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MELD exceptions and new predictive score of death on long waiting lists for liver transplantation
1Center of Gastroenterology and Hepatology, Fundeni Clinical Institute, Bucharest, Romania. speranta.iacob@icfundeni.ro
Background:
Cirrhosis related complications, considered MELD exceptions, proved to add prognostic value to the MELD score in predicting waiting list mortality.
Aim:
To identify the predictive value for death on a long waiting list (WL) for the complications of liver disease.
Methods:
During 2004-2007, 372 consecutive adult patients were listed for liver transplantation (LT). To identify the potential predictors of patient death, univariate and multivariate Cox's proportional hazards regression model was used.
Results:
In the univariate survival analysis the following variables were significant: spontaneous bacterial peritonitis, refractory ascites, hyponatremia, hepatic encephalopathy, hepatorenal syndrome, initial and current MELD score, initial and current Child-Pugh score. The independent predictors of death on our WL were: refractory ascites (p=0.002) and hepatorenal syndrome (p=0.002). Based on a logistic regression analysis a new score has been developed: Score = 1/(1+ exp(-(-4.38 + 1.34 x Refractory ascites + 0.9 x Hepatorenal syndrome + 0.15 x Current MELD). The c-statistic for the new score for prediction of death on the WL was 0.85 compared to 0.80 for current MELD score.
Conclusion:
Refractory ascites and hepatorenal syndrome should add valuable points to the current MELD in order to better prioritize for LT patients included on long WL.
Abbreviations:
Liver transplantation (LT), Model for End-Stage Liver Disease (MELD), waiting list (WL), United Network for Organ Sharing (UNOS), standard deviation (SD), receiver operating characteristic (ROC), hepatitis B virus (HBV), hepatocellular carcinoma (HCC), positive predictive value (PPV), negative predictive value (NPV), Child-Turcotte-Pugh (CTP), hepatic venous pressure gradient (HVPG).
Insights
Cirrhosis complications like refractory ascites and hepatorenal syndrome significantly predict liver transplant waiting list mortality. These factors, when combined with the Model for End-Stage Liver Disease (MELD) score, improve patient prioritization for liver transplantation.
Area of Science:
- Hepatology
- Transplantation Medicine
- Medical Statistics
Background:
- Liver cirrhosis frequently leads to serious complications impacting patient prognosis.
- The Model for End-Stage Liver Disease (MELD) score is standard for prioritizing liver transplant candidates.
- Cirrhosis-related complications may offer additional prognostic information beyond the MELD score.
Purpose of the Study:
- To determine the predictive accuracy of liver disease complications for mortality among patients on a long liver transplant waiting list.
- To evaluate if these complications improve upon the existing MELD score's predictive capabilities.
Main Methods:
- A cohort of 372 adult patients listed for liver transplantation (LT) between 2004 and 2007 was analyzed.
- Univariate and multivariate Cox's proportional hazards regression models were employed to identify predictors of death.
- A novel predictive score was developed using logistic regression, incorporating refractory ascites, hepatorenal syndrome, and the current MELD score.
Main Results:
- Significant univariate predictors of mortality included spontaneous bacterial peritonitis, refractory ascites, hyponatremia, hepatic encephalopathy, hepatorenal syndrome, and MELD/Child-Pugh scores.
- Refractory ascites and hepatorenal syndrome independently predicted death on the waiting list (p=0.002 for both).
- The newly developed score demonstrated a higher predictive accuracy (c-statistic=0.85) compared to the current MELD score (c-statistic=0.80).
Conclusions:
- Refractory ascites and hepatorenal syndrome are critical factors in predicting mortality for liver transplant candidates with long waiting times.
- Incorporating these complications into the MELD score can enhance the prioritization of patients awaiting liver transplantation.
- This refined approach may lead to more equitable and effective organ allocation.
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