Validation of the five-variable Model for End-stage Liver Disease (5vMELD) for prediction of mortality on the liver transplant waiting list
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Published on: September 22, 2023
Robert P Myers1, Puneeta Tandon, Michael Ney
1Liver Unit, Division of Gastroenterology and Hepatology, Department of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
Background:
Modifications to the Model for End-Stage Liver Disease (MELD) have been proposed to improve prioritization of liver transplant (LT) candidates. Using a U.S. database, we derived a revised MELD including sodium and albumin [5-variable MELD (5vMELD)] that improved prediction of waiting list mortality. Our objectives were to confirm the association between hypoalbuminaemia and mortality and to externally validate 5vMELD in Canadian LT candidates.
Methods:
Among adults registered on the LT waiting list at the University of Alberta (01/2000-10/2009), Cox regression determined the association between albumin and 1-year waiting list mortality. The discrimination of MELD, MELDNa and 5vMELD for predicting 1-year mortality were compared using c-statistics.
Results:
Among 677 patients, 17% died and 51% underwent LT within 1 year of listing. Median serum albumin was 3.1 g/dl (IQR 2.6-3.6) and 70% of patients were hypoalbuminaemic (albumin <3.5 g/dl). One-year mortality in patients with normal serum albumin and hypoalbuminaemia were 14% and 29% respectively (P = 0.004). For patients with serum albumin between 2.0 and 4.0 g/dl, an approximately linear, inverse relationship was observed between albumin and 1-year mortality [adjusted hazard ratio (HR) 1.45; 95% CI 1.03-2.03; P = 0.03]. For this outcome, the c-statistic of 5vMELD (0.778) was superior to those of MELD (0.754) and MELDNa (0.765) (both P ≤ 0.05).
Conclusions:
Hypoalbuminaemia is an independent predictor of mortality on the LT waiting list. Compared with MELD and MELDNa, 5vMELD improves prediction of mortality suggesting that modification of these scores to include serum albumin should be considered as a means of prioritizing LT candidates.
Insights
Hypoalbuminemia independently predicts mortality for liver transplant candidates. The 5-variable MELD (5vMELD) score, including albumin, better predicts mortality than standard MELD scores.
Area of Science:
- Hepatology
- Transplant Surgery
- Clinical Biochemistry
Background:
- The Model for End-Stage Liver Disease (MELD) score is used for liver transplant (LT) candidate prioritization.
- Modifications to MELD, such as the 5-variable MELD (5vMELD) incorporating sodium and albumin, aim to improve mortality prediction.
- External validation of 5vMELD in Canadian LT candidates is needed.
Purpose of the Study:
- Confirm the association between hypoalbuminemia and mortality in LT candidates.
- Externally validate the predictive performance of 5vMELD compared to MELD and MELDNa in a Canadian cohort.
Main Methods:
- Cox regression analysis was used to assess the relationship between serum albumin and 1-year waiting list mortality.
- The predictive discrimination of MELD, MELDNa, and 5vMELD for 1-year mortality was compared using c-statistics.
- Data from adult LT candidates at the University of Alberta between 2000 and 2009 were analyzed.
Main Results:
- Hypoalbuminemia (serum albumin <3.5 g/dL) was present in 70% of patients and was associated with significantly higher 1-year mortality (29% vs. 14%).
- An inverse relationship was observed between serum albumin levels (2.0-4.0 g/dL) and 1-year mortality (adjusted HR 1.45).
- The 5vMELD score demonstrated superior predictive ability (c-statistic 0.778) compared to MELD (0.754) and MELDNa (0.765).
Conclusions:
- Hypoalbuminemia is an independent predictor of mortality among patients awaiting liver transplantation.
- The 5vMELD score offers improved prediction of mortality compared to MELD and MELDNa.
- Incorporating serum albumin into MELD scoring should be considered for better prioritization of LT candidates.
