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Journal ArticleDOI

Mind MELD or Ignore It at Your Peril.

01 Jul 2016-JAMA Surgery (American Medical Association)-Vol. 151, Iss: 7

TL;DR: Focusing on more than 700 patients admitted to the intensive care unit within 48 hours of emergency general surgery at 1 of 2 academic medi- cal centers, Havens et al confirm that MELD scores can predict 90- day mortality and that decreases in MELD Scores after 48 hours following intensive care centre admission can also predict out- comes.

AbstractMind MELD or Ignore It at Your Peril Invited Commentary Invited Commentary Mind MELD or Ignore It at Your Peril Ali Zarrinpar, MD, PhD Chronic liver disease (CLD) and its attendant increased risk of operative mortality and morbidity give appropriate pause to many surgeons and patients prior to undertaking any opera- tion, especially an emer- gency. While the American College of Surgeons National Related article at jamasurgery.com Surgical Quality Improve- ment Project Surgical Risk Calculator 1 does not yet incorporate liver disease–specific measures, multiple previous studies have demonstrated the importance of prognostic factors such as Child-Turcotte-Pugh score, serum creatinine level, international normalized ratio, cardiopulmonary comorbidities, and American Society of Anesthesiologists physical status class. 2 Advances in the medical care of patients with CLD and improved outcomes in liver transplantation have made long-term survival in patients who would not otherwise be considered for major surgery quite possible. For these reasons, accurate prognostic models of survival in cirrhotic patients are useful to clinicians. One such prognostic model, the Mayo Clinic Model for End- Stage Liver Disease (MELD) score, has performed well in a num- ber of settings. Despite being initially based on survival after transjugular intrahepatic portosystemic shunt in a highly se- lected group of patients with cirrhosis and without cardiopul- monary comorbidity or intrinsic renal disease, the MELD score provides a reliable estimate of short-term survival over a wide range of liver disease severity and etiology and has become the standard by which deceased donor liver grafts are allocated. 3 The MELD score has also been previously shown in a number of studies to allow for the prediction of postoperative outcomes. 4,5 In this issue of JAMA Surgery, Havens et al 6 add to that list by showing that the MELD score is closely associated with mor- ARTICLE INFORMATION Author Affiliation: Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles. Corresponding Author: Ali Zarrinpar, MD, PhD, Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California, Los Angeles, 757 Westwood Plaza, Ste 8501, Los Angeles, CA 90095 (azarrinpar@mednet.ucla.edu). Published Online: May 18, 2016. doi:10.1001/jamasurg.2016.0839. Conflict of Interest Disclosures: None reported. REFERENCES 1. American College of Surgeons. Surgical Risk Calculator. http://riskcalculator.facs.org/. Accessed April 22, 2016. jamasurgery.com tality following intensive care unit admission among emer- gency general surgery patients with CLD. Focusing on more than 700 patients admitted to the intensive care unit within 48 hours of emergency general surgery at 1 of 2 academic medi- cal centers, they confirm that MELD scores can predict 90- day mortality and that decreases in MELD scores after 48 hours following intensive care unit admission can also predict out- comes. Notwithstanding standard caveats regarding retro- spective data analyses, their study goes far in confirming the utility of the MELD score and elevating it above other preop- erative prognostic factors such as age, organ failure, and ino- tropic support. Beyond sound statistical and clinical validity, the ideal model for prognostic purposes should use a few inexpensive, readily available, noninvasive, objective parameters. Further- more, it should be generalizable to a diverse group of patients, while maintaining the ability to discern gradations within a continuum of risk. The model should be able to assess the risk of death in independent groups of patients with liver disease of varying etiology and severity and also to incorporate sex, ethnic/racial, and geographical diversity. While it appears to satisfy these criteria, the question remains whether the MELD score, now entering its 16th year of service, should be revised, 7 augmented, or replaced with other measures of liver or global function. 8 Furthermore, armed with this reliable preoperative predictor of mortality, how should we use it? Are there ways to optimize some patients before surgery in a way that would improve out- comes and not just delay care? There are predictors of futility in liver transplantation that allow for patient optimization. 9 Prognostic models should compel us to prospectively test ways to improve the efficacy of care in general surgery patients as well. 2. Ziser A, Plevak DJ, Wiesner RH, Rakela J, Offord KP, Brown DL. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery. Anesthesiology. 1999;90(1):42-53. End-Stage Liver Disease score with mortality in emergency general surgery patients [published online May 18, 2016]. JAMA Surg. doi:10.1001 /jamasurg.2016.0789. 3. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33(2): 7. Leise MD, Kim WR, Kremers WK, Larson JJ, Benson JT, Therneau TM. A revised Model for End-Stage Liver Disease optimizes prediction of mortality among patients awaiting liver transplantation. Gastroenterology. 2011;140(7): 4. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132(4):1261-1269. 5. Mayo Clinic. Post-operative mortality risk in patients with cirrhosis. http://www.mayoclinic.org /medical-professionals/model-end-stage-liver -disease/post-operative-mortality-risk-patients -cirrhosis. Accessed March 20, 2016. 6. Havens JM, Columbus AB, Olufajo OA, Askari R, Salim A, Christopher KB. Association of Model for 8. Mobley CM, Zarrinpar A. Portable device for the analysis of liver function: a boon to liver surgery and critical care. Expert Rev Med Devices. 2016;13(1):1-4. 9. Petrowsky H, Rana A, Kaldas FM, et al. Liver transplantation in highest acuity recipients: identifying factors to avoid futility. Ann Surg. 2014; (Reprinted) JAMA Surgery July 2016 Volume 151, Number 7 Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by a University of California - Los Angeles User on 12/20/2016

Topics: Liver function (61%), Liver transplantation (58%), Chronic liver disease (54%), Liver disease (52%)

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Title
Mind MELD or Ignore It at Your Peril.
Permalink
https://escholarship.org/uc/item/5g00h2kz
Journal
JAMA surgery, 151(7)
ISSN
2168-6254
Author
Zarrinpar, Ali
Publication Date
2016-07-01
DOI
10.1001/jamasurg.2016.0839
Peer reviewed
eScholarship.org Powered by the California Digital Library
University of California

Copyright 2016 American Medical Association. All rights reserved.
Invited Commentary
Mind MELD or Ignore It at Your Peril
Ali Zarrinpar, MD, PhD
Chronic liver disease (CLD) and its attendant increased risk of
operative mortality and morbidity give appropriate pause to
many surgeons and patients prior to undertaking any opera-
tion, especially an emer-
gency. While the American
College of Surgeons National
Surgical Quality Improve-
ment Project Surgical Risk
Calculator
1
does not yet incorporate liver disease–specific
measures, multiple previous studies have demonstrated the
importance of prognostic factors such as Child-Turcotte-Pugh
score, serum creatinine level, international normalized ratio,
cardiopulmonary comorbidities, and American Society of
Anesthesiologists physical status class.
2
Advances in the
medical care of patients with CLD and improved outcomes in
liver transplantation have made long-term survival in patients
who would not otherwise be considered for major surgery
quite possible. For these reasons, accurate prognostic models
of survival in cirrhotic patients are useful to clinicians.
One such prognostic model, the Mayo Clinic Model for End-
Stage Liver Disease (MELD) score, has performed well in a num-
ber of settings. Despite being initially based on survival after
transjugular intrahepatic portosystemic shunt in a highly se-
lected group of patients with cirrhosis and without cardiopul-
monary comorbidity or intrinsic renal disease, the MELD score
provides a reliable estimate of short-term survival over a wide
range of liver disease severity and etiology and has become the
standard by which deceased donor liver grafts are allocated.
3
The MELD score has also been previously shown in a number
of studies to allow for the prediction of postoperative
outcomes.
4,5
In this issue of JAMA Surgery,Havensetal
6
add to that list
by showing that the MELD score is closely associated with mor-
tality following intensive care unit admission among emer-
gency general surgery patients with CLD. Focusing on more
than 700 patients admitted to the intensive care unit within
48 hours of emergency general surgery at 1 of 2 academic medi-
cal centers, they confirm that MELD scores can predict 90-
day mortality and that decreases in MELD scores after 48 hours
following intensive care unit admission can also predict out-
comes. Notwithstanding standard caveats regarding retro-
spective data analyses, their study goes far in confirming the
utility of the MELD score and elevating it above other preop-
erative prognostic factors such as age, organ failure, and ino-
tropic support.
Beyond sound statistical and clinical validity, the ideal
model for prognostic purposes should use a few inexpensive,
readily available, noninvasive, objective parameters. Further-
more, it should be generalizable to a diverse group of
patients, while maintaining the ability to discern gradations
within a continuum of risk. The model should be able to
assess the risk of death in independent groups of patients
with liver disease of varying etiology and severity and also to
incorporate sex, ethnic/racial, and geographical diversity.
While it appears to satisfy these criteria, the question
remains whether the MELD score, now entering its 16th year
of service, should be revised,
7
augmented, or replaced with
other measures of liver or global function.
8
Furthermore,
armed with this reliable preoperative predictor of mortality,
how should we use it? Are there ways to optimize some
patients before surgery in a way that would improve out-
comes and not just delay care? There are predictors of futility
in liver transplantation that allow for patient optimization.
9
Prognostic models should compel us to prospectively test
ways to improve the efficacy of care in general surgery
patients as well.
ARTICLE INFORMATION
Author Affiliation: Division of Liver and Pancreas
Transplantation, Department of Surgery, David
Geffen School of Medicine, University of California,
Los Angeles.
Corresponding Author: Ali Zarrinpar, MD, PhD,
Division of Liver and Pancreas Transplantation,
Department of Surgery, David Geffen School of
Medicine, University of California, Los Angeles, 757
Westwood Plaza, Ste 8501, Los Angeles, CA 90095
(azarrinpar@mednet.ucla.edu).
Published Online: May 18, 2016.
doi:10.1001/jamasurg.2016.0839.
Conflict of Intere st Disclosures: None reported.
REFERENCES
1. American College of Surgeons. Surgical Risk
Calculator. http://riskcalculator.facs.org /. Accessed
April 22, 2016.
2. Ziser A, Plevak DJ, Wiesner RH, Rakela J, Offord
KP, Brown DL. Morbidity and mortality in cirrhotic
patients undergoing anesthesia and surgery.
Anesthesiology. 1999;90(1):42-53.
3. Kamath PS, Wiesner RH, Malinchoc M, et al.
A model to predict survival in patients with
end-stage liver disease. Hepatology. 2001;33(2):
464-470.
4. Teh SH, Nagorney DM, Stevens SR, et al. Risk
factors for mortality after surgery in patients with
cirrhosis. Gastroenterology. 2007;132(4):1261-1269.
5. Mayo Clinic. Post-operative mortality risk in
patients with cirrhosis. http://www.mayoclinic.org
/medical-professionals/model-end-stage-liver
-disease/post-operative-mortality-risk-patients
-cirrhosis. Accessed March 20, 2016.
6. Havens JM, Columbus AB, Olufajo OA, Askari R,
Salim A, Christopher KB. Association of Model for
End-Stage Liver Disease score with mortality in
emergency general surgery patients [published
online May 18, 2016]. JAMA Surg. doi:10.1001
/jamasurg.2016.0789.
7. Leise MD, Kim WR, Kremers WK, Larson JJ,
Benson JT, Therneau TM. A revised Model for
End-Stage Liver Disease optimizes prediction of
mortality among patients awaiting liver
transplantation. Gastroenterology. 2011;140(7):
1952-1960.
8. Mobley CM, Zarrinpar A. Portable device for the
analysis of liver function: a boon to liver surgery and
critical care. Expert Rev Med Devices. 2016;13(1):1-4.
9. Petrowsky H, Rana A, Kaldas FM, et al. Liver
transplantation in highest acuity recipients:
identifying factors to avoid futility. Ann Surg.2014;
259(6):1186-1194.
Related article at
jamasurgery.com
Mind MELD or Ignore It at Your Peril Invited Commentary
jamasurgery.com (Reprinted) JAMA Surgery July 2016 Volume 151, Number 7 1/1
Copyright 2016 American Medical Association. All rights reserved.
Downloaded From: http://jamanetwork.com/ by a University of California - Los Angeles User on 12/20/2016
Citations
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493 citations


References
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Journal ArticleDOI
TL;DR: The MELD scale is a reliable measure of mortality risk in patients with end‐stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities in patient groups with a broader range of disease severity and etiology.
Abstract: A recent mandate emphasizes severity of liver disease to determine priorities in allocating organs for liver transplantation and necessitates a disease severity index based on generalizable, verifiable, and easily obtained variables. The aim of the study was to examine the generalizability of a model previously created to estimate survival of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure in patient groups with a broader range of disease severity and etiology. The Model for End-Stage Liver Disease (MELD) consists of serum bilirubin and creatinine levels, International Normalized Ratio (INR) for prothrombin time, and etiology of liver disease. The model's validity was tested in 4 independent data sets, including (1) patients hospitalized for hepatic decompensation (referred to as "hospitalized" patients), (2) ambulatory patients with noncholestatic cirrhosis, (3) patients with primary biliary cirrhosis (PBC), and (4) unselected patients from the 1980s with cirrhosis (referred to as "historical" patients). In these patients, the model's ability to classify patients according to their risk of death was examined using the concordance (c)-statistic. The MELD scale performed well in predicting death within 3 months with a c-statistic of (1) 0.87 for hospitalized patients, (2) 0.80 for noncholestatic ambulatory patients, (3) 0.87 for PBC patients, and (4) 0.78 for historical cirrhotic patients. Individual complications of portal hypertension had minimal impact on the model's prediction (range of improvement in c-statistic: <.01 for spontaneous bacterial peritonitis and variceal hemorrhage to ascites: 0.01-0.03). The MELD scale is a reliable measure of mortality risk in patients with end-stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities.

3,761 citations


Journal ArticleDOI
TL;DR: The MELD scale is a reliable measure of mortality risk in patients with end-stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities in patient groups with a broader range of disease severity and etiology.
Abstract: A recent mandate emphasizes severity of liver disease to determine priorities in allocating organs for liver transplantation and necessitates a disease severity index based on generalizable, verifiable, and easily obtained variables. The aim of the study was to examine the generalizability of a model previously created to estimate survival of patients undergoing the transjugular intrahepatic portosystemic shunt (TIPS) procedure in patient groups with a broader range of disease severity and etiology. The Model for End-Stage Liver Disease (MELD) consists of serum bilirubin and creatinine levels, International Normalized Ratio (INR) for prothrombin time, and etiology of liver disease. The model's validity was tested in 4 independent data sets, including (1) patients hospitalized for hepatic decompensation (referred to as \"hospitalized\" patients), (2) ambulatory patients with noncholestatic cirrhosis, (3) patients with primary biliary cirrhosis (PBC), and (4) unselected patients from the 1980s with cirrhosis (referred to as \"historical\" patients). In these patients, the model's ability to classify patients according to their risk of death was examined using the concordance (c)-statistic. The MELD scale performed well in predicting death within 3 months with a c-statistic of (1) 0.87 for hospitalized patients, (2) 0.80 for noncholestatic ambulatory patients, (3) 0.87 for PBC patients, and (4) 0.78 for historical cirrhotic patients. Individual complications of portal hypertension had minimal impact on the model's prediction (range of improvement in c-statistic: <.01 for spontaneous bacterial peritonitis and variceal hemorrhage to ascites: 0.01-0.03). The MELD scale is a reliable measure of mortality risk in patients with end-stage liver disease and suitable for use as a disease severity index to determine organ allocation priorities.

1,366 citations


Journal ArticleDOI

493 citations


Journal ArticleDOI
TL;DR: MELD score, age, and American Society of Anesthesiologists class can quantify the risk of mortality postoperatively in patients with cirrhosis, independently of the procedure performed and can be used in determining operative mortality risk and whether elective surgical procedures can be delayed until after liver transplantation.
Abstract: Background & Aims: Current methods of predicting risk of postoperative mortality in patients with cirrhosis are suboptimal. The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. The aim of this study was to determine the risk factors for postoperative mortality in patients with cirrhosis. Methods: Patients with cirrhosis (N = 772) who underwent major digestive (n = 586), orthopedic (n = 107), or cardiovascular (n = 79) surgery were studied. Control groups of patients with cirrhosis included 303 undergoing minor surgical procedures and 562 ambulatory patients. Univariate and multivariable proportional hazards analyses were used to determine the relationship between risk factors and mortality. Results: Patients undergoing major surgery were at increased risk for mortality up to 90 days postoperatively. By multivariable analysis, only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, 20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period. Conclusions: MELD score, age, and American Society of Anesthesiologists class can quantify the risk of mortality postoperatively in patients with cirrhosis, independently of the procedure performed. These factors can be used in determining operative mortality risk and whether elective surgical procedures can be delayed until after liver transplantation.

392 citations


01 Jan 2007
Abstract: BACKGROUND & AIMS Current methods of predicting risk of postoperative mortality in patients with cirrhosis are suboptimal. The utility of the Model for End-stage Liver Disease (MELD) in predicting mortality after surgery other than liver transplantation is unknown. The aim of this study was to determine the risk factors for postoperative mortality in patients with cirrhosis. METHODS Patients with cirrhosis (N = 772) who underwent major digestive (n = 586), orthopedic (n = 107), or cardiovascular (n = 79) surgery were studied. Control groups of patients with cirrhosis included 303 undergoing minor surgical procedures and 562 ambulatory patients. Univariate and multivariable proportional hazards analyses were used to determine the relationship between risk factors and mortality. RESULTS Patients undergoing major surgery were at increased risk for mortality up to 90 days postoperatively. By multivariable analysis, only MELD score, American Society of Anesthesiologists class, and age predicted mortality at 30 and 90 days, 1 year, and long-term, independently of type or year of surgery. Emergency surgery was the only independent predictor of duration of hospitalization postoperatively. Thirty-day mortality ranged from 5.7% (MELD score, <8) to more than 50% (MELD score, >20). The relationship between MELD score and mortality persisted throughout the 20-year postoperative period. CONCLUSIONS MELD score, age, and American Society of Anesthesiologists class can quantify the risk of mortality postoperatively in patients with cirrhosis, independently of the procedure performed. These factors can be used in determining operative mortality risk and whether elective surgical procedures can be delayed until after liver transplantation.

376 citations