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Utility of the MELD score for assessing 3-month survival in patients with liver cirrhosis: one more positive answer

2003; Elsevier BV; Volume: 125; Issue: 3 Linguagem: Inglês

10.1016/s0016-5085(03)01147-8

1528-0012

Edoardo G. Giannini, Federica Botta, Roberto Testa,

Hepatocellular Carcinoma Treatment and Prognosis

Dear Sir: We read with great interest the article by Wiesner et al.1Wiesner R. Edwards E. Freeman R. Harper A. Kim R. Kamath P. Kremers W. Lake J. Howard T. Merion R.M. Wolfe R.A. Krom R. United Network for Organ Sharing Liver Disease Severity Score CommitteeModel for end-stage liver disease (MELD) and allocation of donor livers.Gastroenterology. 2003; 124: 91-96Abstract Full Text Full Text PDF PubMed Scopus (1913) Google Scholar concerning the capability of the model for end-stage liver disease (MELD) to rank liver recipients according to the severity of liver disease correctly, and to assess their mortality risk during the wait for orthotopic liver transplantation (OLT). Indeed, their results further support the current use of the MELD score for categorizing patient priority on OLT waiting lists. In Europe, as well as in the United States there is a growing need for such a tool, since we share the same burden (i.e., increasing number of potential liver recipients), and have to face the same limits (i.e., a static number of available cadaveric donor livers). Although we must wait to see whether applying the MELD-based allocation system results in a reduction mortality of patients on waiting lists, there is growing evidence that the MELD score can be applied to patients with various medical, social, and ethnic backgrounds. In fact, it has previously been shown that the MELD score is useful, and better than the Child-Pugh score in predicting 3-month mortality after transjugular intrahepatic portosystemic shunts in American, as well as in European patients.2Malinchoc M. Kamath P.S. Gordon F.D. Peine C.J. Rank J. ter Borg P.C. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.Hepatology. 2000; 31: 864-871Crossref PubMed Scopus (2032) Google Scholar, 3Salerno F. Merli M. Cazzaniga M. Valeriano V. Rossi P. Lovaria A. Meregaglia D. Nicoloni A. Lubatti L. Riggio O. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt.J Hepatol. 2002; 36: 494-500Abstract Full Text Full Text PDF PubMed Scopus (210) Google Scholar Kamath et al. have also shown that the use of the MELD score is of clinical utility in predicting the mortality of patients with end-stage liver disease.4Kamath P.S. Wiesner R.H. Malinchoc M. Kremers W. Thernau T.M. Kosberg C.L. D’Amico G. Dickson E.R. Kim W.R. A model to predict survival in patients with end-stage liver disease.Hepatology. 2001; 33: 464-470Crossref PubMed Scopus (3622) Google Scholar Their series also included a European cohort of patients. In a European cohort of cirrhotic patients, we recently showed that the MELD score is useful for predicting 6-month and 1-year mortality, although no statistically significant differences in accuracy (c-statistic) were observed at this 2 time-points as compared with the Child-Pugh score. Finally, we showed that the MELD scores strictly correlate with residual liver function as evaluated by means of a liver blood flow-dependent parameter of liver function such as the monoethylglycinexylidide test (MEGX test).5Botta F. Giannini E. Romagnoli P. Fasoli A. Malfatti F. Chiarbonello B. Testa E. Risso D. Colla G. Testa R. MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function a European study.Gut. 2003; 52: 134-139Crossref PubMed Scopus (267) Google Scholar In cirrhotic patients, the MEGX test has previously shown to predict pretransplant survival and to be useful in assessing priority for OLT.6Oellerich M. Burdelski M. Lautz H.U. Binder L. Pichlmayr R. Predictors of one-year pretransplant survival in patients with cirrhosis.Hepatology. 1991; 14: 1029-1034Crossref PubMed Scopus (118) Google Scholar, 7Shiffman M.L. Fisher R.A. Sanyal A.J. Edinboro L.E. Luketic V.A. Purdum III, P.P. Raymond P. Posner M.P. Hepatic lidocaine metabolism and complications of cirrhosis Implications for assessing patient priority for hepatic transplantation.Transplantation. 1993; 55: 830-835Crossref PubMed Scopus (33) Google Scholar Although the derangement of the parameters contained in the MELD score (serum creatinine and bilirubin, prothrombin time INR) that can be observed in patients with liver disease has a sound pathophysiological basis, the score itself is nevertheless the result of a statistical analysis. In our opinion, the correlation we observed between the MELD score and the MEGX test results emphasizes the multifaceted significance of the MELD, and further adds to its clinical use. Therefore, we deemed it of interest to further assess the 3-month usefulness of the MELD score and to confirm its correlation with liver function in a European series of patients with liver cirrhosis. We evaluated the 3-month mortality predictive value of the MELD in a cohort of 145 cirrhotic patients. Furthermore, we also correlated the MELD scores of a subgroup of 46 patients with the results of a liver blood flow-independent parameter of liver function such as the 13C-aminopyrine breath test (13C-ABT). The 13C-ABT has proven to be useful in evaluating the prognosis of cirrhotic patients.8Merkel C. Bolognesi M. Bellon S. Bianco S. Honisch B. Lampe H. Angeli P. Gatta A. Aminopyrine breath test in the prognostic evaluation of patients with cirrhosis.Gut. 1992; 33: 836-842Crossref PubMed Scopus (82) Google Scholar During the 3-month follow-up, 13 patients died (9%). MELD score and its parameters, as well as Child-Pugh scores were significantly higher among patients who died as compared with patients who survived during the 3 months (Table 1). MELD scores showed a higher significant correlation with 13C-ABT dose/hour at 30 minutes (n = 46, r = −0.414, P = 0.004) as compared to Child-Pugh scores (r = −0.303, P = 0.04). Receiver operating characteristic (ROC) curves were used to find both the MELD and Child-Pugh scores with the best sensitivity and sensibility in assessing 3-month survival. A MELD score cut-off of 9 had 100% sensitivity (100–100, 95% confidence interval) and 81% specificity (73–87, 95% confidence interval), while a Child-Pugh score of 9 had 62% sensitivity (32–86, 95% confidence interval) and 77% specificity (69–84, 95% confidence interval) in assessing 3-month survival. Comparison of ROC curves showed a statistically significant difference between the c-statistic for MELD score (MELD score area under the ROC curve = 0.947, 0.897–0.977, 95% confidence interval) and the c-statistic for the Child-Pugh score (Child-Pugh score area under the ROC curve = 0.757, 0.679 to −0.825, 95% confidence interval, P = 0.01, Figure 1). Table 1MELD Parameters, MELD Scores, and Child-Pugh Scores of the Patients According to their 3-Month OutcomeUnitsSurvivalDeceased within 3 monthsPCreatininemg/dL1.0 ± 0.32.2 ± 1.60.0003Bilirubinmg/dL2.5 ± 3.35.4 ± 5.20.004INR1.5 ± 0.41.9 ± 0.70.002MELDscore6 ± 517 ± 60.0001Child-Pughscore8 ± 210 ± 20.002NOTE. Data are shown as mean ± standard deviation. Statistical analysis was carried out by means of Mann-Whitney U-test. Open table in a new tab NOTE. Data are shown as mean ± standard deviation. Statistical analysis was carried out by means of Mann-Whitney U-test. Thus, our results further underscore the importance of the MELD score in evaluating 3-month survival prognosis of cirrhotic patients, and confirm its superiority as compared to Child-Pugh score at this time point. Our findings also confirm that the MELD score correlates with residual liver function, further supporting the evidence of a relationship between this important prognostic tool and the progressive decrease in the hepatocellular functioning mass. Lastly, this correlation is noteworthy since it is even better than the correlation observed between liver function and Child-Pugh score. We hope that these findings will provide at least one more positive answer to the numerous and important questions regarding the assessment of disease severity in cirrhotic patients and OLT waiting list priority. ReplyGastroenterologyVol. 125Issue 3Preview Full-Text PDF