Model For End-stage Liver Disease Scoring System Research Articles

Revising the MELD Score to Address Sex-Bias in Liver Transplant Prioritization for a German Cohort.

(1) Background: Prioritization of patients for liver transplantation in Germany relies on the MELD (model for end-stage liver disease) scoring system that does not consider the patient's sex. Many studies have shown that women are disadvantaged by the MELD score. Using a large patient cohort from a German liver transplant centre, we investigated options to reduce gender inequality in the patient prioritization for liver transplantation. (2) Methods: We calculated female-as-male MELD scores in our cohort by substituting the serum creatinine of a female patient with that of their male equivalent to test for the fairness of the scores. We investigated the effects of the female-as-male scores compared to the original MELD score of 1759 patients listed for liver transplantation. (3) Results: Serum creatinine sex correction (female-as-male) for MELD scores added up to 5.4 points in females, while the median changed by +1.6 points for females. We identified 72 females with an original MELD score < 20, for whom the adjusted female-as-male MELD score would be >20, thus giving them a better chance to receive a liver transplant. (4) Conclusions: Mathematical conversion of female to male creatinine concentrations identified disadvantages in liver transplantation prioritization for females and ascertained MELD 3.0 as having high potential to compensate for these inequalities.

Prevalence of Cardiac Dysfunction in Cirrhosis and Its Relation With Meld Score

Background: Cardiac structural and functional abnormalities have been described in patients of liver cirrhosis. The constellation of these abnormalities is termed as cirrhotic cardiomyopathy (CCM) and its prevalence remains unknown, mostly because the disease is latent and shows itself when the patient is subjected to stress. This study was designed to evaluate the prevalence of cardiac dysfunction in patients of liver cirrhosis and to analyze its relation with model for end-stage liver disease (MELD) score. Methods: Hundred patients of liver cirrhosis were enrolled for the study and divided into 3 groups according to MELD score: ≤9, 10-19, and ≥20. All study participants underwent detailed cardiac assessment with Doppler echocardiography. Prevalence of cardiac dysfunction and its relation with MELD score was determined. Results: Prevalence of CCM and diastolic dysfunction (DD) was 48% and 30%, respectively. A total of 82%, 59%, and 50% patients had prolonged corrected QT interval (QTc), isovolumic relaxation time (IVRT), and deceleration time (DT), respectively. Prevalence of CCM, DD and prolonged QTc, IVRT, and DT had significant correlation with MELD score ( P &lt; .05). Conclusion: Patients with cirrhosis had impaired cardiac function, mainly present as CCM and DD, and the extent of dysfunction was correlated with the MELD score. Hence, MELD scoring system can be used to predict risk of occurrence of cardiac dysfunction in cirrhosis.

The Role of von Willebrand Factor Antigen in Predicting Survival of Patients with HBV-Related Cirrhosis

Objective The model for end-stage liver disease (MELD) scoring system cannot be used to assess the deterioration of patients with liver cirrhosis caused by infection and portal hypertension. Elevated von Willebrand factor antigen (vWF-Ag) in plasma is associated with portal pressure and complications in patients with liver cirrhosis. We aimed to evaluate whether the addition of vWF-Ag can improve the risk prediction ability of the MELD scoring system. Methods A total of 228 patients with hepatitis B virus (HBV)-related liver cirrhosis were eligible for inclusion in this retrospective study. The vWF-Ag level was assessed by enzyme-linked immunosorbent assay (ELISA). The endpoint of this study was defined as the time to liver transplantation or death. Univariate and multivariate analyses were performed to assess the risk factors associated with transplant-free mortality. Receiver operating characteristic (ROC) curve analysis was used to assess potential discriminatory variables for transplant-free mortality. Results During a median follow-up interval of 30.23 months, 124 patients (54.4%) reached the endpoint of this study. Patients who died or underwent liver transplantation had elevated levels of MELD and vWF-Ag. Moreover, vWF-Ag and MELD showed comparable predictive potential for transplant-free survival (area under the curve [AUC], vWF-Ag = 0.71; AUC, MELD = 0.73). Ultimately, vWF-Ag can significantly improve the predictive potential of MELD in determining transplant-free mortality (AUC, MELD-vWF-Ag = 0.79, P = 0.006). Conclusion An elevated vWF-Ag level was independently associated with transplant-free mortality in patients with liver cirrhosis. The inclusion of vWF-Ag in the MELD scoring system can improve mortality predictions in patients with liver cirrhosis.

A Prospective Multicenter Study of the Chinese Scoring System for Hepatitis B Liver Failure

Objective: To evaluate the clinical utility of a Chinese scoring system for hepatitis B liver failure in a prospective and multicenter study.Methods: Clinical data for 1,143 patients with hepatitis B liver failure who had been followed up for a minimum of 6 months were collected from seven liver disease centers across China. The disease severity and prognosis for the patients were predicted using the Chinese scoring system and compared to those predicted with the model for end-stage liver disease (MELD) score, MELD-Na score, and Child-Turcotte-Pugh (CTP) score.Results: The Chinese scoring system was more effective at predicting the outcomes of survival and mortality than the MELD score. In the peak disease stage, the area under the receiver operating characteristic curve for the Chinese scoring system was 0.954, significantly higher than that (0.896) for the MELD scoring system (P < 0.001). The positive prediction at 30, 90, and 180 days with the Chinese scoring system was 0.764 (95% CI: 0.714–0.808), 0.731 (95% CI: 0.694–0.769), and 0.724 (95% CI: 0.679–0.765), also significantly higher than that with the MELD, MELD-Na, and CTP scores (P < 0.001). In addition, the Chinese scoring system was superior to the MELD, MELD-Na, and CTP scores (P < 0.001) at predicting the prognosis of patients with hepatitis B liver failure at both 30 and 180 days.Conclusion: The Chinese scoring system demonstrated superior performance to the three established scoring systems in assessing the severity and outcomes of hepatitis B liver failure in this cohort.

Comparison of Scores for Child-Pugh Criteria and Standard and Modified Models for End-Stage Liver Disease to Assess Cardiac Hepatopathy in Heart Transplant Recipients.

Congestive hepatopathy as a result of advanced heart failure correlates with poor outcomes. Thus, risk-scoring systems have been established to assess the risks for cardiac surgery and hearttransplant, although these systems were originally designed to measure mortality risk in patients with end-stage liver disease. We compared the scores for the Child-Pugh criteria andstandardandmodifiedModels for End-Stage LiverDisease to evaluate the effect of preoperative liver dysfunction on postoperative outcomes inpatients with heart failure who underwent heart transplant. Data of 60 consecutive patients who underwent orthotopic heart transplant were analyzed from a historical cohort study from January 1, 2015, to December 31, 2018. We calculated the scores for Child-Pugh criteria and the standard and modified Models for End-Stage Liver Disease. Of the 60 total patients, 48 were male patients, with a median age of 43 years (range, 13-69 years). Twenty patients died before the end of the study. The causes of death were cardiac, liver, and renal diseases. The mortality risk increased 25% (interquartile range, 0.05-0.51) for the patients with 1 point higher score compared with the patients with 1 point lower score based on a modified Model for End-Stage Liver Disease (P = .01). Preoperative liver dysfunction has a significant effect on patient survival. The modified Modelfor End-Stage LiverDisease scoring system could be an effective predictor of perioperative risk stratification for patients with congestive hepatopathy who are undergoing cardiac transplant.

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.

Risk assessment of cirrhosis patients with esophageal and gastric variceal bleeding by three scoring systems

Objective To compare the risk assessment capability of model for end-stage liver disease (MELD), glasgow-blatchford score (GBS), and the AIMS65 scoring system for liver cirrhosis patients with esophageal and gastric variceal bleeding (EGVB). Methods A retrospective analysis was made on data of 182 cirrhosis patients with EGVB admitted to the Department of Gastroenterology, General Hospital of Tianjin Medical University from January 1, 2015 to March 1, 2018. According to the MELD, GBS and AIMS65 scoring system, the corresponding scores of each were calculated to evaluate the ability of the three scoring systems to correctly classify EGVB as a high-risk patient . The receiver operating characteristic curve was drawn to compare the predictive value of three scoring systems for different clinical outcomes (blood transfusion, rebleeding, and death). The area under curve (AUC)>0.7 was believed to have higher accuracy. Results The clinical outcomes of 182 patients included blood transfusion in 113 (62.1%) cases, rebleeding in 31 (17.0%) cases, and death of 11 (6.0%) cases. The MELD score was 7-25, GBS was 3-16, and AIMS65 score was 0-3. There were 4 (2.2%) patients with MELD score < 9, 139 (76.4%) patients with AIMS65 score 0-1, including 68 patients with AIMS65 score of 0 and 71 patients with AIMS65 score of 1. The AUC of MELD, GBS and AIMS65 for predicting blood transfusion was 0.514 (95%CI: 0.439-0.589), 0.681 (95%CI: 0.608-0.748), and 0.669 (95%CI: 0.596-0.737), respectively. When predicting rebleeding, the AUC of MELD, GBS and AIMS65 was 0.525 (95%CI: 0.449-0.599), 0.528 (95%CI: 0.453-0.602) and 0.580 (95%CI: 0.505-0.652), respectively. When predicting in-hospital mortality, the AUC of MELD, GBS and AIMS65 was 0.642 (95%CI: 0.567-0.711), 0.581 (95%CI: 0.505-0.653) and 0.786 (95%CI: 0.719-0.843), respectively. AIMS65 was superior to MELD (P=0.083 6) and GBS (P=0.047 0). Conclusion GBS can correctly classify cirrhosis patients with EGVB as high-risk group , and is better than AIMS65 and MELD scoring system. MELD, GBS and AIMS65 all have poor accuracy in predicting blood transfusion and rebleeding, AIMS65 has a higher predictive value for death. Key words: Prognosis; Liver cirrhosis; Esophageal and gastric variceal bleeding; Scoring system

A Potential Further Refinement of the MELD Scoring System

Key variables in the original model for end-stage liver disease (MELD) score for predicting mortality in patients awaiting liver transplantation are

Integrated model for end-stage liver disease maybe superior to some other model for end-stage liver disease-based systems in addition to Child-Turcotte-Pugh and albumin-bilirubin scores in patients with hepatitis B virus-related liver cirrhosis and spontaneous bacterial peritonitis.

For mortality prediction of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis, no direct comparisons have been made among the eight models, Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease (MELD), MELD-Na, integrated MELD (iMELD) score, MELD to sodium (MESO) index, modification of the MELD scoring system (Refit MELD), Refit MELD-Na and Albumin-Bilirubin (ALBI) score. Between January 2005 and July 2017, 314 patients who met the criteria for liver cirrhosis with the first episode of SBP were enrolled in this retrospective study. Clinical and laboratory data were obtained at diagnosis. Patients were followed up until February 2018 or death. Patients were predominantly middle-aged male. Hepatitis B virus (HBV) infection accounted for the majority of the etiologies (41.7%) with 33.6% of the patients received antivirals. The in-hospital mortality rate was 39.8%. The cumulative 3-month and 6-month mortality rates were 51.6 and 60.2%, respectively. For patients with HBV related, not hepatitis C virus or alcohol related, liver cirrhosis, iMELD had the highest area under receiver operating characteristic curve (AUC) and was significantly superior to MELD, MESO, and Refit MELD in addition to CTP and ALBI scores in predicting 3-month and 6-month mortality. For patients with HBV-related liver cirrhosis and SBP, iMELD had the highest AUC among these eight models and was significantly superior to MELD, MESO, and Refit MELD in addition to CTP and ALBI scores in predicting 3-month and 6-month mortalities.

Utility of MELD scoring system for assessing the prognosis of acute fatty liver of pregnancy

ObjectiveTo evaluate the value of Model for end-stage liver disease (MELD) in assessing the prognosis of acute fatty liver of pregnancy (AFLP). Study designThis was a retrospective study. From January 2010 to July 2018, data of 53 women diagnosed with AFLP in the third affiliated hospital of Sun Yat-Sen University were collected. Blood samples were collected on admission and MELD score was calculated. The MELD score was calculated by using the original MELD formula as shown: 9.57 log (creatinine) + 3.78 log (bilirubin) + 11.20 log (international normalized ratio, INR) + 6.43. The perinatal outcomes were documented. ResultsNine women were excluded as they were transfered to our hospital after delivery in other hospitals. The remaining 44 women had average age of 28.8 ± 5.2 years. The MELD score showed good performance in predicting most of the perinatal complications of AFLP with all the area under the receiver operating characteristic (ROC) curves (AUC) > 0.8, including ascites (AUC: 0.91, 95% CI: 0.78–0.98), wound seroma (AUC: 0.91, 95% CI: 0.78–0.93), hepatic encephalopathy (AUC: 0.93, 95% CI: 0.82–0.99), DIC (AUC: 0.87, 95% CI: 0.74–0.95), sepsis (AUC: 0.93, 95% CI: 0.82–0.99), renal insufficiency (AUC: 0.94, 95% CI: 0.82–0.99) and stillbirth (AUC: 0.85, 95% CI: 0.71–0.94). Nearly all the maternal complications were more frequently happened in MELD score ≥30 group (P < 0.05). ConclusionMELD scoring system may be a suitable method for assessing the prognosis of AFLP.

Abstract 19685: Liver Dysfunction as Reflected by MELD (the Model For End Stage Liver Disease) Score Could Better Predict Postoperative Outcome in Patients Undergoing Cardiac Surgery than Child-Turcotte-Pugh Classification

Background: Liver dysfunction increases postoperative morbidity and mortality following cardiac surgery. Child-Turcotte-Pugh (CTP) classification had been used in the evaluation of liver function. More recently, the composite model for end stage liver disease (MELD) score has become recognized as a more robust and objective scoring system than CTP classification. However, the predictive power of CTP and MELD scores for postoperative outcome in patients undergoing cardiac surgery has not yet been fully elucidated. Methods and Results: Postoperative outcome and preoperative liver function estimated by the CTP classification or the MELD scores were investigated in 1856 consecutive patients (69.3% male, age 66. 8±12.2 years) undergoing cardiac surgery between 2010 and 2013 at our institution. The proportions of patients in CTP class A, B and C were 91.8% (n=1704), 8.1% (n=151) and 0.05% (n=1); and mean MELD scores in patients in each CTP class were 9.4, 15.5 and 36.7, respectively. A MELD cutoff value of 12 can predict postoperative mortality with a sensitivity and specificity of 78.7 and 63.9%, respectively, with an area under the curve (AUC) from the ROC analysis of 0.75248 (p&lt;0.0001). Child class B/C predicts morality with a sensitivity and specificity of 23.7 and 92.2%. High MELD score (&gt;12) was associated with longer intubation time (33.6±5.1 vs. 12.2±2.7 hours, p&lt;0.0001), longer ICU (4.8±0.3 vs. 2.2±0.2 days, p&lt;0.0001) and total-hospital stay (34.5±1.0 vs. 22.8±0.6 days, p&lt;0.0001) and more incidence of renal replacement therapy requirement (46.0 vs. 4.4%, p&lt;0.0001) than those with low MELD scores (&lt;12). The predictive strength of the MELD, MELD component variables and CTP class (B/C vs. A) were quantitatively compared based on AUC by using the DeLong test, which revealed that MELD score was the strongest predictor for morality (pairwise comparison, all p&lt;0.05). Conclusions: Assessment of liver dysfunction using the MELD scoring system is useful for predicting postoperative morality and morbidity following cardiac surgery. MELD scoring system was a stronger predictor for morality than CTP classification.

Infectious complications in the era of MELD.

Infections are a major cause for morbidity and mortality in liver transplant recipients. So far there has been no study systematically investigating the correlation between the MELD (Model for End-Stage Liver Disease) scoring system and complications caused by infections. The aim of the present retrospective study was to evaluate the impact of the pretransplant MELD score on incidence and mortality of pneumonia and septicemia in liver transplant recipients. The clinical courses of 201 liver transplant recipients between 12/2006 and 3/2009 were recorded and analyzed on the basis of chart review. Patients were stratified into three groups (pretransplant MELD score: group I 6-20, group II ≥ 21-30, group III ≥ 31-40) and compared in terms of incidence of infection and survival. The mean pretransplant MELD score was 22 ± 12. There were 81 patients in group I, 65 patients in group II, and 55 patients in group III. There was no difference in incidence of infections between the MELD groups. However, septicemia-associated mortality was significantly higher in group III. A high MELD score is not associated with higher incidence of infections but it is associated with a significantly higher mortality in the case of septicemia. Prevention of infections is of utmost importance, especially in liver transplant recipients with high MELD scores.

Evaluated the Child-Turcotte-Pugh classification and MELD score for the prognosis of laparoscopic cholecystectomy in patients with cirrhosis

Objective To evaluate the preoperative liver function and prognosis of laparoscopic cholecystectomy (LC) in patients with cirrhosis,using the Child-Turcotte-Pugh classification and the model for end-stage liver disease(MELD) score.Methods From January 2009 to June 2013,973 patients who were admitted to the Department of General Surgery of our hospital and the HuiZhou Municipal Central Hosptial were studied.Of the 373 patients with cirrhosis,38 patients were excluded because of Child C,MELD ＞ 30,or laparotomy.The remaining 335 patients who received laparoscopic cholecystectomy were randomly divided into two groups The Child grade and MELD score were retrospectively analyzed.Results There was no significant difference in intraoperative hemorrhage between the Child A group [(106 ± 11) ml] and the Child B group [(109 ± 11) ml] (P ＞ 0.05).The R ＜ 14 scores in the MELD group [(58 ± 15) ml] was significantly lower than that in the R≥ 14 group [(120 ± 28) ml] (P ＜ 0.01).There was no significant difference in postoperative complications between the Child group A (10 cases,12％) and the Child group B (17 cases,21％) (P ＞0.05).There was a significantly lower incidence in the R ＜ 14 scores in the MELD group (10 cases,12％) than the R ≥ 14 group (27 cases,33％) (P ＜ 0.05).There was also no significant difference in the hospital stay between the Child A group (9 ± 1) and the Child B group (10 ± 2)(P ＞0.05) ; the R ＜ 14 score of the MELD group (7 ± 1) was significantly less than that of the R≥ 14 group (11 ±2) (P ＜0.01).There was no significant difference in the cost of hospitalization between the Child A group (1.337 ± 0.063) and the Child B group (1.359 ± 0.089) (P ＞ 0.05) ; the R ＜ 14 group (MELD score 1.108 ± 0.123) was significantly less than that of the R ≥ 14 group (1.568-± 0.117)(P ＜ 0.01).Conclusion Compared with the Child-Turcotte-Pugh classification,the MELD score was more scientific,objective and accurate in judging the preoperative liver function.It helped to predict the amount of intraoperative hemorrhage and postoperative morbidity,reduced hospital stay and hospitalization expenses.Therefore,the MELD scoring system more objectively guided the treatment of patients with cholecystitis with cirrhosis. Key words: Cholecystitis ; Cirrhosis ; Laparoscopic cholecystectomy ; Child-Turcotte-Pugh classification; MELD score

The “July Effect” Does Not Have Clinical Relevance in Liver Transplantation

In the beginning of the academic year, medical errors are often attributed to inexperienced medical staff. This potential seasonal influence on health care outcomes is termed the "July effect." No study has demonstrated the July effect in liver transplantation. We reviewed retrospectively collected data from the United Network for Organ Sharing for patients who underwent liver transplantation from October 1987 to June 2011 to determine if surgical outcomes were worse in July compared with rest of the year. We found no clinical difference in early graft survival (91.11% vs. 90.72%, p = 0.045) and no difference in early patient survival (94.71% vs. 94.42%, p = 0.057). Survival at 1 year, 3 years, and 5 years was also compared and no notable differences were detected. Because the Model for End-stage Liver Disease (MELD) score implementation in 2002 affected the acuity of liver transplant recipients, we further stratified our data to compare pre- and post-MELD survival to remove subjectivity as a confounding factor. MELD stratification revealed no seasonal difference in outcomes. There was no difference in rate of graft failure and acute and chronic rejection between groups. Our findings show no evidence of the July effect in liver transplantation. Each July, thousands of medical residents take on new responsibilities in patient care. It has been suggested that these new practitioners may produce errors that contribute to worse patient outcomes in the beginning of the academic year-a phenomenon called the "July effect." Currently, there are few research studies with controversial evidence of poorer outcomes in July, and no articles address the effect of new medical staff in the setting of liver transplantation. Our study compares short-, medium-, and long-term graft and patient survival between July and August and the remaining months using national data. We also examine survival before and after the implementation of the MELD scoring system to determine its effect on outcomes in the beginning of the academic year.

Hepatic Dysfunction in Ambulatory Patients With Heart Failure: Application of the MELD Scoring System for Outcome Prediction

This study evaluated the Model for End-Stage Liver Disease (MELD) score and its modified versions, which are established measures of liver dysfunction, as a tool to assess heart transplantation (HTx) urgency in ambulatory patients with heart failure. Liver abnormalities have a prognostic impact on the outcome of patients with advanced heart failure. We retrospectively evaluated 343 patients undergoing HTx evaluation between 2005 and 2009. The prognostic effectiveness of MELD and 2 modifications (MELDNa [includes serum sodium levels] and MELD-XI [does not include international normalized ratio]) for endpoint events, defined as death/HTx/ventricular assist device requirement, was evaluated in our cohort and in subgroups of patients on and off oral anticoagulation. The MELD and MELDNa scores were excellent predictors for 1-year endpoint events (areas under the curve: 0.71 and 0.73, respectively). High scores (>12) were strongly associated with poor survival at 1 year (MELD 69.3% vs. 90.4% [p< 0.0001]; MELDNa 70.4% vs. 96.9% [p< 0.0001]). Increased scores were associated with increased risk for HTx (hazard ratio: 1.10 [95% confidence interval: 1.06 to 1.14]; p< 0.0001 for both scores), which was independent of other known risk factors (MELD p= 0.0055; MELDNa p= 0.0083). Anticoagulant use was associated with poor survival at 1 year (73.7% vs. 86.4%; p= 0.0118), and the statistical significance of MELD/MELDNa was higher in patients not receiving oral anticoagulation therapy. MELD-XI was a fair but limited predictor of the endpoint events in patients receiving oral anticoagulation therapy. Assessment of liver dysfunction according to the MELD scoring system provides additional risk information in ambulatory patients with heart failure.

Evaluation of the prognosis of fulminant viral hepatitis in late pregnancy by the MELD scoring system

The purpose of this paper was to analyze the prognosis of women with fulminant viral hepatitis in late pregnancy (FVHILP) by the Model for End-Stage Liver Disease (MELD) scoring system. A retrospective study involving patients admitted to two tertiary hospitals between January 1, 1994 and June 30, 2011 was undertaken. The relations between MELD scores and change of MELD score over time (ΔMELD) and prognosis during hospitalization were analyzed. Among the 54 patients with FVHILP, the MELD scores on admission were significantly higher in the non-survival group than those in the survival group (p < 0.05). Among the 26 FVHILP patients who underwent cesarean section, the MELD scores before and after cesarean section were both significantly higher in the non-survival group (p < 0.05). The ΔMELD scores (before operation and three days after operation) significantly increased in the non-survival group (p < 0.05). The concordance (c-statistic) values were all greater than 0.8. The MELD scoring system shows excellent short-term predictive value for the prognosis of FVHILP.

Hepatic dysfunction and survival after orthotopic heart transplantation: Application of the MELD scoring system for outcome prediction

The prevalence of heart failure (HF) is rising and the only corrective treatment is cardiac transplantation. Advanced HF is associated with congestive hepatopathy and progressive functional and ultrastructural changes of the liver. We hypothesized that hepatic dysfunction is associated with impaired clinical outcome after heart transplantation. Data of 617 adult patients (75% men, mean age 53 ± 12 years, mean BMI 25 ± 4, mean ejection fraction 19 ± 9%) undergoing orthotopic heart transplantation (OHT) were analyzed retrospectively. Deviation from institutional normal ranges was used to define abnormal liver function. Standard Model for End-stage Liver Disease (MELD) scores were calculated and a modified MELD score with albumin replacing INR (modMELD) was created to eliminate the confounding effects of anti-coagulation. Before OHT, AST, ALT and total bilirubin were elevated in 20%, 18% and 29% of the population, respectively. Total protein and albumin were decreased in 25% and 52% of the population, respectively. By 2 months post-transplantation, percentages of individuals with pathologic values decreased significantly, except for ALT, total protein and albumin, all of which took longer to normalize. Individuals with a higher pre-transplantation MELD or modMELD score had worse outcome 30 days post-transplant and reduced long-term survival over a 10-year follow-up. In this large, single-center retrospective study, we demonstrated the dynamics of liver dysfunction after cardiac transplantation and that elevated MELD scores indicating impaired liver function are associated with poor clinical outcome after OHT. Thus, pre-operative liver dysfunction has a significant impact on survival of patients after cardiac transplantation.

Correlations between MELD score and left ventricular function in patients with end-stage liver disease

To evaluate the correlations between MELD score and left ventricular function in patients with end-stage liver disease. A total of 92 patients who prepared for orthotopic liver transplantation from January 2002 to May 2008 were enrolled in this study. Of these Patients, 75 were males and 17 were females, and the mean age was 50.3+/-9.5 years; 85 were cirrhosis, 7 were cirrhosis with primary liver cancer. Preoperative information, including biochemical parameters, coagulation parameters, indicators of hepatitis virology, two-dimensional echocardiography and electrocardiogram were collected. According to MELD (the Model for End-stage Liver Disease) scoring system, these subjects were categorized into three groups: MELD score is less than or equal to 9 points (31 cases, 33.7%); 10 is less than or equal to MELD score is less than or equal to 19 points (45 cases, 48.9%); MELD score is more than or equal to 20 points (16 cases, 17.4%). The relationships between MELD score and classification and cardiac function were determined by chi-square test, analysis of variance, rank sum test and correlation analysis, et al. MELD score was significantly correlated with left atrial diameter (LAD), interventricular septum thickness (IVST), left ventricular end-diastolic diameter (LVEDD), aortic flow (AF), cardiac output (CO), QRS interval (QRSI) and corrected QT interval (QTc) (r = 0.317, 0.341, 0.228, 0.387, 0.325, 0.209 and 0.347, respectively; P value less than 0.01, respectively); except QRSI, these variables and left ventricular posterior wall thickness (LVPWT) were also correlated with INR (a MELD component) (r = 0.282, 0.319, 0.322, 0.435, 0.275, 0.320 and 0.237, respectively; P value less than 0.01, respectively); LAD, LVEDD, AF, CO and QTc were correlated with serum total bilirubin (r = 0.241, 0.219, 0.357, 0.246 and 0.253, respectively; P value less than 0.05, respectively); IVST and E/A ratio (A blood flow [from left atrium to left ventricular] velocity ratio between early diastole [E wave] and late diastole[A wave] ) were correlated with serum creatinine (r = 0.216 and -0.343; P value less than 0.05 and 0.01); the proportion of E/A is less than or equal to 1 in all subjects was 46.7% (43/92), and 48.4% (15/31), 35.6% (16/45) and 75.0% (12/16) in each group, besides, there was statistically significant difference between 10 is less than or equal to MELD score is less than or equal to 19 points group and MELD score is more than or equal to 20 points group (X2 = 7.359, P = 0.009). There are different degrees of left ventricular structure, function and electrophysiological changes in patients with end-stage liver disease, these anomalies also will be increased with the MELD score increasing.

The effect of donor race on the survival of Black Americans undergoing liver transplantation for chronic hepatitis C: Is racial mismatch a predictor of graft survival?

Chronic liver diseases are the 12th leading cause of death in the United States, and the burden of disease has been projected to increase substantially in the next several decades. Hepatitis C virus (HCV) is the most common disorder leading to liver transplantation, and its late-stage complications are expected to result in increased hospitalizations and morbidity. The epidemiology of chronic hepatitis C, the natural history of the disease, and its response to therapy are greatly influenced by racial and ethnic differences. African Americans exhibit a higher prevalence of hepatitis C–positive viral serology, and in comparison with nonHispanic whites, they are twice as likely to get infected with genotype 1, which reduces the probability of sustained virological clearance when they are treated. The dissimilarity in viral clearance has been speculated to be a function of racial variation in immunological reactivity. A study of HCV-specific CD41 cell response indicated that even though African Americans have a significantly greater proliferative response to HCV NS3NS5 antigens than non-Hispanic whites, the HCV-specific CD41 T-cell proliferative response is dysfunctional, and the production of gamma interferon, a cytokine that inhibits protein synthesis and RNA replication of subgenomic and genomic HCV replicons, is reduced in this population. The speculated dysfunctional immunological reactivity would explain partially why African Americans progress more often to cirrhosis than nonHispanic whites. Nevertheless, more recently, the National Institutes of Health–sponsored Viral Resistance to Antiviral Therapy of Chronic Hepatitis C (VIRAHEP-C) study, with all of its substudies, has failed to show any racial difference in viral genetics or immunological variability to which the lack of response to antiviral treatment could be attributed. Race also seems to play an important role in access to liver transplantation and in graft survival post–orthotopic liver transplantation (OLT). Prior to the introduction of the Model for End-Stage Liver Disease (MELD), liver organ allocation was based on subjective parameters such as severity of ascites and grade of hepatic encephalopathy. Several studies performed during the pre-MELD era illustrated that African American were underrepresented on the transplant waiting list and among recipients of transplantation. African Americans were also more likely to be referred for liver transplantation at a later stage of their disease in comparison with white patients and had a higher probability of becoming too ill or dying while waiting for liver transplantation. The use of the MELD scoring system has provided a more objective method for the assessment of severity of liver disease and eliminated race as a predictor of organ allocation and as a risk factor for death on the waiting list. The effect of race and ethnicity on post–liver transplantation outcomes has also been extensively reviewed; the most common findings are the reduced 2and 5-year patient survival observed in African Americans after liver transplantation and the in-

Prediction of the prognosis of patients with acute‐on‐chronic hepatitis B liver failure using the model for end‐stage liver disease scoring system and a novel logistic regression model

The objective of this study was to determine the predictive value of the model for end-stage liver disease (MELD) scoring system in patients with acute-on-chronic hepatitis B liver failure (ACLF-HBV), and to establish a new model for predicting the prognosis of ACLF-HBV. A total of 204 adult patients with ACLF-HBV were retrospectively recruited between July 1, 2002 and December 31, 2004. The MELD scores were calculated according to the widely accepted formula. The 3-month mortality was calculated. The validity of the MELD model was determined by means of the concordance (c) statistic. Clinical data and biochemical values were included in the multivariate logistic regression analysis based on which the regression model for predicting prognosis was established. The receiver-operating characteristic curves were drawn for the MELD scoring system and the new regression model and the areas under the curves (AUC) were compared by the z-test. The 3-month mortality rate was 57.8%. The mean MELD score for the patients who died was significantly greater than those who survived beyond 3 months (28.7 vs 22.4, P = 0.003). The concordance (c) statistic (equivalent to the AUC) for the MELD scoring system predicting 3-month mortality was 0.709 (SE = 0.036, P < 0.001, 95% confidence interval 0.638-0.780). The independent factors predicting prognosis were hepatorenal syndrome (P < 0.001), liver cirrhosis (P = 0.009), HBeAg (P = 0.013), albumin (P = 0.028) and prothrombin activity (P = 0.011) as identified in multivariate logistic regression analysis. The regression model that was constructed by the logistic regression analysis produced a greater prognostic value (c = 0.891) than the MELD scoring system (z = 4.333, P < 0.001). The MELD scoring system is a promising and useful predictor for 3-month mortality of ACLF-HBV patients. Hepatorenal syndrome, liver cirrhosis, HBeAg, albumin and prothrombin activity are independent factors affecting the 3-month mortality. The newly established logistic regression model appears to be superior to the MELD scoring system in predicting 3-month mortality in patients with ACLF-HBV.