Comparison of four models for end-stage liver disease in evaluating the prognosis of cirrhosis

The Development and Appraisal of MELD 3.0 in Liver Diseases: Good Things Never Come Easy

Since its proposal, the Model for End-Stage Liver Disease (MELD) score has been employed to predict short-term mortality among patients with chronic liver disease and those awaiting liver transplantation, serving as the primary criterion for organ allocation. However, as the demographic and epidemiological characteristics of chronic liver disease and liver transplantation have evolved, a range of MELD-related scores has emerged, including MELD-Na, iMELD, delta MELD, MELD XI, MELD-LA, and pediatric end-stage liver disease, culminating in the recently proposed MELD 3.0, which builds upon MELD-Na. This study aimed to comprehensively review and summarize relevant studies on MELD 3.0 in various scenarios, assessing its effectiveness in organ allocation, post-transplantation outcomes, and mortality prediction for patients with end-stage liver disease. Our preliminary findings indicate superior predictive performance of MELD 3.0, warranting further in-depth investigations to broaden its clinical implications.

Artificial intelligence-based evaluation of prognosis in cirrhosis

Cirrhosis represents a significant global health challenge, characterized by high morbidity and mortality rates that severely impact human health. Timely and precise prognostic assessments of liver cirrhosis are crucial for improving patient outcomes and reducing mortality rates as they enable physicians to identify high-risk patients and implement early interventions. This paper features a thorough literature review on the prognostic assessment of liver cirrhosis, aiming to summarize and delineate the present status and constraints associated with the application of traditional prognostic tools in clinical settings. Among these tools, the Child-Pugh and Model for End-Stage Liver Disease (MELD) scoring systems are predominantly utilized. However, their accuracy varies significantly. These systems are generally suitable for broad assessments but lack condition-specific applicability and fail to capture the risks associated with dynamic changes in patient conditions. Future research in this field is poised for deep exploration into the integration of artificial intelligence (AI) with routine clinical and multi-omics data in patients with cirrhosis. The goal is to transition from static, unimodal assessment models to dynamic, multimodal frameworks. Such advancements will not only improve the precision of prognostic tools but also facilitate personalized medicine approaches, potentially revolutionizing clinical outcomes.

Position paper on perioperative management and surgical risk in the patient with cirrhosis

INTRODUCTION

Management of the patient with cirrhosis of the liver that requires surgical treatment has been relatively unexplored. In Mexico, there is currently no formal stance or expert recommendations to guide clinical decision-making in this context.

AIMS

The present position paper reviews the existing evidence on risks, prognoses, precautions, special care, and specific management or procedures for patients with cirrhosis that require surgical interventions or invasive procedures. Our aim is to provide recommendations by an expert panel, based on the best published evidence, and consequently ensure timely, quality, efficient, and low-risk care for this specific group of patients.

RESULTS

Twenty-seven recommendations were developed that address preoperative considerations, intraoperative settings, and postoperative follow-up and care.

CONCLUSIONS

The assessment and care of patients with cirrhosis that require major surgical or invasive procedures should be overseen by a multidisciplinary team that includes the anesthesiologist, hepatologist, gastroenterologist, and clinical nutritionist. With respect to decompensated patients, a nephrology specialist may be required, given that kidney function is also a parameter involved in the prognosis of these patients.

Derivation and validation of prognostic models for predicting survival outcomes in Acute-on-chronic liver failure patients

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of chronic liver disease associated with high bacterial infection (BI) and short-term mortality. However, many ACLF prognostic predictive modelsare complicated. The aim of this study is to develop prognostic models for ACLF patients to predict BI and mortality. We retrospective recruited 263 patients with ACLF from Shandong Provincial Hospital and Taizhou Enze Medical Center (Group) Enze Hospital. ACLF was defined according to the Asian Pacific Association for the Study of the Liver (APASL) criteria. Multivariable logistic regression was used to derive prediction models for occurring BI and 28-day mortality in ACLF patients. Ninety seven of 263 patients (37%) occurred BI and 41 of 155 (26%) died within 28 days of admission. C-reactive protein (CRP), glucose, and albumin were the independent predictors for occurring BI during the hospital stay. We also found that hepatic encephalopathy (HE), prothrombin time, activated partial thromboplastin time (APRI), and glucose were the independent predictors of 28-day mortality of ACLF patients. Using logistic regression model, we generated a new modified MELD model (M-MELD) by incorporating HE, APRI, and glucose. AUC of M-MELD model was 0.871, which were significantly higher than MELD score (AUC:0.734), MELD-Na score (AUC:0.742), and integrated MELD score (iMELD) (AUC:0.761). HE, MELD score, APRI, and blood glucose were independent risk factors for 28-day mortality of ACLF patients. The modified MELD model (M-MELD) by incorporating HE, APRI, and glucose has better discriminative performances compared with MELD in predicting 28-day mortality.

Exploring and predicting mortality among patients with end-stage liver disease without cancer: a machine learning approach

OBJECTIVE

End-stage liver disease is a global public health problem with a high mortality rate. Early identification of people at risk of poor prognosis is fundamental for decision-making in clinical settings. This study created a machine learning prediction system that provides several related models with visualized graphs, including decision trees, ensemble learning and clustering, to predict mortality in patients with end-stage liver disease.

METHODS

A retrospective cohort study was conducted: the training data were from patients enrolled from January 2009 to December 2010 and followed up to December 2014; validation data were from patients enrolled from January 2015 to December 2016 and followed up to January 2019. Hospitalized patients with noncancer-related chronic liver disease were identified from the hospital's electrical medical records.

RESULTS

In traditional multivariable logistic regression and Cox proportional hazard model, prothrombin time of international normalized ratio, which was significant with P value = 0.002, odds ratio = 2.790 and hazard ratio 1.363. Besides, blood urea nitrogen and C-reactive protein were also significant, with P value <0.001 and 0.026. The area under the curve was 0.771 in the receiver operating characteristic curve. In machine learning, blood urea nitrogen and age were regarded as the primary factors for predicting mortality. Creatinine, prothrombin time of international normalized ratio and bilirubin were also significant mortality predictors. The area under the curve of the random forest and AdaBoost was 0.838 and 0.792.

CONCLUSION

The machine learning techniques provided a comprehensive assessment of patient conditions; it could help physicians make an accurate diagnosis of chronic liver disease and improve healthcare management.

Screening for impaired liver function as a risk factor for drug safety at hospital admission of surgical patients

Background Hepatic insufficiency can affect patient safety and should therefore be considered during drug therapy. Hospital admission offers an ideal point to screen for patients at risk and to adjust drug therapy accordingly. Objective To assess the number of patients admitted to hospital with clinically elevated liver parameters. To identify high-risk patients in need of potential drug therapy adjustment to liver function by calculation of liver scores. Finally, to investigate whether pre-hospital medication needed adjustment to liver function. Setting Patients admitted to surgical wards of a tertiary teaching hospital. Method Surgical patients were included in a 3-month retrospective study. A pharmacist-led screening process, including recording of elevated liver parameters and calculation of liver scores (Child-Pugh-score, Model of End-stage Liver Disase [MELD], MELDNa), was used to assess frequency of hepatic insufficiency and patients potentially needing medication adjustment. Additionally, pre-hospital medication was checked for contraindications and correct dosage with regard to liver function. Main outcome measure Percentage of surgical patients with clinically elevated liver parameters at admission, percentage of patients with hepatic insufficiency potentially needing drug therapy adjustment, and percentage of pre-hospital drug intakes not adjusted to liver function. Results Of 1200 patients, 130 (11%) had at least one clinically relevant elevated liver parameter at hospital admission. Of these, need for drug adjustment to liver function was found for 16-36%, depending on the liver score used (equivalent to 2-4% of all patients), with the highest number of patients detected by the MELD- and MELDNa-score. Pre-hospital medication concerned 719 drug intakes and was contraindicated in 2%, dosage not adjusted in 3%, and evaluation not possible in 44% of all drug intakes due to lack of information on the drug. Conclusion A significant proportion of patients admitted for surgery have clinically elevated liver parameters and potentially need medication adjustment. A pharmacist-led screening already at hospital admission can support the identification of patients with clinically relevant elevated liver parameters and patients at risk by calculating liver scores under routine conditions. Evaluation of drug adjustment to liver function is challenging, since no data are available in routine resources for a considerable number of drugs.

Survival prediction among patients with non-cancer-related end-stage liver disease

BACKGROUND

Predicting the survival of non-cancer related end-stage-liver-disease patients in general practice has been difficult for physicians because of the extremely variable trajectories due to multiple complex clinical factors, hence it remains a challenging issue to date. This study aimed to develop and validate a specific prognostic scoring system to early recognize the prognosis and improve the quality of end-of life care for non-cancer end-stage-liver-disease population.

MATERIALS AND METHODS

A multicentre, retrospective cohort study was conducted during January 2010 ~ December 2012 and continued follow-up until December 2014. A cox proportional hazard regression analysis was used to derive and validate an optimized model. The main outcome measures were the 28-day, 3-month, 6-month, and 12-month mortality prediction. The performance of the novel model was evaluated, including discrimination and calibration.

RESULTS

A total of 4,080 consecutive subjects were enrolled. The AUROCs for the 3-month survival discrimination in the MELD, MELD-Na and novel model were 0.787, 0.705 and 0.804 (P<0.001); the 6-month survival discrimination were 0.781, 0.702 and 0.797 (P<0.001); the overall survival discrimination were 0.771, 0.694 and 0.785 (P = 0.002) respectively, whereas the novel model showed a significantly higher discrimination power than did the MELD and MELD-Na for the 3-month, 6-month and overall survival prediction. In addition, calibration of external validation cohort showed no statistical difference in all 5 groups compared with the observed groups.

CONCLUSION

This is a clinically relevant, validated scoring system that can be used sequentially to stratify the prognosis in non-cancer cirrhotic populations, which may help the patients along with medical team in decision making to improve the quality of end-of-life care.

Serum lipids as an indicator for the alteration of liver function in patients with hepatitis B

Background

Hepatitis B virus (HBV) exerts an intense impact on host lipid metabolism. Hence the aim of present study is to determine metabolic derangement that occurred in subjects suffering from hepatitis B patients.

Methods

The fasting blood samples were collected from hepatitis B patients (n = 50) attended in Taluka hospital TandoAdam, Sindh with age and gender matched controls (n = 50). Serum lipid profile and fatty acid (FA) composition were analyzed by micro-lab and gas chromatography.

Results

The hepatitis B patients have significantly lower level (p < 0.01) of lipid profile including total cholesterol (TC), triacylglyceride (TAG), high density lipoprotein-C (HDL-C) very low density lipoprotein-cholesterol (VLDL-C), low density lipoprotein-cholesterol (LDL-C), and total lipid (TL) in comparison to controls, indicating hypolipidemia in patients. The result of total FA composition of HBV patients in comparison to controls reveal that myristic, palmitic, docosahexaenoic acids were significantly (p < 0.05) higher, while linoleic, eicosatrienoic, arachidonic, eicosapentaenoic acids were lower in HBV patients in comparison to controls. The elongase, ∆5 and ∆6-desaturase enzymes activities were found lower, while ∆9-desaturase activity was higher in hepatitis B patients as compared to controls, which indicates the impaired lipid metabolism.

Conclusion

The serum saturated fatty acid (SFA) and monounsaturated fatty acid (MUFA) were increased while polyunsaturated fatty acid (PUFA) was reduced in both total and free form in hepatitis B patients due to altered activities of enzyme desaturases with impaired PUFA metabolism and non-enzymatic oxidation.

Electronic supplementary material

The online version of this article (10.1186/s12944-018-0683-y) contains supplementary material, which is available to authorized users.

Model for End-Stage Liver Disease and Seven Derivations to Prioritize Liver Transplant Candidates: Which Is the Winner?

OBJECTIVES

Under the present liver transplant policy, patients with the highest risk of death receive preference for organ placement. The aim of this study was to evaluate the Model for End-stage Liver Disease (MELD) and seven prognostic derivatives of this test for outcome prediction in cirrhotic patients on liver transplant wait lists.

MATERIAL AND METHODS

The study included 416 patients (65.9% male; age 49 ± 13.9 years) who were entered to liver transplant wait lists from January 2013 to October 2016. Study endpoints were 3-month, 6-month, and 1-year mortality.

RESULTS

All prognostic models had acceptable overall performances (0.12 < Brier score < 0.21). The MELD-to-serum sodium ratio test outperformed its counterparts at all 3 endpoints. Estimated C statistics ranged from 0.77 to 0.83. The largest value at 3 months was for the 5-variable MELD score (0.83), and the largest value at 6 months (0.82) and 1 year (0.83) was for the MELD-albumin score. The Hosmer-Lemeshow goodness-of-fit test and calibration plots revealed underestimation for the entire range of predicted risk (P < .001). With decision curve analysis, the MELD-to-serum sodium ratio and United Kingdom Model for End-Stage Liver Disease scoring tests covered the most extensive range of optimal threshold probabilities.

CONCLUSIONS

Although some derivations, including sodium and albumin, showed effective prioritization of liver transplant candidates, poor calibration statistics highlighted the need for a recalibration process as an inevitable prerequisite before daily clinical use of these tests at the individual level.

Comparison of five models for end-stage liver disease in predicting the survival rate of patients with advanced hepatocellular carcinoma

Prognosis of patients with advanced hepatocellular carcinoma (HCC) is under expectation. Life expectancy more than 3 months is one inclusion criteria for molecular targeted drugs in clinical trials. The main purpose of this research is to compare Model for End-Stage Liver Disease (MELD) and four MELD-based prognostic models in predicting the survival rate of advanced HCC patients. One hundred eighty-three patients with advanced HCC who were not amendable to standard anti-tumor therapy were retrospectively analyzed. Data were collected to classify patients according to MELD, Model for End-Stage Liver Disease with the incorporation of serum sodium (MELD-NA), Model for End-Stage Liver Disease to ascites and sodium (MELD-AS), integrated Model for End-Stage Liver Disease (iMELD), and Model for End-Stage Liver Disease to sodium (MESO) scores at diagnosis. 1-, 3-, and 6-month survivals were the end points used in the analysis. When predicting 1-month survival, MELD-AS, MELD, and MESO were the top 3 ranking staging systems. When predicting 3-month survival, area under the receiver operating characteristic curve (AUC) of MELD-AS is significantly higher than that of the other models (P < 0.05). When predicting 6-month survival, AUCs of MELD-AS and MELD-NA are significantly higher than those of the other models (P < 0.05). Cutoff point of MELD-AS is 23.11 with 40.5 % sensitivity and 93.8 % specificity at 1 month, 9.5 with 76.9 % sensitivity and 59.5 % specificity at 3 months, and 18.5 with 27.0 % sensitivity and 89.1 % specificity at 6 months. MELD-based scores of death group are significantly higher than those of survivors within 1 and 3 months (P < 0.001). Independent prognostic factors identified by multivariate analysis included persistent ascites, serum sodium, and thrombosis. MELD-AS is the best model in the prediction of short and intermediate survival among the five models for end-stage liver disease analyzed for Chinese advanced HCC patients.

The performance of prognostic models as predictors of mortality in patients with acute decompensation of cirrhosis

BACKGROUND

Although several prognostic models have been proposed for cirrhotic patients listed for transplantation, the performance of these scores as predictors of mortality in patients admitted for acute decompensation of cirrhosis has not been satisfactorily investigated.

AIMS

To study MELD, MELD-Na, MESO, iMELD, Refit-MELD and Refit MELD-Na models as prognostic predictors in cirrhotic patients admitted for acute decompensation, and to compare their performance between admission and 48 hours of hospitalization to predict in-hospital mortality.

MATERIAL AND METHODS

This cohort study included cirrhotic patients admitted to hospital due to complications of the disease. Individuals were evaluated on admission and after 48 h of hospitalization, and mortality was evaluated during the present admission.

RESULTS

One hundred and twenty-three subjects with a mean age of 54.26 ± 10.79 years were included; 76.4% were male. Mean MELD score was 16.43 ± 7.08 and 52.0% of patients were Child-Pugh C. Twenty-seven patients (22.0%) died during hospitalization. Similar areas under the curve (AUROCs) for prognosis of mortality were observed when different models were compared on admission (P > 0.05) and after 48 h of hospitalization (P > 0.05). When models executed after 48 h of hospitalization were compared to their corresponding model calculated on admission, significantly higher AUROCs were obtained for all models (P < 0.05), except for MELD-Na (P = 0.075) and iMELD (P = 0.119).

CONCLUSION

The studied models showed similar accuracy as predictors of in-hospital mortality in cirrhotic patients admitted for acute decompensation. However, the performance of these models was significantly better when applied 48 h after admission when compared to their calculation on admission.

MELD-Na: effective in predicting rebleeding in cirrhosis after cessation of esophageal variceal hemorrhage by endoscopic therapy

BACKGROUND AND AIMS

There is no study verifying the predictive value of model for end-stage liver disease and sodium (MELD-Na) for rebleeding and its associated mortality in cirrhotic patients after cessation of acute esophageal variceal hemorrhage (AVH) by endoscopic therapy. This study aimed to determine the predictive value of MELD-Na by comparing with MELD or Child-Turcotte-Pugh (CTP) scores.

PATIENTS AND METHODS

Consecutive adult cirrhotic patients after cessation of AVH by endoscopic therapy (endoscopic variceal ligation or sclerotherapy injections) within 48 hours of admission admitted from 2003 to 2012 were analyzed. The clinical characteristics and laboratory data at admission were documented, based on which MELD-Na, MELD, and CTP scores were calculated.

RESULTS

Among 429 patients who had complete control of AVH, 97 patients (22.6%) suffered esophageal variceal rebleeding within 3 months and 206 patients (48.0%) within 1 year. Fifty-three patients (12.4%) died within 3 months and 98 patients (22.8%) within 1 year from rebleeding. The area under receiver operator characteristics curve of the MELD-Na score for predicting rebleeding and its associated mortality was significantly higher than that of the MELD and the CTP score (rebleeding: 0.83 vs. 0.77 vs. 0.69 for 3 months and 0.85 vs. 0.80 vs. 0.65 for 1 year, P<0.05; mortality: 0.81 vs. 0.75 vs. 0.66 for 3 months and 0.82 vs. 0.78 vs. 0.68 for 1 year, P<0.05).

CONCLUSIONS

The MELD-Na score is clinically useful in predicting 3-month and 1-year rebleeding and its associated mortality in cirrhotic patients after cessation of AVH by endoscopic therapy.

New advances in the use of serum prealbumin as an index of liver function

Serum prealbumin, mainly synthesized in the liver, can be used to assess the function of liver protein synthesis, reserve and nutritional status with many advantages such as convenience, accuracy and fewer interference factors; however, it is clinically used often as an independent factor, and there is little systematic, relevant and prospective research on it. Although serum prealbumin test has been used for a long time, many clinicians do not attach great importance to the characteristics of changes in serum prealbumin. In this paper, we will review new characteristics of biochemistry structure and function of serum prealbumin, and relevance between serum prealbumin and serum albumin, cholesterol, cholinesterase, total bile acids, prothrombin time, Child-Turcotte-Pugh, and model of end-stage liver stage.

Different models in predicting the short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND AND AIMS

Effective assessing the prognosis of patients with end-stage liver disease is always challenging. This study aimed to investigate the accuracy of different models in predicting short-term prognosis of patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF).

MATERIAL AND METHODS

We retrospectively evaluated survival of a cohort of patients with at least 3-month follow up. The receiver-operating-characteristic curves (ROC) were drawn for Child-Turcotte-Pugh (CTP) classification, King's College Hospital (KCH) criteria, model for end-stage liver disease (MELD), MELD combined with serum sodium (Na) concentration (MELDNa), integrated MELD (iMELD) and logistic regression model (LRM).

RESULTS

Of the 273 eligible patients, 152 patients (55.7%) died within 3-month follow up. In cirrhotic patients (n = 101), the AUCs of LRM (0.851), MELDNa (0.849), iMELD (0.845) and MELD (0.840) were all significantly higher than those of KCH criteria (0.642) and CTP (0.625) (all p < 0.05), while the differences among LRM, MELD, MELDNa and iMELD were not significant, and the most predictive cutoff value was 0.5176 for LRM, 30 for MELDNa, 47.87 for iMELD and 29 for MELD, respectively. In non-cirrhotic patients (n = 172), the AUC of LRM (0.897) was significantly higher than that of MELDNa (0.776), iMELD (0.768), MELD (0.758), KCH criteria (0.647) and CTP (0.629), respectively (all p < 0.05), and the most predictive cutoff value for LRM was -0.3264.

CONCLUSIONS

LRM, MELD, MELDNa and iMELD are with similar accuracy in predicting the shortterm prognosis of HBV-ACLF patients with liver cirrhosis, while LRM is superior to MELD, MELDNa and iMELD in predicting the short-term prognosis of HBV-ACLF patients without liver cirrhosis.

Systematic review of noncancer presentations with a median survival of 6 months or less

PURPOSE

We report on clinical indicators of 6-month mortality in advanced noncancer illnesses and the effect of treatment on survival.

METHODS

The MEDLINE database was searched comprehensively to find studies evaluating survival for common advanced noncancer illnesses. We retrieved and evaluated studies that reported a median survival of ≤1 year and evaluated prognostic factors or effect of treatment on survival. We extracted data on presentations with median survivals of ≤6 months for heart failure, chronic obstructive pulmonary disease, dementia, geriatric failure to thrive, cirrhosis, and end-stage renal failure. Independent risk factors for survival were combined and included if their combination was associated with a 6-month mortality of ≥50%.

RESULTS

The search identified 1000 potentially relevant studies, of which 475 were retrieved and evaluated, and 74 were included. We report the common clinical presentations that are consistently associated with a 6-month median survival. Even though advanced noncancer syndromes differ clinically, a universal set of prognostic factors signals progression to terminal disease, including poor performance status, advanced age, malnutrition, comorbid illness, organ dysfunction, and hospitalization for acute decompensation. Generally, a 6-month median survival is associated with the presence of 2-4 of these factors. With few exceptions, these terminal presentations are quite refractory to treatment.

CONCLUSION

This systematic review summarizes prognostic factors common to advanced noncancer illness. There is little evidence at present that treatment prolongs survival at these terminal stages.

Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit

BACKGROUND & AIMS

Cirrhotic patients admitted to an Intensive Care Unit (ICU) have a poor prognosis. Identifying patients in whom ICU care will be useful can be challenging. The aim of this study was to assess the predictive value of prognostic scores with respect to mortality and to identify mortality risk factors.

METHODS

Three hundred and seventy-seven cirrhotic patients admitted to a Liver ICU between May 2005 and March 2009 were enrolled in this study. Their average age was 55.5±11.4 years. The etiology of cirrhosis was alcohol (68%), virus hepatitis (18%), or mixed (5.5%). The main causes of hospitalization were gastrointestinal hemorrhage (43%), sepsis (19%), and hepatic encephalopathy (12%).

RESULTS

ICU and in-hospital mortality rates were 34.7% and 43.0%, respectively. Infection was the major cause of death (81.6%). ROC curve analysis demonstrated that SOFA (0.92) and SAPS II (0.89) scores calculated within 24h of admission predicted ICU mortality better than the Child-Pugh score (0.79) or MELD scores with (0.79-0.82) or without the incorporation of serum sodium levels (0.82). Statistical analysis showed that the prognostic severity scores, organ replacement therapy, and infection were accurate predictors of mortality. On multivariate analysis, mechanical ventilation, vasopressor therapy, bilirubin level at admission, and infection were independently associated with ICU mortality.

CONCLUSIONS

For cirrhotic patients admitted to the ICU, SAPS II, and SOFA scores predicted ICU mortality better than liver-specific scores. Mechanical ventilation or vasopressor therapy, bilirubin levels at admission and infection in patients with advanced cirrhosis were associated with a poor outcome.

Model for end-stage liver disease combined with serum prealbumin to predict the prognosis of patients with decompensated liver cirrhosis

OBJECTIVE

To evaluate the prognostic value of model for end-stage liver disease (MELD) combined with serum prealbumin (PA) in patients with decompensated liver cirrhosis.

METHODS

A total of 252 patients were enrolled in the study and followed 1 year. PA was measured and MELD score was calculated on the first day of admission. Analysis of variance (anova) was used to assess correlation between PA level and MELD score. Multivariable Cox proportional hazards model was used to screen the prognosis related factors. Kaplan-Meier survival curves were drawn.

RESULTS

Of the 252 patients, 28 died within 3 months, 58 within 6 months and 91 within 1 year. Serum PA level in dead patients was significantly lower than that in survival patients (P < 0.005) and decreasing with increasing of MELD score. Cox analysis showed that MELD score > 18 (RR = 2.749) and PA < 70 mg/L (RR = 2.412) were independent prognosis risk factors. The risk ratio of MELD score combined with PA level (1.854, P < 0.01) was higher than that of MELD score alone (1.054, P < 0.05). Kaplan-Meier survival curve analysis showed that MELD score ≤ 18 combined with PA ≥ 70 mg/L could clearly discriminate patients who would survive or die within 6 month and 1 year follow up.

CONCLUSION

MELD score ≤ 18 combined with PA ≥ 70 mg/L could predict the 6-month and 1-year prognosis of patients with decompensated liver cirrhosis, and was superior to that of MELD score alone.

Do chronic liver disease scoring systems predict outcomes in trauma patients with liver disease? A comparison of MELD and CTP

BACKGROUND

Although the Child-Turcotte-Pugh (CTP) score is an established outcome prediction tool for patients with liver disease, the Model for End-Stage Liver Disease (MELD) score has recently supplanted CTP for patients awaiting transplantation. Currently, data regarding the use of CTP in trauma is limited, whereas MELD remains unstudied. We compared MELD and CTP to determine which scoring system is a better clinical outcome predictor after trauma.

METHODS

A review of trauma admissions during 2003-2008 revealed 68 patients with chronic liver disease. Single and multiple variable analyses determined predictors of hepatic complications and survival. MELD and CTP were compared using odds ratios and area under the receiver operating curve (AUC) analyses. A p value ≤0.05 was significant.

RESULTS

The mean MELD and CTP scores of the population were 13.1 ± 6.0 and 8.3 ± 1.8, respectively (mean ± SD). Overall, 73.5% had one or more complications and 29.4% died. When survivors were compared with nonsurvivors, no difference in mean MELD scores was found, although mean CTP score (survivors, 7.7 ± 1.5; nonsurvivors, 9.4 ± 1.9; p = 0.001) and class ("C" survivors, 12.1%; "C" nonsurvivors, 56.3%; p = 0.002) were different, with survival relating to liver disease severity. Odds ratios and AUC determined that MELD was not predictive of hepatic complications or hospital survival (p > 0.05), although both CTP score and class were predictive (p < 0.05; AUC > 0.70).

CONCLUSION

Trauma patients suffering from cirrhosis can be expected to have poorer than predicted outcomes using traditional trauma scoring systems, regardless of injury severity. Scoring systems for chronic liver disease offer a more effective alternative. We compared two scoring systems, MELD and CTP, and determined that CTP was the better predictor of hepatic complications and survival in our study population.

Six score systems to evaluate candidates with advanced cirrhosis for orthotopic liver transplant: Which is the winner?

Many prognostic systems have been devised to predict the outcome of liver transplantation (LT) candidates. Today, the Model for End-Stage Liver Disease (MELD) is widely used for organ allocation, but it has shown some limitations. The aim of this study was to investigate the performance of MELD compared to 5 different score models. We evaluated the prognostic ability of MELD, modified Child-Turcotte-Pugh, MELD-sodium, United Kingdom MELD, updated MELD, and integrated MELD in 487 candidates with cirrhosis for LT at the Bologna Transplant Centre, Bologna, Italy, between 2003 and 2008. Calibration analysis by Hosmer-Lemeshow test, calibration curves, and concordance c-statistics (area under the receiver operating characteristic curve [AUC]) were calculated at 3, 6, and 12 months. Actual cumulative survival curves, taking into account the event of interest in the presence of competing risk, were obtained using the best cutoffs identified by AUC. For each score, the Hosmer-Lemeshow test revealed a good calibration. Integrated MELD showed calibration curves closer to the line of perfect predicting ability, followed by MELD-sodium at 3 months and modified Child-Turcotte-Pugh at 6 months. MELD-sodium AUCs at 3 and 6 months (0.798 and 0.765, respectively) and integrated MELD AUC at 6 months (0.792) were better than standard MELD (P < 0.05). Actual survival curves showed that these 2 scores were able to identify the patients with the highest drop-out risk. In conclusion, MELD-sodium and integrated MELD were the best prognostic models to predict drop-out rates among patients awaiting LT.