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Value of MELD and MELD-Based Indices in Surgical Risk Evaluation of Cirrhotic Patients: Retrospective Analysis of 190 Cases

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Abstract

Background

Recent studies have suggested that the Model for End-Stage Liver Disease (MELD) may represent a promising alternative to the Child-Turcotte-Pugh classification as a predictive factor of operative mortality and morbidity. This study was designed to evaluate the value of MELD and four MELD-based indices (iMELD: integrated MELD; MESO: MELD to sodium ratio; MELD-Na: MELD with incorporation of sodium; MELD-XI: MELD excluding the International Normalized Ratio) in the quantification of surgical risk for patients with cirrhosis and compare its prognostic value with the Child-Turcotte-Pugh classification and two derived scores (proposed by Huo and Giannini, respectively).

Methods

A retrospective study of 190 patients with cirrhosis, operated on in our department between 1993 and 2008, was undertaken.

Results

Forty-three percent of patients were included in Child-Turcotte-Pugh A class, and their mean MELD score was 12.2 ± 4.9 (range, 6.4–35.2). Mortality and morbidity rates were 13% and 24%, respectively. In global analysis of mortality, MELD-based indices presented an acceptable prognostic performance (auROC = 71–77%), similar to the three analyzed Child-Turcotte-Pugh-derived scores. iMELD demonstrated the highest prognostic capacity (auROC = 77%; 95% confidence interval (CI), 66–88; p = 0.0001); operative death probability was 4% (95% CI, 3.6–4.4) when the score was inferior to 35, 16.1% (95% CI, 14.4–17.9) between 35 and 45, and 50.1% (95% CI, 42.2–58.1) when superior to 45. In elective surgical procedures, iMELD represented a useful prognostic factor of operative mortality (auROC = 80%; 95% CI, 63–97; p = 0.044) with significant correlation and better accuracy then MELD and Child-Turcotte-Pugh-derived indices.

Conclusions

In this study, iMELD was a useful predictive parameter of operative mortality for patients with cirrhosis submitted to elective procedures. Further studies are necessary to define the relevance of MELD-based indices in the individual surgical risk evaluation.

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Abbreviations

iMELD:

Integrated MELD

MESO:

MELD to sodium ratio

MELD-Na:

MELD with incorporation of sodium

MELD-XI:

MELD excluding the international normalized ratio

σ:

Spearman’s correlation coefficient.

References

  1. del Olmo JA, Flor-Lorente B, Flor-Civera B et al (2003) Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg 27:647–652

    Article  PubMed  Google Scholar 

  2. Pugh RN, Murray-Lyon IM, Dawson JL et al (1973) Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 60:646–649

    Article  PubMed  CAS  Google Scholar 

  3. Freeman RB (2005) MELD: the holy grail of organ allocation? J Hepatol 42:16–20

    Article  PubMed  Google Scholar 

  4. Mansour A, Watson W, Shayani V et al (1997) Abdominal operations in patients with cirrhosis: still a major surgical challenge. Surgery 122:730–736

    Article  PubMed  CAS  Google Scholar 

  5. O’Leary JG, Friedman LS (2007) Predicting surgical risk in patients with cirrhosis: from art to science. Gastroenterology 132:1609–1610

    Article  PubMed  CAS  Google Scholar 

  6. Durand F, Valla D (2005) Assessment of the prognosis of cirrhosis: Child-Pugh versus MELD. J Hepatol 42:S100–S107

    Article  PubMed  Google Scholar 

  7. Malinchoc M, Kamath PS, Gordon FD et al (2000) A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 31:864–871

    Article  PubMed  CAS  Google Scholar 

  8. Teh SH, Nagorney DM, Stevens SR et al (2007) Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology 132:1261–1269

    Article  PubMed  Google Scholar 

  9. Northup PG, Wanomaker RC, Lee VD et al (2005) Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis. Ann Surg 242:244–251

    Article  PubMed  Google Scholar 

  10. Cucchetti A, Ercolani G, Vivarelli M et al (2006) Impact of model for end-stage liver disease (MELD) score on prognosis after hepatectomy for hepatocellular carcinoma on cirrhosis. Liver Transpl 12:966–971

    Article  PubMed  Google Scholar 

  11. Befeler AS, Palmer DE, Hoffman M et al (2005) The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease is superior to Child-Turcotte-Pugh classification in predicting outcome. Arch Surg 140:650–654

    Article  PubMed  Google Scholar 

  12. Farnsworth N, Fagan SP, Berger DH et al (2004) Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients. Am J Surg 188:580–583

    Article  PubMed  Google Scholar 

  13. Perkins L, Jeffries M, Patel T (2004) Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis. Clin Gastroenterol Hepatol 2:1123–1128

    Article  PubMed  Google Scholar 

  14. Huo TI, Lee SD, Lin HC (2008) Selecting an optimal prognostic system for liver cirrhosis: the model for end-stage liver disease and beyond. Liver Int 28:606–613

    PubMed  Google Scholar 

  15. Kamath PS, Kim WR, Advanced liver disease study group (2007) The model for end-stage liver disease (MELD). Hepatology 45:797–805

    Article  PubMed  Google Scholar 

  16. Durand F, Valla D (2008) Assessment of prognosis of cirrhosis. Semin Liver Dis 28:110–122

    Article  PubMed  CAS  Google Scholar 

  17. Cholongitas E, Papatheodoridis GV, Vangeli M et al (2005) Systematic review: the model for end-stage liver disease–should it replace Child-Pugh’s classification for assessing prognosis in cirrhosis? Aliment Pharmacol Ther 22:1079–1089

    Article  PubMed  CAS  Google Scholar 

  18. Luca A, Angermayr B, Bertolini G et al (2007) An integrated MELD model including serum sodium and age improves the prediction of early mortality in patients with cirrhosis. Liver Transp 13:1174–1180

    Article  Google Scholar 

  19. Biggins SW, Kim WR, Terrault NA et al (2006) Evidence-based incorporation of serum sodium concentration into MELD. Gastroenterology 130:1652–1660

    Article  PubMed  Google Scholar 

  20. Huo TI, Wang YW, Yang YY et al (2007) Model for end-stage liver disease score to serum sodium ratio index as a prognostic predictor and its correlation with portal pressure in patients with liver cirrhosis. Liver Int 27:498–506

    Article  PubMed  CAS  Google Scholar 

  21. Huo T, Lin H, Huo SC et al (2008) Comparison of four model for end-stage liver disease-based prognostic systems for cirrhosis. Liver Transpl 14:837–844

    Article  PubMed  Google Scholar 

  22. Heuman DM, Habib A, Abou-Assi S et al (2005) Rationally derived Child-Turcotte-Pugh (CTP) subclasses permit accurate stratification of near-term risk in cirrhotic patients referred for liver transplantation. Gastroenterology 128:A-734

    Google Scholar 

  23. Huo TI, Lin HC, Wu JC et al (2006) Proposal of a modified Child-Turcotte-Pugh scoring system and comparison with the model for end-stage liver disease for outcome prediction in patients with cirrhosis. Liver Transpl 12:65–71

    Article  PubMed  Google Scholar 

  24. Giannini E, Botta F, Fumagalli A et al (2004) Can inclusion of serum creatinine values improve the Child-Turcotte-Pugh score and challenge the prognostic yield of the model for end-stage liver disease score in the short-term prognostic assessment of cirrhotic patients? Liver Int 24:465–470

    Article  PubMed  Google Scholar 

  25. Papatheodoridis GV, Cholongitas E, Dimitriadou E et al (2005) MELD vs. Child-Pugh and creatinine-modified Child-Pugh score for predicting survival in patients with decompensated cirrhosis. World J Gastroenterol 11:3099–3104

    PubMed  Google Scholar 

  26. Angermayer B, Koening F, Cejna M et al (2002) Creatinine-modified Child-Pugh score (CPSC) compared with MELD-score to predict survival in patients undergoing TIPS. Hepatology 36:860A

    Article  Google Scholar 

  27. Ferenci P, Lockwood A, Mullen K et al (2002) Hepatic encephalopathy: definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th world congress of gastroenterology, Vienna, 1998. Hepatology 35:716–721

  28. ASA physical status classification system. American Society of Anesthesiologists website. http://www.asahq.org/clinical/physical status.htm.2008. Accessed 28 Feb 2008

  29. Lorimer JW, Doumit G (2007) Comorbidity is a major determinant of severity in acute diverticulitis. Am J Surg 193:681–685

    Article  PubMed  Google Scholar 

  30. Charlson ME, Szatrowski TP, Peterson J et al (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47:1245–1251

    Article  PubMed  CAS  Google Scholar 

  31. Sutton R, Bann S, Brooks M et al (2002) The surgical risk scale as an improved tool for risk-adjusted analysis in comparative surgical audit. Br J Surg 89:763–768

    Article  PubMed  CAS  Google Scholar 

  32. Neary WD, Prytherch D, Foy C et al (2007) Comparison of different methods of risk stratification in urgent and emergency surgery. Br J Surg 94:1300–1305

    Article  PubMed  CAS  Google Scholar 

  33. Heuman DM, Mihas AA, Habib A et al (2007) MELD-XI: a rational approach to “sickest first” liver transplantation in cirrhotic patients requiring anticoagulant therapy. Liver Transpl 13:30–37

    Article  PubMed  Google Scholar 

  34. Teh SH, Sheppard BC, Schwartz J et al (2008) Model for end-stage liver disease score fails to predict perioperative outcome after hepatic resection for hepatocellular carcinoma in patients without cirrhosis. Am J Surg 195:697–701

    Article  PubMed  Google Scholar 

  35. Durand F (2006) Risk scores in cirrhotic patients: from non-transplant surgery to transplantation and back. J Hepatol 44:620–621

    Article  PubMed  Google Scholar 

  36. Hoteit MA, Ghazale AH, Bain AJ et al (2008) Model for end-stage liver disease score versus child score in predicting the outcome of surgical procedures in patients with cirrhosis. World J Gastrenterol 14:1774–1780

    Article  Google Scholar 

  37. Schroeder RA, Marroquin CE, Bute BP et al (2006) Predictive indices of morbidity and mortality after liver resection. Ann Surg 243:373–379

    Article  PubMed  Google Scholar 

  38. Bingener J, Cox D, Michalek J et al (2008) Can the MELD score predict perioperative morbidity for patients with liver cirrhosis undergoing laparoscopic cholecystectomy? Am Surg 74:156–159

    PubMed  Google Scholar 

  39. Filsoufi F, Salzberg SP, Rahmanian PB et al (2007) Early and late outcome of cardiac surgery in patients with liver cirrhosis. Liver Transp 13:990–995

    Article  Google Scholar 

  40. Londoño M, Cárdenas A, Guevara M et al (2007) MELD score and serum sodium in the prediction of survival of patients with cirrhosis awaiting liver transplantation. Gut 56:1283–1290

    Article  PubMed  CAS  Google Scholar 

  41. Lisman T, van Leeuwen Y, Adelmeijer J et al (2008) Interlaboratory variability in assessment of the model of end-stage liver disease score. Liver Int 28:1344–1351

    Article  PubMed  Google Scholar 

  42. Huo TI, Wu JC, Lin HC et al (2005) Evaluation of the increase in model for end-stage liver disease (MELD) score overtime as a prognostic predictor in patients with advanced cirrhosis: risk factor analysis and comparison with initial MELD and Child-Turcotte-Pugh score. J Hepatol 42:826–832

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. IIIrd Surgical Department, Coimbra University Medical School and Hospitals, Praceta Prof. Mota Pinto, 3000-075, Coimbra, Portugal

    Beatriz P. Costa, F. Castro Sousa, Marco Serôdio & César Carvalho

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  1. Beatriz P. Costa
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  2. F. Castro Sousa
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  3. Marco Serôdio
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  4. César Carvalho
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Correspondence to Beatriz P. Costa.

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Costa, B.P., Castro Sousa, F., Serôdio, M. et al. Value of MELD and MELD-Based Indices in Surgical Risk Evaluation of Cirrhotic Patients: Retrospective Analysis of 190 Cases. World J Surg 33, 1711–1719 (2009). https://doi.org/10.1007/s00268-009-0093-4

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  • DOI: https://doi.org/10.1007/s00268-009-0093-4

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