MELD is superior to King's college and Clichy's criteria to assess prognosis in fulminant hepatic failure

Abstract

Assessment of prognosis in fulminant hepatic failure (FHF) is essential for the need and appropriate timing of orthotopic liver transplantation (OLT). In this study we investigated the prognostic efficacy of King's College criteria, Clichy's criteria, Model for End-Stage Liver Disease (MELD), and Pediatric End-Stage Liver Disease (PELD) in 120 consecutive patients with FHF. Survival with medical therapy (18%), death without OLT (15%), and receipt of a liver transplant were similar in adults (n ϭ 64) and children (n ϭ 56). MELD scores were significantly higher in patients who died compared to those who survived without OLT, both in adults (38 Ϯ 7 vs. 26 Ϯ 7, P ϭ 0.0003) and children (39 Ϯ 7 vs. 23 Ϯ 6, P ϭ 0.0004). Using logistic regression analysis in this cohort of patients, concordance statistics were significantly higher for MELD (0.95) and PELD (0.99) when compared to King's College (0.74) and Clichy's criteria (0.68). When data was analyzed in a Cox model including patients receiving transplants and censoring the time from admission, the concordance statistic for MELD (0.77) and PELD (0.79) remained significantly higher than that of King's College criteria but not higher than that of Clichy's criteria. In conclusion, this study is the first to show that MELD and PELD are superior to King's College and Clichy's criteria to assess prognosis in FHF. However, because data was generated from a single center and included a rather low number of patients who survived or died without OLT, further confirmation of our findings is required. Liver Transpl 13: 822-828, 2007.

Prognostic impact of lactate in acute liver failure

“…3 In fact, lactate alone at 12 hours had similar performance to SOFA and better performance than King's criteria (AUC: 0.76, 0.79, and 0.65, respectively). 3 Importantly, the negative predictive value (NPV), which is low in many prognostic scores in FHF, as acknowledge by Yantorno et al 2 in their discussion, was higher for lactate at 12 hours (NPV: 0.73), compared to the NPV of the King's criteria (NPV: 0.65) in our study, 3 and to the NPVs of the new prognostic score and MELD score (NPV: 0.65 and 0.61, respectively) in the study by Dhiman et al 1 Thus, we believe that further studies are needed to assess the prognostic accuracy of any new markers both early in the course of FHF and serially, as Dr. O'Grady 9 emphasized in the editorial accompanying the Dhiman et al 1 article. This should lead to better prognostication at different time points during the evolution of the FHF.…”

To MELD or not to MELD, that is a question

“…Patients from the study of Dhiman et al 2 exclusively had a viral etiology for FHF, whereas patients from the other study 1 had multifactorial causes. The etiology of FHF might be important because the King's College criteria have proposed different predictive variables for FHF with respect to the use or nonuse of acetaminophen.…”

“…1,2 The two studies by Yantorno et al 1 from Argentina and Dhiman et al 2 from India investigated the prognostic ability of the Model for End-Stage Liver Disease (MELD), King's College, and Clichy criteria for predicting the mortality in patients with fulminant hepatic failure (FHF). Yantorno et al reported that MELD is the best prognostic model among the three, whereas Dhiman et al found that a combination of the parameters (clinical prognostic indicators) from these models is more accurate.…”

“…The etiology of FHF might be important because the King's College criteria have proposed different predictive variables for FHF with respect to the use or nonuse of acetaminophen. Patients with a variety of etiologies, as in the study of Yantorno et al, 1 may have different clinical manifestations that are directly related to the patient outcome. Second, the current two studies were intended to establish the optimal criteria to distinguish who should undergo liver transplantation and who should not.…”

MELD—good for many, not as good for others … at least for now

“…MELD has also been shown to have utility in predicting outcome in patients suffering from acute liver failure, alcoholic hepatitis, and in patients with chronic liver disease undergoing surgery or experiencing traumatic injury [14][15][16][17][18]. To date, however, it has not been shown to reliably predict post-liver transplant mortality.…”