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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”


Can the Model for End-Stage Liver Disease (MELD) Predict Post-Transplantation

http://organtx.org/tx/ctp-meld.htm

Outcomes? Dallas, TX -- Nov. 5, 2001/Xpress Press/ - The Model for End-Stage Liver Disease (MELD) has already proven to be highly successful in assessing 3-month mortality in patients with end-stage liver disease. Acknowledging that an ideal organ allocation policy may consider both post-transplant outcome and pre-transplant risk, developers of the MELD examined their model in determining post-transplant outcome.

Can indicators of liver disease severity before liver transplantation (OLT) predict the outcome following OLT? Can pretransplant data predict post-OLT outcomes? The researchers compared three indices of liver disease severity as predictors of posttransplant outcome: MELD, the Child-Turcotte-Pugh score, and Mayo OLT Outcome (MOLTO) model. In two centers, 1,585 patients undergoing primary OLT were studied. Survival of patient and graft three months post-OLT was the primary outcome parameter; operative blood loss of less than 2.1 liters, ICU stay of less than 3 days, and hospital stay of less than 14 days were secondary outcome parameters.

The researchers determined that there was a statistically significant association between posttransplant outcome and pretransplant disease severity, as measured by the three indices. However, the accuracy of prediction of posttransplant outcome based on pretransplant disease severity was limited in individual patients, regardless of the disease severity index used. The researchers concluded that developing a model that accurately predicts liver transplant outcome in an individual patient will be difficult due to the random occurrence of events unrelated to pretransplant severity of disease.

Dr. W. Ray Kim points out that "although the study demonstrates that it is difficult to predict post-OLT outcome on an individual level, policy recommendations may be made on an aggregate level, as to the level of disease severity to optimize OLT outcome."

Dr. Kim points to the high degree of selection among OLT recipients: "As some patients who were extremely ill and unlikely to survive the transplantation procedure had been excluded from transplantation and therefore not captured in the data, those who had OLT with high MELD prior to OLT had some favorable factors working for them." The significant selection process in the data worked against the model's predictive ability. If the same study is done a few years after MELD is adopted as the only method of selecting liver recipients, effectively eliminating subjectivity in patient selection, Dr. Kim believes "the results would show better prediction because the data would include individuals with a full range of MELD scores."

In patients with a high level of disease severity, resource-intensive efforts, such as ventilatory support and hemodialysis, are commonly needed for care after liver transplantation. It is the hope that with the implementation of the MELD system for organ allocation for liver transplantation, those patients with high MELD scores could be transplanted early, eliminating extensive waiting times, increasing post-OLT outcome success, and reducing cost. "In addition," according to Dr. Kim, "the availability of living donor transplantation provides additional options to improve the liver transplant outcome."

LIVER (III): The MELD Model. Disease Severity Scoring in the Cirrhotic Patient 
www.fonendo.com 10/03/2001 
Introduction 
The Child and Turcotte classification system, published in 1964, has become the predominant method to assess prognosis in cirrhotic patients. They stratified patients undergoing shunt surgery to relieve portal hypertension according to their risk, selecting empirically five parameters (serum albumin, serum bilirubin, ascites, encephalopathy, and nutritional status) to which they attributed one of three risk levels, and converted the composite into one of three classes. The problem was that three of the elements (ascites, nutrition, and encephalopathy) were very subjective. In 1972, Pugh modified the Child-Turcotte classification to obtain an instrument to predict outcome after portosystemic surgery. Pugh substituted prothrombin time in place of nutritional status, thereby obviating the most subjective element. 

The focus on Child-Turcotte-Pugh scores in clinical practice has shifted in the
United States with the changing demographics of orthotopic liver transplantation. In recent years we have started to trying to count and sum the score more accurately. The philosophy underlying allocation of scarce donor livers is that candidates with more urgent disease should take priority over those with less urgent indications. This policy mandates that we have a system that grades the urgency of patients on the waiting list. 

The CTP classification is the model most widely used to determine prognosis in patients with liver disease. Although the original purpose of this system was to assess the operative risk in patients undergoing surgical portosystemic shunt, the classification has been used to stratify patients on the waiting list for liver transplantation. The CTP classification is based on serum albumin, serum bilirubin, prothrombin time, ascites, and encephalopathy. Although the classification system has not been formally evaluated for its statistical accuracy, it has been shown to be useful in the assessment of prognosis in patients with cirrhosis. However, when used as a disease severity index to determine priority in organ allocation, the CTP system has a number of limitations. These are further explained. 

(1) limited discriminatory ability. Even when the CTP score, as opposed to CTP class, is used, there are only 8 levels of difference between the least sick transplant candidates (CTP score = 7) and the most advanced (CTP score = 15). This creates many ties (i.e., transplant candidates with the same score) and necessitates an emphasis on waiting time as a tie breaker. In addition, it is not able to evaluate patients with markedly abnormal laboratory parameters (so-called ceiling effect). 

(2) subjective interpretation of parameters. The CTP score has parameters that require subjective assessment, namely ascites and encephalopathy. When originally described, determination of ascites was based on physical examination. Currently, however, ultrasound examination is frequently used to detect the presence of ascites. Detection of encephalopathy is dependent on the examiner, and there is no accepted definition of refractory encephalopathy. Thus, the scores given for the degree of ascites and encephalopathy are difficult to standardize. 

(3) variability in the measurement of the laboratory parameters. Even the more objective elements in the CTP system, namely albumin and prothrombin time, may vary from one laboratory to another. 

The UNOS allocation scheme defines broad categories of urgency, often called UNOS statuses. The UNOS rules determined that accumulated waiting time would break the tie between competing candidates within the same UNOS status. Consequently, this scheme encouraged placing patients on the waiting list early, so that they could gather valuable waiting time. 

In 1999, in response to a directives of the Department of Health and Human Services and a report of the IOM (Institute of Medicine), UNOS (United Network for Online Sharing) proposed to change the rules that govern the allocation of donor organs to patients with chronic liver disease. The new rules propose to replace the Child-Turcotte-Pugh classification as the basis for determining urgency for liver transplantation with the Mayo End-stage Liver Disease (MELD) score. 

What is MELD 

Like the Child classification, the MELD score was designed to predict the outcome of decompressive therapy for portal hypertension. The difference is that MELD was derived from prospectively gathered data rather than empirically constructed data. Calculation of the MELD score is based on serum bilirubin, prothrombin time calculated as International Normalized Ratio, and serum creatinine. The MELD score has advantages when compared with the Child-Pugh score. First, it uses objective parameters second, its objective parameters are less subject to center-to-center variability than is the Child classification and third, the MELD score increases as the three constituent parameters deteriorate, whereas the individual scoring elements in the Child score remain fixed once a defined threshold has been reached. 

The MELD score is a slight modification of the risk score used in the original TIPS model. For ease of use, the score was multiplied by 10 and then rounded to the nearest integer. Thus, the formula for the MELD score is 3.8loge(bilirubin [mg/dL]) + 11.2loge(INR) + 9.6loge(creatinine [mg/dL]) + 6.4(etiology: 0 if cholestatic or alcoholic, 1 otherwise). 

It can be calculated the 3-month mortality range. For further information, please, visit: http://www.mayo.edu/int-med/gi/model/mayomodl-5.htm 




Kamath recently studied four independent pretransplantation populations: (1) patients hospitalized for decompensated liver disease, (2) ambulatory patients with noncholestatic cirrhosis, (3) patients with primary biliary cirrhosis, and (4) unselected patients from the 1980s with cirrhosis. They found that the MELD score was useful in grading the risk of death at three time intervals relevant to the decision to undertake liver transplantation (1 week, 3 months, and 1 year). 

He concluded that 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. 

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: lower than .01 for spontaneous bacterial peritonitis and variceal hemorrhage to ascites: 0.01-0.03). 

Furthermore, the addition of clinical phenomena often associated with decompensation and worse outcome, such as ascites, encephalopathy, variceal bleeding, or spontaneous bacterial peritonitis, did not substantially improve the degree of fit between the MELD score and the actual outcome. 

Finally, the inclusion of a broad diagnostic category (cholestatic or alcoholic vs. the rest), which was in the original score, was found to be unnecessary. The latter point was a potential area of contention whenever MELD was to be applied to populations awaiting liver transplantation. Of interest, the authors found also that the Child-Turcotte-Pugh score is a discriminating prognostic model for predicting 3-month survival (c-statistic .84). 

Kamath also proved that the addition of spontaneous bacterial peritonitis, encephalopathy, variceal bleeding, or ascites to the MELD scale did not improve the accuracy of the model. This indicates that patients with severe liver disease are the ones likely to get complications of liver disease and, thus, the complications are not independent predictors of survival. 

Limitations to the MELD scale 

Most of the data available to the authors were mostly based on patients with advanced liver disease. (Overall, the 3-month mortality among the data sets used in the first report range between 2% and 21%). Thus, it is mandatory to warrant further validation of the MELD scale in patients with early stage cirrhosis. 

Further investigation on the optimal measurement of renal function in this context may be needed, to support that the influence of the age, sex, and body mass on the MELD score is unlikely to be clinically significant. 

Conclusion 

According to Forman, there are 4 expectable consequences of adopting the MELD score, in place of the Child-Turcotte-Pugh criteria, on donor liver allocation in the United States. 

1. Waiting time as a tie-breaker will probably be gone. In the new system, the patient's priority will rise with derangement of serum bilirubin, serum creatinine, and International Normalized Ratio. One problem could exist whether the overseeing office is being bombarded with frequent reiterations of laboratory results on the same patients. 

2. It probably will give an advantage to those patients with intrinsic kidney failure. 

3. It will mean a shift in the population undergoing liver transplantation towards patients with less favorable prognosis. While this is the intended goal, there may be a negative impact on posttransplantation outcomes, given that patient and graft survival are linked to the degree of illness of the recipient at the time of transplantation. 

Finally, It is still required a method for accommodating the special cases who are not well served by any general prognostic scoring system. These patients include persons with cancer, with metabolic disorders such as hyperoxaluria or with symptoms, such as intractable pruritus, that are compelling indications for transplantation. 

MELD is a reliable measure of short-term mortality risk in patients with end-stage liver disease of diverse etiology and severity, as well as a comprehensive indicator of physiologic reserve of patients with decompensated cirrhosis. In addition, many of its characteristics such as the use of easily available, objective parameters as well as its advantage over the CTP score such as continuous, interval scale, lack of ceiling or floor effect, and stability of laboratory measures make it a good candidate for its utilization in the allocation decisions for liver transplantation. 

BIBLIOGRAPHY 

Forman LM, Lucey MR. Predicting the prognosis of chronic liver disease: An evolution from child to MELD. Hepatology. 2001 Feb33(2):473-475. No abstract available. 

Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D'amico G, Dickson ER, Kim WR. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001 Feb33(2):464-470. 

Langer B, Taylor BR, Mackenzie DR, Gilas T, Stone RM, Blendis L. Further report of a prospective randomized trial comparing distal splenorenal shunt with end-to-side portacaval shunt. An analysis of encephalopathy, survival, and quality of life. Gastroenterology 198588:424-429 
-------------------------------------------------
AASLD: MELD not Superior to Child-Pugh for Predicting Outcome of Acute Variceal Bleeding

By Lauri Gray Eaton
Special to DG News 
DALLAS, TX -- November 14, 2001 -- Two different systems for predicting liver disease mortality are virtually identical in determining both outcome in hospitalized patients and long-term mortality after an episode of acute variceal bleeding. 

In a study of 239 patients followed for a median of 348 days (a total span of 0-1255 days), a multi-center team compared the two predictive systems. 

Their findings were presented at the annual meeting of the American Association for the Study of Liver Diseases (AASLD), held Nov. 9-13, in Dallas, Texas. 

The Child-Pugh score has long been used in predicting mortality in acute variceal bleeding, and the Mayo End-stage Liver Disease (MELD) score is a more recent tool found valuable in predicting mortality in both end-stage liver disease and for those undergoing elective transjugular intrahepatic portosystemic shunt (TIPS) surgery. 

Until now, the two have not been compared head-to-head in predicting mortality from acute variceal bleeding, said the study’s lead author, Naga Chalasani, MD, of the Indiana University School of Medicine in Indianapolis. 

MELD prioritizes patients based on three factors: the international normalized ratio (INR), a measure of the blood’s ability to clot (also termed prothrombin time); the bilirubin level in the blood, a measure of liver function; the creatinine level in the blood, a measure of kidney function. 

The Child-Pugh scale also uses these measures, but includes two additional criteria considered subjective -- the presence of encephalopathy and the presence of ascites, or fluid in the abdomen. 

MELD was originally designed to predict mortality after the TIPS procedure, done to control bleeding within the liver. Since then, the model has been validated and refined against at least six databases of patients with varying degrees of liver failure. In every case, the MELD score has had a high degree of predicting who had a high risk of dying without a transplant. 

"The MELD score is an excellent predictor of both in-hospital and long-term mortality following an episode of acute variceal bleeding," Dr. Chalasani said. "However, it’s predictability is not superior to Child-Pugh score."

Thanks to cfiske@mediaone.net: New System for Donated Livers Tested 6-29-01 By LAURA MECKLER .c The Associated Press WASHINGTON (AP) - Early testing of a new system for distributing donated livers indicates it would save lives, and the nation's transplant network recommended Friday that it be implemented nationwide. Under the new system, waiting liver patients would be ranked using sophisticated medical criteria rather than by how long they've been on the waiting list. The transplant network is trying to ensure that the sickest patients get to the top of the list.

The system got tentative approval last year from the United Network for Organ Sharing, which then tested it over several months to see if the models it relied on were accurate. They were, and the board recommended that the system be implemented, possibly by the end of the year. The nation faces an acute shortage of livers, with nearly 18,000 people now waiting. About 5,000 liver transplants were performed last year, but 1,636 people died waiting for a new one. The network said technical issues still need to be resolved, including rankings for children.

The network, meeting in San Diego, also approved a resolution condemning organ brokers, who help arrange for the buying and selling of organs in other countries. This typically involves a living donor, who may sell a kidney or a piece of liver. ``We cannot investigate or govern the transplant activities of other nations. We must, however, strongly reiterate the ethical principles of the U.S. transplant system,'' the network's president, Dr. Patricia Adams, said Friday in a statement.

Under the current system for distributing livers, patients are grouped into four broad categories. Within each group, those waiting the longest get first chance at the livers. But many transplant experts believe waiting time is a poor way to measure how sick a patient is. The new policy would still give first chance to Status 1 patients - those who become suddenly ill and are expected to die within a week. But everyone else would get a number, from 1 to 40, with the highest numbers for the sickest patients. Patient scores would be determined by a combination of three medical factors: the body's ability to form a blood clot; the ability to break down hemoglobin; and kidney function, which can be affected by a failing liver. The system, developed by the Mayo Clinic, is known as MELD, for Mayo End-Stage Liver Disease. Ties in patient scores will be broken by waiting time.
United Network for Organ Sharing: http://www.unos.org

To MELD or not to MELD? 
Hepatology July 2001 • Volume 34 • Number 1 To the Editor
We read with interest the article by Kamath et al. and the accompanying editorial by Forman and Lucey concerning a new prognostic score for cirrhosis.1,2 The investigators are to be congratulated for endeavoring to create more objective measures of prognosis than those in current use, which are susceptible to “manipulation” by concerned clinicians. However, we have a problem with the data as presented in Table 3. This gives the 3-month death rates for 4 groups of patients with varying MELD scores. They are (1) hospitalized patients, (2) ambulatory noncholestatic patients, (3) ambulatory primary biliary cirrhosis patients, and (4) historical controls. If the MELD score were the sole predictor of death, then survival should be the same for patients within each MELD group. However, this clearly is not the case. In each of the MELD categories (9, 10-19, 20-29), hospitalized patients appear to have an increased mortality compared with the 2 ambulatory groups, although statistical analysis of this was not done. We have performed an analysis of hospitalized versus ambulatory noncholestatic patients and found a statistically significant difference in survival for a MELD score 10-19 (P < .0001). The difference for patients with a score 9 is not significant, whereas that for a score 20-29 is P = .06. It would be important to do a similar analysis for 12-month survival. Kamath et al. state that in-hospital survival was not affected by factors such as spontaneous bacterial peritonitis, variceal hemorrhage, ascites, and encephalopathy. Thus, there seem to be factors not measured by the investigators that may be influencing mortality in already hospitalized patients, an issue that could be important if the MELD score becomes the sole arbiter of priority listing for liver transplantation.



Copyright © 2001 by the American Association for the Study of Liver Diseases.
doi:10.1053/jhep.2001.26164
Geoffrey W. McCaughan, M.B.B.S., F.R.A.C.P., Ph.D.
Simone I. Strasser, M.B.B.S., F.R.A.C.P., M.D.
A.W. Morrow Gastroenterology and Liver Centre
Royal Prince Alfred Hospital
Camperdown, Australia
References
1. Kamath PS, Wiesner RH, Malichoc M, Kremer W, Therneau TM, Kosberg CL, D'Amico G, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001;33:464-470.
2. Forman LM, Lucey MR. Predicting the prognosis of chronic liver disease: an evolution from Child to MELD. Hepatology 2001;33:473-475.

Thanks to LarryEMorgan@netscape.net : New liver-donation system backed - Nation’s transplant network endorses plan ASSOCIATED PRESS June 29 01 — Early testing of a new system for distributing donated livers indicates it would save lives, and the nation’s transplant network recommended Friday that it be implemented nationwide. 

UNDER THE NEW system, waiting liver patients would be ranked using sophisticated medical criteria rather than by how long they’ve been on the waiting list. The transplant network is trying to ensure that the sickest patients get to the top of the list. The system got tentative approval last year from the United Network for Organ Sharing, which then tested it over several months to see if the models it relied on were accurate. They were, and the board recommended that the system be implemented, possibly by the end of the year. 

The nation faces an acute shortage of livers, with nearly 18,000 people now waiting. About 5,000 liver transplants were performed last year, but 1,636 people died waiting for a new one. The network said technical issues still need to be resolved, including rankings for children. The network, meeting in San Diego, also approved a resolution condemning organ brokers, who help arrange for the buying and selling of organs in other countries. This typically involves a living donor, who may sell a kidney or a piece of liver. “We cannot investigate or govern the transplant activities of other nations. We must, however, strongly reiterate the ethical principles of the U.S. transplant system,” the network’s president, Dr. Patricia Adams, said Friday in a statement. Under the current system for distributing livers, patients are grouped into four broad categories. Within each group, those waiting the longest get first chance at the livers. But many transplant experts believe waiting time is a poor way to measure how sick a patient is. 

The new policy would still give first chance to Status 1 patients — those who become suddenly ill and are expected to die within a week. But everyone else would get a number, from 1 to 40, with the highest numbers for the sickest patients. Patient scores would be determined by a combination of three medical factors: the body’s ability to form a blood clot; the ability to break down hemoglobin; and kidney function, which can be affected by a failing liver. The system, developed by the Mayo Clinic, is known as MELD, for Mayo End-Stage Liver Disease. Ties in patient scores will be broken by waiting time.

Changes Ahead for Liver-Transplant Priority List - But Not Everyone Is On Board With Proposed New System 5-30-01 By Daniel DeNoon, WebMD Medical News   (Atlanta) -- If you are one of the nearly 18,000 Americans waiting for a liver transplant, you already know one hard, cold fact: there aren't enough livers to go around. Last year only 5,000 patients got liver transplants, so your life depends on getting to the top of the list. Now the rules may be changing. 

The lists that determine who gets donated organs is kept by a fiercely independent nonprofit organization called the United Network for Organ Sharing or UNOS. Since the 1950s, UNOS has used the same basic system for getting livers to patients who need them most: the Child-Turcotte-Pugh (CTP) scoring system. 

Now it looks like they are getting ready for something new. It's called the Model for End Stage Liver Disease or MELD. The old CTP system depended on a doctor's opinion of how bad some of a patient's symptoms had become. The MELD system doesn't ask anybody's opinion -- it is based on laboratory tests and a patient's precise diagnosis. 

Most studies -- but not all of them -- show that MELD works at least as well as the old system in predicting which waiting-list patients will die if they don't get the next available liver. "Because the MELD system is felt to do a better job of stratifying patients, it gives them some assurance that if they are sick and need a new liver they are more likely to be placed at the top of the list," C. Wright Pinson, MD, MBA, tells WebMD. "The MELD system seems to do a better job of identifying the patient who is at highest risk of early death. It gives patients a better chance of appearing at the top of the list when they need to." "We wanted a way of allocating organs to patients with roughly equal severity of illness and likelihood of transplant success," says Todd K. Howard, MD, chair of the UNOS liver allocation committee. "MELD is the first step in predicting who is the sickest patient." 

Pinson, chief of liver transplantation and chief of staff at Vanderbilt University Hospital in Nashville, recently co-chaired a lively roundtable debate on the proposed new MELD standard here at the Digestive Disease Week conference. During the conference, a group of researchers from Saint Louis University presented a study suggesting that the MELD system fails to appreciate the severity of illness in patients with several life-threatening conditions due to acute liver disease. "Patients who are [in this category] require continuous intensive care and are at high risk of acquiring hospital infections that would disqualify them from getting a transplant," said Alex S. Befeler, MD, a liver expert at Saint Louis University, during the heated debate set off by this presentation. 

Calming the waters was the elder statesman of liver allocation, Jeremiah G. Turcotte, MD. Turcotte helped develop the CTP system that bears his name. He is the newly elected president of UNOS and is emeritus professor at the University of Michigan. "There will never be a perfect scoring system -- any system will need periodic reassessment and refinement," Turcotte says. "MELD is very promising, and its validation is an essential step. As physicians and investigators, most of us are disposed to analyze statistical tools based on scientific methods. 

But organ allocation is a public-policy effort. Liver-disease-severity scoring is a moving target: the waiting list is growing, the average severity of illness among patients on the list is increasing, and indications for transplant are expanding. The 
discrepancy between organs available and people on the waiting list is dramatic." 
Whether MELD can help resolve these growing problems remains to be seen. Pinson says that UNOS now is testing the MELD system against the extensive patient histories in its database. If this study shows that MELD works at least as well as CTP, there likely will be changes in the rules of the waiting game. 

Merits Of MELD System For Liver Organ Allocation Debated 5-24-01 WESTPORT (Reuters Health) - The way in which donor livers are allocated in the US may soon change. The United Network for Organ Sharing (UNOS) is currently testing a new liver organ allocation system, the Model for End-Stage Liver Disease, or MELD. 

Study findings presented at the Digestive Disease Week annual meeting in Atlanta suggest that the MELD system for liver organ allocation is "at least as accurate or more accurate than the decades-old Child Turcotte Pugh (CTP) scale," Dr. C. Wright Pinson, of Vanderbilt University in Nashville, Tennessee, told reporters. 

Dr. Pinson moderated a special session entitled "To MELD or not to MELD?" in which participants debated the two systems. 

"The CTP system may have been satisfactory in the past, but with more and more people waiting for organs, a finer gradation or more continuous stratification system was felt to be advantageous," Dr. Pinson said. 

There are three main limitations of the CTP scale, according to the researcher. It includes only a limited number of categories, it does not include a measure of renal function, and it includes two criteria considered to be subjective: the presence of encephalopathy and the presence and intractability of ascites. 

The MELD system takes away the subjective measures included in CTP, prioritizing patients based solely on three objective measures: the international normalized ratio, bilirubin level, and creatinine level. 

"MELD has been validated and refined in at least six databases of patients with varying degrees of liver failure," Dr. Richard B. Freeman, of Tufts University in Boston, said in a statement released by meeting organizers. "In every case, the MELD score had a high degree of predicting who had a high risk of dying without a transplant." Dr. Freeman headed the UNOS committee that recommended the MELD system. 

UNOS is currently using both the MELD and CTP systems to evaluate everyone on its waiting list, and a comparison of the outcomes should be available in the next 6 to 8 months. 

A model to predict survival in patients with end-stage liver disease
Hepatology February 2001 • Volume 33 • Number 2 - Special Article
Patrick S. Kamath1
Russell H. Wiesner1
Michael Malinchoc2
Walter Kremers2
Terry M. Therneau2
Catherine L. Kosberg1
Gennaro D'Amico3
E. Rolland Dickson1
W. Ray Kim1,2
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. (HEPATOLOGY 2001;33:464-470.)

Abbreviations
IOM Institute of Medicine
CTP Child-Turcotte-Pugh
MELD Model for End-Stage Liver Disease
TIPS transjugular intrahepatic portosystemic shunt
PBC primary biliary cirrhosis
INR International Normalized Ratio
CI confidence interval
SBP spontaneous bacterial peritonitis
ISI International Sensitivity Index

Publishing and Reprint Information
From the 1Division of Gastroenterology and Hepatology, and the 2Department of Health Science Research, Mayo Clinic and Foundation, Rochester, MN; and the
3Divisione di Medicina, Ospedale V Cervello, Palermo, Italy.
Received November 13, 2000.
Accepted December 10, 2000.
Supported by a grant from the National Institutes of Health (DK-34238).
The data presented in this manuscript have been presented and discussed at the OPTN/UNOS Liver and Intestinal Organ Transplantation Committee.
Address reprint requests to: W. Ray Kim, M.D., M.B.A., Gastroenterology and Hepatology (Ch10), Mayo Clinic and Foundation, 200 First Street, SW, Rochester, MN 55905. E-mail: kim.woong@mayo.edu ; fax: 507-266-2810.
Copyright © 2001 by the American Association for the Study of Liver Diseases.
0270-9139/01/3302-0021$35.00/0
doi:10.1053/jhep.2001.22172 

Hepatology February 2001 • Volume 33 • Number 2 - Editorials
Predicting the prognosis of chronic liver disease: An evolution from child to MELD
Lisa M. Forman, M.D.
Michael R. Lucey, M.D.

Abbreviations
MEGX monoethylglycinezylidide
IOM Institute of Medicine
MELD Mayo End-Stage Liver Disease

Publishing and Reprint Information
From the Division of Gastroenterology, Department of Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA.
Received December 19, 2000.
Accepted December 20, 2000.
Address reprint requests to: Michael R. Lucey, M.D., F.R.C.P.I., Division of Gastroenterology, 3 Ravdin Building, Hospital of the University of Pennsylvania, 34th and Spruce Street, Philadelphia, PA 19104. E-mail: lucey@mail.med.upenn.edu ; fax: 215-349-5915.
Copyright © 2001 by the American Association for the Study of Liver Diseases.

 

 

 

 

 

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