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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.
Abstract: Mind 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

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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
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Journal ArticleDOI
TL;DR: In the past few years, changes have been made in the diagnosis, preoperative preparation, surgical and anesthetic management and perioperative care of patients with liver disease, and the aim of this review is to examine whether these changes have resulted in improvedPerioperative outcomes.
Abstract: Background: Patients with cirrhosis have a reduced life expectancy. Anesthesia and surgery have been associated with clinical decompensation in patients with cirrhosis. Metbods: The authors retrospectively reviewed the records of all patients with the diagnosis of cirrhosis who underwent any surgical procedure under anesthesia at their institution between January 1980 and January 1991 (n = 733). Univariate and multivariate analyses were used to identify the variables associated with perioperative complications and short- and long-term survival. Results: The perioperative mortality rate (within 30 days of surgery) was 11.6%. The perioperative complication rate was 30.1%. Postoperative pneumonia was the most frequent complication. Multivariate factors that were associated with perioperative complications and mortality included male gender, a high Child-Pugh score, the presence of ascites, a diagnosis of cirrhosis other than primary biliary cirrhosis (especially cryptogenic cirrhosis), an elevated creatinine concentration, the diagnosis of chronic obstructive pulmonary disease, preoperative infection, preoperative upper gastrointestinal bleeding, a high American Society of Anesthesiologists physical status rating, a high surgical severity score, surgery on the respiratory system, and the presence of intraoperative hypotension. Conclusion: Risk factors have been identified for patients with cirrhosis who undergo anesthesia and surgery.

362 citations

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TL;DR: Risk factors have been identified for patients with cirrhosis who undergo anesthesia and surgery and short- and long-term survival are identified.
Abstract: Several studies have demonstrated increased morbidity and mortality in patients with cirrhosis undergoing anesthesia and surgery. Cirrhosis is a chronic liver disease, which may affect all body systems. The severity of the disease, assessed by the Child-Pugh classification, has a substantial effect on patient outcome. The extent of surgery and co-morbid conditions also have a major impact. In the past few years, changes have been made in the diagnosis, preoperative preparation, surgical and anesthetic management and perioperative care of patients with liver disease. The aim of this review is to examine whether these changes have resulted in improved perioperative outcomes.

177 citations

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TL;DR: Cardiac risk, pretransplant septic shock, and comorbidities are the most important predictors and can be used for risk stratification in these highest acuity recipients.
Abstract: Objective:To identify medical predictors of futility in recipients with laboratory Model of End-Stage Liver Disease (MELD) scores of 40 or more at the time of orthotopic liver transplantation (OLT).Background:Although the survival benefit for transplant patients with the highest MELD scores is indis

158 citations

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TL;DR: Modification of MELD score to update coefficients, change upper and lower bounds, and incorporate serum sodium levels improved wait-list mortality prediction and should increase efficiency of allocation of donated livers.

129 citations

Journal ArticleDOI
TL;DR: The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.
Abstract: Importance Emergency general surgery (EGS) patients have a disproportionate burden of death and complications. Chronic liver disease (CLD) increases the risk of complications following elective surgery. For EGS patients with CLD, long-term outcomes are unknown and risk stratification models do not reflect severity of CLD. Objective To determine whether the Model for End-Stage Liver Disease (MELD) score is associated with increased risk of 90-day mortality following intensive care unit (ICU) admission in EGS patients. Design, Setting, and Participants We performed a retrospective cohort study of patients with CLD who underwent an EGS procedure based on International Classification of Diseases, Ninth Revision ( ICD-9 ) procedure codes and were admitted to a medical or surgical ICU within 48 hours of surgery between January 1, 1998, and September 20, 2012, at 2 academic medical centers. Chronic liver disease was identified using ICD-9 codes. Multivariable logistic regression was performed. The analysis was conducted from July 1, 2015, to January 1, 2016. Main Outcomes and Measures The primary outcome was all-cause 90-day mortality. Results A total of 13 552 EGS patients received critical care; of these, 707 (5%) (mean [SD] age at hospital admission, 56.6 [14.2] years; 64% male; 79% white) had CLD and data to determine MELD score at ICU admission. The median MELD score was 14 (interquartile range, 10-20). Overall 90-day mortality was 30.1%. The adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score was 1.63 (95% CI, 1.34-1.98). A decrease in MELD score of more than 3 in the 48 hours following ICU admission was associated with a 2.2-fold decrease in 90-day mortality (odds ratio = 0.46; 95% CI, 0.22-0.98). Conclusions and Relevance In this study, MELD score was associated with 90-day mortality following EGS in patients with CLD. The MELD score can be used as a prognostic factor in this patient population and should be used in preoperative risk prediction models and when counseling EGS patients on the risks and benefits of operative intervention.

20 citations