Selecting an optimal prognostic system for liver cirrhosis: the model for end‐stage liver disease and beyond

Abstract

In comparison with the Child–Turcotte–Pugh (CTP) system, recent studies suggested that the model for end‐stage liver disease (MELD) may more accurately predict the survival for patients with cirrhosis. In the US, the liver allocation system was changed in 2002 from a status‐based algorithm utilizing CTP scores to one using continuous MELD severity scores as a reference system in prioritizing adult patients on the waiting list. Direct evidence that demonstrates the benefits of MELD is the fact that the mortality rates of transplant candidates on the waiting list have remarkably decreased after the implementation of the MELD. The MELD score is closely associated with the degree of portal hypertension as reflected by the hepatic venous pressure gradient. Hyponatraemia occurs as a result of advanced cirrhosis, and a serum sodium (Na) level <126 mEq/L at the time of listing for transplantation is a strong independent predictor of mortality. Several MELD‐derived prognostic models that incorporate serum Na into calculation have been proposed in the hopes of further improving the MELD's prognostic accuracy. Additionally, serum parameters such as creatinine and international normalized ratio are subject to interlaboratory variations and may need unifying standardizations. Patients with refractory complications of cirrhosis may need a priority MELD score to prioritize them on the waiting list. Appropriate modifications and the fine‐tuning of the MELD based on well‐designed prospective studies are necessary in solving the current controversial issues.

Hepatic enhancement during the hepatobiliary phase after gadoxetate disodium administration in patients with chronic liver disease: The role of laboratory factors

“…The mean MELD score in the patients with imaging stigmata of cirrhosis was 11.0 (SD 4.0; range [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20], and the mean MELD score in patients without imaging stigmata of cirrhosis was 7.3 (SD 1.3; range 5-10) (P < 0.004). Because all patients in the subgroup without imaging stigmata of cirrhosis had MELD scores 10, this subgroup was compared with a subgroup that had imaging stigmata of cirrhosis and also had MELD scores 10 (n ¼ 45).…”

“…For each of the patients with history of parenchymal liver disease, Model for End-Stage Liver Disease (MELD) score with UNOS modification was obtained using standard formula: MELD ¼ 3.8 Â Ln(bilirubin[mg/dL])þ11.2 Â Ln(International Normalized Ratio [INR]) þ 9.6 Â Ln(creatinine [mg/dL]) (8)(9)(10)(11).…”

Analysis of 83 consecutive liver transplants performed at a tertiary care reference hospital in the interior of the state of Sao Paulo

“…OLT has a significant preoperative risk and the success of the procedure is due in part to appropriate selection of recipients from a medical, psychological and social viewpoint, to insure perfect patient adherence to the available medical care 13,14 .…”

“…There still is no way to assess with precision the functional reserve of a cirrhotic liver or to predict the chances of survival of a recipient of a liver transplant. Several studies have been conducted in an attempt to find indicators that predict death or survival after OLT 4,13,15 . However, current indexes are unable to accurately predict which patients will have a high probability of posttransplant survival.…”

A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

“…(7) MELD has revolutionized prognostication in cirrhosis but has several well-described limitations. (8)(9)(10) One of these is its inability to account for an individual's performance status. Performance status and the linked concept of frailty are known robust predictors of adverse outcomes in diverse populations (11)(12)(13)(14)(15)(16)(17) including cirrhosis, (18)(19)(20)(21) often outperforming traditional prognostic markers.…”