MELD is MELD is MELD? Transplant center–level variation in waitlist mortality for candidates with the same biological MELD

Ishaque, Tanveen; Kernodle, Amber; Motter, Jennifer D.; Jackson, Kyle R.; Chiang, Teresa Po‐Yu; Getsin, Samantha; Boyarsky, Brian J.; Gentry, Sommer E.; Segev, Dorry L.; Massie, Allan B.

doi:10.1111/ajt.16603

Cited by 2 publications

(4 citation statements)

References 34 publications

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“…Data from a single LT center also remove center-level variation in practices and waitlist mortality, which has been shown to influence outcomes in candidates with the same biological MELD. 34 Furthermore, we used thorough statistical methods to comparatively assess both the discrimination and calibration of models in the overall cohort and in specific subgroups. Additionally, we identified model cutoffs to stratify those at higher risk of death.…”

Section: Discussionmentioning

confidence: 99%

MELD-GRAIL and MELD-GRAIL-Na Are Not Superior to MELD or MELD-Na in Predicting Liver Transplant Waiting List Mortality at a Single-center Level

Chetwood

Wells

Tsoutsman

et al. 2022

Transplantation Direct

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Background. Controversy exists regarding the best predictive model of liver transplant waiting list (WL) mortality. Models for end-stage liver disease–glomerular filtration rate assessment in liver disease (MELD-GRAIL) and MELD-GRAIL-Na were recently described to provide better prognostication, particularly in females. We evaluated the performance of these scores compared to MELD and MELD-Na. Methods. Consecutive patients with cirrhosis waitlisted for liver transplant from 1998 to 2017 were examined in this single-center study. The primary outcome was 90-d WL mortality. MELD, MELD-Na, MELD-GRAIL, and MELD-GRAIL-Na at the time of WL registration were compared. Model discrimination was assessed with area under the receiver operating characteristic curves and Harrell’s C-index after fitting Cox models. Model calibration was examined with Grønnesby and Borgan’s modification of the Hosmer-Lemeshow formula and by comparing predicted/observed outcomes across model strata. Results. The study population comprised 1108 patients with a median age of 53.5 (interquartile range 48–59) y and male predominance (74.9%). All models had excellent areas under the receiver operating characteristic curves for the primary outcome (MELD 0.89, MELD-Na 0.91, MELD-GRAIL 0.89, MELD-GRAIL-Na 0.89; all comparisons P > 0.05). Youden index cutoffs for 90-d mortality were as follows: MELD, 19; MELD-Na, 22; MELD-GRAIL, 18; and MELD-GRAIL-Na, 17. Variables associated with 90-d mortality on multivariable Cox regression were sodium, bilirubin, creatinine, and international normalized ratio. There were no differences in model discrimination using Harrell’s C-index. All models were well calibrated; however, divergence between observed and predicted mortality was noted with scores ≥25. Conclusion. There were no demonstrable differences in discrimination or calibration of GRAIL-based models compared with MELD or MELD-Na in our cohort. This suggests that GRAIL-based models may not have meaningful improvements in discriminatory ability when applied to other settings.

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Section: Discussionmentioning

confidence: 99%

MELD-GRAIL and MELD-GRAIL-Na Are Not Superior to MELD or MELD-Na in Predicting Liver Transplant Waiting List Mortality at a Single-center Level

Chetwood

Wells

Tsoutsman

et al. 2022

Transplantation Direct

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“…In each centre, management of critically ill cirrhosis patients followed general and disease‐specific international guidelines 18,19 . In all jurisdictions, patients were listed and prioritised for LT primarily based on MELD score 20 …”

Section: Methodsmentioning

confidence: 99%

“…18,19 In all jurisdictions, patients were listed and prioritised for LT primarily based on MELD score. 20 Primary exposures were serum ammonia levels on ICU Days 1-2 or 3. Primary endpoint was all-cause hospital mortality.…”

Section: Definitions Exposures and Outcomesmentioning

confidence: 99%

“…On the same day, median (IQR) serum INR, bilirubin and ammonia (arterial) were 1.9 (1.5-2.5), 5.2 (2.2-14.1) mg/dL and 96 (62-137) μmol/L, respectively. On ICU Day 1, median (IQR) CLIF-SOFA, CLIF-C-ACLF and MELD scores were 13 (10)(11)(12)(13)(14)(15), 57 (50-64) and 26 (18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29)(30)(31)(32)(33), respectively. On ICU Day 3, median (IQR) CLIF-SOFA, CLIF-C-ACLF and MELD scores were 12 (9)(10)(11)(12)(13)(14)(15)(16), 55 (48-63) and 25 (17)(18)(19), respectively.…”

Section: Baseline Characteristics and Outcomes (Derivation Cohort)mentioning

confidence: 99%

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Early serum ammonia variation in critically ill patients with cirrhosis: A multicentre cohort study

Cardoso

Kim

Pereira

et al. 2023

Aliment Pharmacol Ther

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SummaryBackgroundSerum ammonia variation in critically ill patients with cirrhosis has been poorly studied.AimTo describe and assess the impact of serum ammonia variation in these patients' outcomes.MethodsWe studied patients ≥18 years old admitted to the intensive care units (ICUs) at University of Alberta Hospital (Edmonton, Canada) and Curry Cabral Hospital (Lisbon, Portugal; derivation cohort, n = 492) and Northwestern University Hospital (Chicago, USA; validation cohort, n = 600) between January 2010 and December 2021. Primary exposure was ICU days 1–3 serum ammonia. Primary endpoint was all‐cause hospital mortality.ResultsIn the derivation cohort, 330 (67.1%) patients were male and median (IQR) age was 57 (50–63) years. On ICU day 1, median ammonia was higher in patients with grade 3/4 hepatic encephalopathy (HE) than those with grade 2 HE or grade 0/1 HE (112 vs. 88 vs. 77 μmoL/L, respectively; p < 0.001). Furthermore, medium ammonia was higher in hospital non‐survivors than survivors (99 vs. 86 μmol/L; p < 0.030). Following adjustment for significant confounders (age, HE, vasopressor use and renal replacement therapy delivery), higher ICU day 2 ammonia was independently associated with higher hospital mortality (adjusted OR per each 10 μmoL/L increment [95% CI] = 1.11 [1.01–1.21]; p = 0.024). In the validation cohort, this model with serial ammonia (ICU days 1 and 3) predicted hospital mortality with reasonably good discrimination (c‐statistic = 0.73) and calibration (R2 = 0.19 and Brier score = 0.17).ConclusionsAmong patients with cirrhosis in the ICU, early serum ammonia variation was independently associated with hospital mortality. In this context, serial serum ammonia may have prognostic value.

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MELD is MELD is MELD? Transplant center–level variation in waitlist mortality for candidates with the same biological MELD

Abstract: This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes.

Cited by 2 publications

References 34 publications

MELD-GRAIL and MELD-GRAIL-Na Are Not Superior to MELD or MELD-Na in Predicting Liver Transplant Waiting List Mortality at a Single-center Level

MELD-GRAIL and MELD-GRAIL-Na Are Not Superior to MELD or MELD-Na in Predicting Liver Transplant Waiting List Mortality at a Single-center Level

Early serum ammonia variation in critically ill patients with cirrhosis: A multicentre cohort study

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