Showing papers on "Model for End-Stage Liver Disease published in 2005"

Transection of the oesophagus for bleeding oesophageal varices

Abstract: Emergency ligation of bleeding oesophageal varices using the Milnes Walker technique was performed in 38 patients. Haemorrhage continued or recurred in hospital in 11 patients, all of whom subsequently died. A further 10 patients died in hospital following operation from hepatic failure and a variety of other causes. Five patients were finally considered suitable for elective shunt surgery, but of 12 patients who were discharged without a further operation, only 2 have re-bled. Although the overall 6-month survival was 32 per cent, in patients with good preoperative liver function this rose to 71 per cent, and the simple scoring system for grading the severity of disturbance of liver function was found to be of value in predicting the outcome of surgery. Since the results of emergency ligation of bleeding oesophageal varices in our hands have been so disappointing we are currently using it less and are trying the mesenteric caval jump graft as an emergency operation for the control of bleeding varices.

Systematic review: The model for end-stage liver disease--should it replace Child-Pugh's classification for assessing prognosis in cirrhosis?

Abstract: Summary Background: Prognosis in cirrhotic patients has had a resurgence of interest because of liver transplantation and new therapies for complications of end-stage cirrhosis. The model for end-stage liver disease score is now used for allocation in liver transplantation waiting lists, replacing Child-Turcotte-Pugh score. However, there is debate as whether it is better in other settings of cirrhosis. Aim: To review studies comparing the accuracy of model for end-stage liver disease score vs. Child-Turcotte-Pugh score in non-transplant settings. Results: Transjugular intrahepatic portosystemic shunt studies (with 1360 cirrhotics) only one of five, showed model for end-stage liver disease to be superior to Child-Turcotte-Pugh to predict 3-month mortality, but not for 12-month mortality. Prognosis of cirrhosis studies (with 2569 patients) none of four showed significant differences between the two scores for either short- or long-term prognosis whereas no differences for variceal bleeding studies (with 411 cirrhotics). Modified Child-Turcotte-Pugh score, by adding creatinine, performed similarly to model for end-stage liver disease score. Hepatic encephalopathy and hyponatraemia (as an index of ascites), both components of Child-Turcotte-Pugh score, add to the prognostic performance of model for end-stage liver disease score. Conclusions: Based on current literature, model for end-stage liver disease score does not perform better than Child-Turcotte-Pugh score in non-transplant settings. Modified Child-Turcotte-Pugh and model for end-stage liver disease scores need further evaluation.

Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis.

Abstract: Chronic liver failure affects multiple organ systems and results in a shortened life expectancy. Previous reports have demonstrated increased perioperative morbidity and mortality in patients with cirrhosis.1 This morbidity likely is related to the disruption that liver disease exerts on blood flow as well as on biochemical and metabolic pathways. The preprocedure use of diuretics and operative use of anesthetics further strains the liver and associated pathways. The morbidity and mortality of cirrhotic patients undergoing a variety of surgical procedures has been well documented.2 This documentation has contributed to the concern many surgeons express when confronted with individuals with known liver disease who may need surgical procedures. Despite this, as many as 10% of cirrhotic patients will require surgical procedures, often when their liver disease is poorly compensated.3 Risk stratification for these patients is difficult and often precludes surgical intervention. Historically, the severity of cirrhotic liver disease has been calculated using the Child-Pugh (CP) class. The variables used in the calculation of the CP class were not the result of systematic analysis but rather emerged from clinical experience. The CP class has been shown to be valuable in determining prognosis in cirrhotic patients undergoing medical management.4 Additionally, the CP score has been shown to have significant prognostic influence on postoperative complications and mortality. This influence was demonstrated across a range of different surgical procedures and was significant by both univariate and multivariate analyses.2 However, other authors have reported the Child classification and Pugh score failed to predict postoperative 30-day mortality.1 This failure may be related to the limitations of the CP system, including the subjective interpretation of parameters such as ascites and encephalopathy, as well as a limited discriminatory ability. The MELD score originally was developed and validated to assess the short-term prognosis of patients with cirrhosis undergoing the transjugular intrahepatic portosystemic shunt (ie, TIPS) procedure.5 The score consists of 3 objective, easily obtainable variables: serum International Normalized Ratio (INR), total bilirubin, and creatinine levels. It subsequently has been shown to be a reliable marker of mortality risk in both hospitalized and ambulatory patients with cirrhosis.6 The score's usefulness appears to be irrespective of underlying disease etiology. The predictive capabilities of the MELD score have been studied in a variety of conditions, including primary biliary cirrhosis and primary sclerosing cholangitis.6,7 Additionally, the MELD score has been demonstrated to be predictive of in-hospital and 1-year mortality in patients presenting with acute variceal bleeding.8 The MELD score also has been recently validated to predict 1-year and 5-year mortality in a large cohort of nontransplant cirrhosis patients with widely varying causes and severities of chronic liver disease.9 Since February 2002, the United Network for Organ Sharing (UNOS) has used a modified MELD score for liver transplantation organ allocation based on its utility as an easily verifiable, objective scoring system with multiple gradations, and its role as a superior disease severity index. The objective of this study is to determine the ability of the MELD score to predict 30-day mortality for patients with cirrhosis undergoing nontransplant surgical procedures.

The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome.

Abstract: Hypothesis We hypothesized that the model for end-stage liver disease (MELD) score may be a better and less subjective method than the Child-Turcotte-Pugh score for stratifying patients with cirrhosis before abdominal surgery. Design Retrospective medical record review. Setting Tertiary care institution. Patients Fifty-three adult patients with histologically proven cirrhosis undergoing abdominal surgery at Saint Louis University Hospital, St Louis, Mo, between 1991 and 2001. Those undergoing hepatic surgery (such as resection or transplantation) or closed abdominal surgery (such as hernia repair) were excluded. Main Outcome Measure A poor outcome after surgery was defined as death or liver transplantation within 90 days of the operative procedure or a hospital stay of longer than 21 days. Demographic, clinical, and laboratory features predictive of poor outcome were assessed by multivariate analysis. Results A total of 13 patients (25%) had poor outcomes including 9 deaths (17%). Model for end-stage liver disease score and plasma hemoglobin levels lower than 10 g/dL were found to be independent predictors of poor outcomes. A MELD score of 14 or greater was a better clinical predictor of poor outcome than Child-Turcotte-Pugh class C. Conclusions A MELD score of 14 or greater should be considered as a replacement for Child-Turcotte-Pugh class C as a predictor of being very high risk for abdominal surgery. Patients with cirrhosis with hemoglobin levels lower than 10 g/dL should receive corrective blood transfusions before abdominal surgery.

A comparison of liver transplantation outcomes in the pre‐ vs. post‐MELD eras

Abstract: Summary Background: The model for end stage liver disease (MELD)-based organ allocation system is designed to prioritize orthotopic liver transplantation (OLT) for patients with the most severe liver disease. However, there are no published data to confirm whether this goal has been achieved or whether the policy has affected long-term post-OLT survival. Aim: To compare pre-OLT liver disease severity and long-term (1 year) post-OLT survival between the pre- and post-MELD eras. Methods: Using the United Network of Organ Sharing database, we compared two cohorts of adult patients undergoing cadaveric liver transplant in the pre-MELD (n = 3857) and post-MELD (n = 4245) eras. We created multivariable models to determine differences in: (i) pre-OLT liver disease severity as measured by MELD; and (ii) 1-year post-OLT outcomes. Results: Patients undergoing OLT in the post-MELD era had more severe liver disease at the time of transplantation (mean MELD = 20.5) vs. those in the pre-MELD era (mean MELD = 17.0). There were no differences in the unadjusted patient or graft survival at 1 year post-OLT. This difference remained insignificant after adjusting for a range of prespecified recipient, donor, and transplant centre-related factors in multivariable survival analysis. Conclusions: Although liver disease severity is higher in the post- vs. pre-MELD era, there has been no change in long-term post-OLT patient or graft survival. These results indicate that the MELD era has achieved its primary goals by allocating cadaveric livers to the sickest patients without compromising post-OLT survival.

Assignment of steatotic livers by the Mayo model for end‐stage liver disease

Abstract: Summary Prognosis after liver transplantation depends on a combination of recipient and donor variables. The purpose of this study is to define an allocation system of steatotic donor livers relative to recipient model for end-stage liver disease (MELD) score. We reviewed 500 consecutive OLT, computing the MELD score for each recipient. Fatty infiltration in grafts was categorized in no steatosis, 10–30%, 30–60% and ≥60% steatosis. MELD score did not affect preservation injury and graft dysfunction, which were increased with fat content. Recipient and graft survivals lowered when increasing MELD score. Outcome in low-risk recipients (MELD ≤9) was not altered with steatosis, except those with ≥60%. Survival functions in moderate-risk recipients (MELD 10–19) were moderately affected with 10–30% steatosis and severely with those with >30. Exactly 30–60% steatotic grafts work poorly in high-risk recipients (MELD ≥20), and very poorly with ≥60% steatosis. Prognosis of candidates is optimally influenced when divergence of recipient–donor risks is presented.

Spectrum of pneumonia in the current era of liver transplantation and its effect on survival.

Abstract: OBJECTIVE To examine the frequency and microbial pattern of pneumonia and its effect on survival in the current era of orthotopic liver transplantation (OLT). PATIENTS AND METHODS At the Mayo Clinic in Jacksonville, Fla, the medical records of consecutive patients who underwent their first OLT between February 1998 and January 2001 were retrospectively reviewed through the end of the first year post-transplantation. RESULTS Of 401 study patients, 20 developed pneumonia; estimates of incidence with corresponding 95% confidence interval (CI) at 1 and 12 months were 3% (1%-5%) and 5% (3%-7%), respectively. Pseudomonas aeruginosa was the predominant microorganism identified (in 8 of 14 patients) during the first month after transplantation. Between the second and sixth months, 2 of the 4 cases of pneumonia were due to fungal infections of Aspergillus fumigatus. Cytomegalovirus was associated with Aspergillus in 1 patient. No other viral or Pneumocystis carinii pneumonia was diagnosed. There were only 2 cases of pneumonia between 7 months and 1 year after transplantation, neither of which was fungal. Approximately 40% (95% CI, 14%-58%) of patients with pneumonia died within 1 month after diagnosis. The relative risk of mortality in the first month after onset of pneumonia was estimated to be 24 (95% CI, 10-54), which is strong evidence of increased risk of mortality with pneumonia (P CONCLUSIONS Pneumonia appears to occur less often after OLT than previously reported but still has a substantial negative effect on survival. In the early period after OLT, P aeruginosa continues to be the predominant organism causing pneumonia.

Predictors of death on the waiting list for liver transplantation characterized by a long waiting time.

Abstract: The number of patients dying while on the liver transplantation (LT) waiting list (WL) has continued to increase in recent years as a result of severe shortage of organs. Therefore, it is important to evaluate the existing models that predict death on the WL and to determine the independent predictors of death. The study cohort comprised 152 adult patients listed for LT in our centre over a period of 2 years (January 2001 to January 2003). The 12-month survival rate has been calculated by Kaplan-Meier method. The survival analysis performed by Cox proportional hazard model has evaluated the three parameters which compose the model for end-stage liver disease (MELD) score. Forty-four patients (28.9%) died while listed for LT. The survival rate was 92% at 3 months, 80% at 6 months and 69% at 12 months. Median survival was not reached. MELD score was found to be an excellent predictor of death at 12 months on our WL--c-statistic (area under curve) 0.84. In our survival analysis, only international normalized (prothrombin) ratio (INR) and serum creatinine were identified as an independent predictors of death (P < 0.0001). A new simplified version of the MELD score, which does not include serum bilirubin, is proposed and its c-statistic as predictor for death on the WL at 12 months is 0.86, as good as the original MELD score, when evaluated on our list. There is a fourfold increase in mortality on our WL for LT between 3 and 12 months after the inclusion. A simplified version of the MELD score, using only serum creatinine and INR might be taken into account when predicting 12 months mortality on WL with longer waiting time, but it has to be confirmed by other prospective studies.

Different model for end-stage liver disease score block distributions may have a variable ability for outcome prediction.

Abstract: BACKGROUND The model for end-stage liver disease (MELD) scoring system has become the prevailing criteria for organ allocation in liver transplantation. However, it is not clear if the predictive accuracy of MELD is equally homogeneous in different distribution of MELD score blocks. METHODS We investigated 472 cirrhotic patients (mean MELD, 14.3+/-5.5), and compared the predictive accuracy of MELD and the corresponding Child-Turcotte-Pugh (CTP) scores in patients with low ( 14) MELD score range by using c-statistic for area under the receiver operating characteristic curve (AUC) at different time frames. RESULTS The MELD scores well correlated with CTP scores at baseline (rho=0.492, P 0 1). Among patients with high MELD scores, MELD was consistently more accurate than the CTP system in predicting the mortality at 3- (AUC, 0.715 vs. 0.543, P=0.020), 6- (0.705 vs. 0.536, P=0.003), 9- (0.737 vs. 0.507, P<0.001) and 12-month (0.716 vs. 0.526, P<0.001), respectively. CONCLUSIONS MELD has a better performance only in a subset of patients with higher MELD scores. The outcome in patients with lower range MELD scores cannot be reliably predicted solely with their MELD scores, and alternative prognostic markers should be used in conjunction to enhance the predictive accuracy.

Assessment of short-term survival after liver transplant by the Model for End-Stage Liver Disease.

Abstract: The Model for End-Stage Liver Disease (MELD) score has demonstrated the ability to predict mortality among patients with chronic liver disease on the liver waiting list. The aim of this study was to assess the capability of the MELD score to correctly predict posttransplantation survival in Spain and to determine specific thresholds of MELD above which liver transplantation should be discouraged and the patient removed from the waiting list. Methods In this study, we retrospectively applied the MELD score to 168 patients at time of transplantation to estimate 1-month and 3-month posttransplant survivals by stratifying them into four groups: group A, MELD score 24. Results One-, 2-, and 3-month survivals were 84.3%, 80% and 79.5%, respectively. One-, 2-, and 3-month survivals in group A (18 patients) were identical (77.8%). In group B (80 patients), 1-month survival was 84.8%, and 2- and 3-month survivals were 78.4%. In group C (42 patients) 1-month survival was 90.5% and 2- and 3-month survivals were 88%. One-, 2-, and 3-month survivals in group D (28 patients) were 77.9%, 74%, and 70%, respectively. We defined a new group (group E) formed by patients with MELD score ≤24. When we compared 1-, 2-, and 3-month survival rates in group E (85.6%, 81.25%, and 81.25%, respectively) with survival rates in group D, the difference was not significant (P > .05). Conclusions Although overall outcomes of patients whose MELD scores were high at the time of liver transplantation were inferior to those of patients whose MELD scores were lower, there was no significant difference for specific thresholds of MELD above which liver transplantation should be discouraged and the patient removed from the waiting list.

Liver transplantation outcomes under the model for end-stage liver disease and pediatric end-stage liver disease

Abstract: Purpose of reviewDeceased-donor liver allocation has undergone a significant change in approach and execution with the adoption of the MELD/PELD (model for end-stage liver disease/pediatric end-stage liver disease) system in February 2002. This review focuses on the key reports summarising the results of this allocation system and studies examining different aspects and deficiencies of this system. Recent findingsThe institution of the MELD/PELD system was preceded by several important analyses in which prospective validation of the MELD and PELD models showed they had a high degree of concordance for predicting mortality risk for adult and pediatric candidates, respectively, who were waiting for liver transplantation. Additional studies documented the rationale for the policy change and outlined the specifics of the system. Results after 1 year of allocation under this new system showed a slight reduction in waiting list mortality and an increase in liver transplant rates compared with liver allocation for the year prior. Other reports examined regional differences in MELD score at transplant, the effect of changes in priority for candidates with hepatocellular carcinoma, the effectiveness of regional review boards for identifying higher-risk candidates, and variations in MELD score calculation due to international normalised ratio laboratory technique differences as well as patient survival. SummaryThe MELD/PELD-based liver allocation system is a much more objective system that can be quantified and studied for results. Future modifications will be made using this evidence-based approach.