 25%, and 39% for ACLF grades 1, 2, 3a, and 3b, respectively). Using a Fine and Gray regression model, we identified an interaction between MELD and ACLF grade, with ACLF having a higher impact at lower MELD scores. Other variables included candidate's age, sex, liver disease etiology, listing MELD, ACLF grade, obesity, and performance status. A score developed using parameter estimates from the interaction model on the derivation cohort (n = 9,181) stratified the validation cohort (n= 9,235) into quartiles: Q1 (score <10.42), Q2 (10.42-12.81), Q3 (12.82-15.50), and Q4 (>15.50). Waitlist mortality increased with each quartile from 13%, 18%, 23%, and 36%, respectively. Observed vs. expected waitlist mortality deciles in the validation cohort showed good calibration (goodness of fit p= 0.98) and correlation (R= 0.99). Among selected candidates who have ACLF at listing, MELD score and ACLF interact in predicting cumulative risk of 90-day waitlist mortality, with higher impact of ACLF grade at lower listing MELD score. Validating these findings in large prospective studies will support consideration of both MELD and ACLF when prioritizing transplant candidates and allocating liver grafts. In patients with cirrhosis listed for liver transplantation, the presence of multiorgan failure, a condition referred to as acute-on-chronic liver failure, is associated with high waiting list mortality rates. Current organ allocation policy disadvantages patients with this condition. This study describes and validates a new scoring method that performs better than the currently available scoring systems. Further validation of this approach may reduce the deaths of patients with cirrhosis and acute-on-chronic liver failure on the transplant waiting list.

Comparing Mortality Risk Predictive Ability of Different Scoring Systems in Cirrhotic Patients with Bacteremia.

Patients with liver cirrhosis and bacteremia have substantially higher risk of mortality and morbidity. Our study aimed to investigate scoring systems that can predict the mortality risk in patients with cirrhosis and bacteremia. A single-center, retrospective cohort study was performed among adult patients who visited the emergency department from January 2015 to December 2018. All patients diagnosed with liver cirrhosis and bacteremia were enrolled and divided into survivor and nonsurvivor groups for comparison based on their 30-day in-hospital mortality event. The Pitt bacteremia score (PBS), model for end-stage liver disease (MELD) score, Child–Pugh score, and quick sequential Organ Failure Assessment (qSOFA) score were calculated and compared using the area under the receiver operating characteristic (AUROC) curves. A total of 127 patients (survivor: 86; nonsurvivor: 41) were eligible for this study. Compared with the nonsurvivor group, patients in the survivor group had significantly lower MELD score (22 ± 7 vs. 29 ± 5, p < 0.001), lower proportion of high qSOFA (score ≥ 2) (23.3% vs. 51.2%, p < 0.01), and high PBS (score ≥ 4) (7.0% vs. 34.1%, p < 0.001) category. There was also a significantly different distribution in Child–Pugh classification between the two groups (p < 0.01). The survivor group had significantly lower proportion of acute-on-chronic liver failure (27.9% vs. 68.3%, p < 0.001) and fewer number of organ failures (p < 0.001). In comparison of the discriminative ability in mortality risk prediction, PBS (AUROC = 0.83, 95% CI = 0.75–0.90, p < 0.001) and MELD scores (AUROC = 0.78, 95% CI = 0.70–0.86, p < 0.001) revealed a better predictive ability than Child–Pugh (AUROC = 0.69, 95% CI = 0.59–0.70, p < 0.01) and qSOFA scores (AUROC = 0.65, 95% CI = 0.54–0.75, p < 0.01). PBS and MELD scores both demonstrated a superior ability of predicting mortality risk in cirrhotic patients with bacteremia.

S1133 MELD, MELD-Na, and MELD-Albumin Scores as Predictors of Mortality in Patients With SARS-CoV-2: An Uncanny Relationship During Troubling Times

INTRODUCTION: Coronavirus disease 2019 (SARS-CoV-2) is an ongoing outbreak, capable of causing severe acute respiratory disease. Patients diagnosed with SARS-CoV-2 have significant morbidity and mortality. The model for end-stage liver disease (MELD) score, MELD-Na and MELD-Albumin scores are used to predict mortality in patients with liver disease. METHODS: This is a single center retrospective cohort study of patients diagnosed with 2019 Novel Coronavirus (SARS-CoV-2) between March of 2020 and May of 2020. The primary outcome includes all cause in-hospital mortality. Our study aimed to validate the utility of the various scores in predicting mortality in patients diagnosed with SARS-CoV-2. RESULTS: MELD, MELD-Na and MELD-Albumin was evaluated in a cohort of 71 patients. The analysis included 31/71 (43.66%) men with a mean age of 66 ± 16 years. The median MELD, MELD-Na and MELD-Albumin scores were 28.8, 27.9 and 30.2 respectively. A cutoff value of 30 was assigned to stratify patients into low and high groups. Mortality rates for patients with a low MELD, MELD-Na and MELD-Albumin score (< 30) was 20.45%, 18.6% and 15.15% respectively. Mortality rates for patients with a high MELD, MELD-Na and MELD-Albumin score ( >30) was 45%, 47.62% and 41.94% respectively. All three scores can be used to predict mortality in patients who developed PCR-positive SARS-CoV-2. CONCLUSION: MELD, MELD-Na and MELD-Albumin are valid prognostic scores that can be used as good predictors of mortality in patients with PCR-confirmed SARS-CoV-2. MELD-Albumin appears to have the highest predictive potential.Table 1.: MELD, MELD-Na and MELD-Albumin and respective mortality rates

Sex Differences in Portopulmonary Hypertension

Portopulmonary hypertension (POPH), pulmonary arterial hypertension that develops in the setting of portal hypertension, can lead to right-sided heart failure and death. Being female is a known risk factor for POPH, but little is known about the effect of sex on clinical manifestations, hemodynamics, treatment response, and survival. We sought to characterize sex differences in clinical characteristics, pulmonary hemodynamics, treatment response, and survival in patients with POPH. We performed a retrospective cohort study of adult candidates for liver transplant (LT) who had POPH within the Organ Procurement and Transplantation Network database. Females and males were compared. Multivariate regression was performed to assess the association between sex and pulmonary vascular resistance (PVR) and survival. Patients were also stratified by age (50 years) to determine how age modifies the relationship between sex and hemodynamics and survival. We included 190 adults (103 male, 87 female). Compared with men, women had a lower model for end-stage liver disease (MELD) score (12.1± 4.2 vs13.8 ± 4.9; P= .01) and were more likely to have autoimmune liver disease. Women had a higher baseline PVR (610.6 ± 366.6 vs461.0 ± 185.3 dynes-s-cm-5; P< .001) and posttreatment PVR (244.6 ± 119.5 vs202.0 ± 87.7 dynes-s-cm-5; P= .008) and a greater treatment response (ΔPVR) (-359.3 ± 381.9 vs-260.2 ± 177.3 dynes-s-cm-5; P= .03). In multivariate analysis, female sex (or gender) remained associated with a higher baseline PVR (P= .008). Women and men had overall similar survival (P > .05). When patients were stratified by age, being female was independently associated with worse waiting list survival after adjusting for MELD and PVR in younger patients (HR, 6.61; 95%CI, 1.25-35.08; P= .03) but not in older patients. Compared with male candidates, female candidates for LT who had POPH had a higher PVR and lower MELD score and were more likely to have autoimmune liver disease. Women and men had similar overall survival, but female sex (or gender) was associated with worse survival in younger patients.

Multiple Regional Listing Increases Liver Transplant Rates for Those With Model for End-stage Liver Disease Score

Multiple listing (ML) at >1 transplant center is one mechanism to combat the geographic disparities in liver transplantation (LT) rates. The objective of our study was to determine the impact of multiple listing on LT rates. We examined the United Network of Organ Sharing database from 2002 to 2016 after excluding those listed for multiple organs, hepatocellular carcinoma, or living donor LT. The waitlist mortality and LT rates for the ML groups and the single listed (SL) group were compared after stratifying patients by the Model for End-Stage Liver Disease (MELD) with a cutoff at 15 (<15 and ≥15). Of the 83 935 listed during the study period, 80 351 were listed in a single center (SL group), and 3584 were listed in >1 center (ML group). Of the ML groups, 2028 (2.4%) were listed at multiple donor service areas but within the same region (ML-SR) and 1556 (1.9%) listed in different regions (ML-DR). The median MELD at LT was 20, 21, and 24 for ML-DR, ML-SR, and SL groups, respectively (P = 0.001). Although the probability of receiving LT was significantly higher for the ML groups relative to the SL group for both MELD groups (<15 and ≥15), the impact was the highest for ML-DR group. At MELD score <15, the probability of LT was 72% for ML-DR, 38% for ML-SR, and 32% for SL groups. At MELD score ≥15, the probability of LT was 79% for ML-DR, 67% for ML-SR, and 61% for SL groups. Multiple listing appeared to considerably improve a patient's chance of receiving LT and survival with the highest benefit for those with low MELD scores (<15) listed at multiple regions.

Meld Scoring System to Predict Outcomes in Patients Who Undergo VV ECMO Implantation

Veno-venous Extracorporeal membrane oxygenation (VV ECMO) is gaining popularity in the management of severe acute respiratory distress syndrome (ARDS) and bridge patients to lung recovery or transplantation. Several risk factors have been reported to predict prognosis of patients with lung failure. The Model for End-Stage Liver Disease (MELD) system provides a score based on a patient's international normalized ratio (INR) and creatinine and total bilirubin levels. Originally, the score was used to measure mortality risk in patients with end-stage liver disease. In this current analysis, we evaluated the ability of the MELD scoring system to predict clinical outcomes in patients who underwent VV ECMO. We also analyzed the incidence of morbidity including acute kidney injury (AKI), gastrointestinal bleeding (GI bleeding), pump malfunction, oxygenator dysfunction in patients supported with VV ECMO. This is a retrospective review of an institutional ECMO database. We included consecutive patients from January 2015 through February 2019. During the study period, 71 patients underwent VV ECMO implantation at our center and were included in our study (Table 1). Patients were divided into two groups on the basis of their MELD score. Of the 71 patients, Patients were stratified into two cohorts: those with a MELD score <12 (n=50) and ≥12 (n=21). Kaplan-Meier analysis demonstrated a lower overall survival for patients with MELD scores ≥12 who underwent VV ECMO implantation compared to those with MELD scores <12 (p<0.01), and increased risk of AKI (p<0.001) and dialysis (p<0.001) compared to patients with MELD score <12. These findings suggest that a MELD score ≥12 was associated with a higher postoperative mortality rate than that seen in patients with a lower MELD score. MELD scoring system can be used to predict outcomes in patients with advanced respiratory failure patients who undergo VV ECMO implantation.

Prognostic index consisting of early post‐transplant variables &lt;2 weeks in adult living‐donor liver transplantation

AimSix‐month recipient mortality after adult‐to‐adult living‐donor liver transplantation (LDLT) remains high. Early and accurate prediction of recipient outcome and continuous monitoring of recipient severity after surgery are both essential for guiding appropriate care. This study was designed to identify early post‐transplant parameters associated with 6‐month mortality, and thereby to construct a discriminatory prognostic index (PI).MethodsWe retrospectively analyzed 400 consecutive primary adult‐to‐adult LDLTs in our center (2006–2017). Perioperative variables were comprehensively analyzed for their accuracy in predicting recipient mortality by comparing the area under the receiver operating characteristic (AUROC) of each factor.ResultsThe AUROCs of preoperative predictive factors, for example, Model for End‐stage Liver Disease (MELD) score and donor age, were 0.56 and 0.64, respectively, whereas those of post‐transplant platelet count (PLT), total bilirubin (T‐BIL), and prothrombin time – international normalized ratio (INR) on postoperative day (POD)‐7−14 were 0.71/0.84, 0.68/0.82, and 0.71/0.78, respectively. Logistic regression analysis provided a formula: PIPOD‐14 = 3.39 + 0.12 × PLTPOD‐14 − 0.09 × T‐BILPOD‐14 − 1.23 × INRPOD‐14, indicating a high AUROC of 0.87. Recipient 6‐month survival with PIPOD‐14 < 2.38 (n = 173) was 71.7%, whereas that with PIPOD‐14 ≥ 2.38 (n = 222) was 97.7% (P < 0.001). The AUROCs of PIPOD‐7 were as high as 0.8 in the subgroups with younger donors (<50 years of age), right lobe grafts, ABO‐identical/compatible combinations, or low MELD score (<20), indicating usefulness of PI to identify unexpectedly complicated cases within the first week.ConclusionsA novel, post‐transplant survival estimator, PI, accurately predicts recipient 6‐month mortality within 1–2 weeks after adult LDLT. Daily monitoring of PI could facilitate early interventions including retransplantation in critically ill patients.