Preoperative Delta-MELD Score Does Not Independently Predict Mortality After Liver Transplantation

Abstract

Changes in model for end-stage liver disease (MELD) score of ≥5 points over 30 days (delta-MELD) is an independent predictor for death in patients awaiting liver transplantation. The aim of the current study was to determine if a positive change in MELD score occurring over the 30 days immediately prior to liver transplantation was predictive of posttransplant mortality. MELD scores from the day of transplantation and 30 days prior to transplantation were calculated for 1510 UNOS patients and used to compute a delta-MELD score. Multivariate modeling determined predictors of posttransplant mortality. Patients with a preoperative delta-MELD ≥ 5 had higher absolute MELD scores at transplant, shorter mean posttransplant survival and higher mortality. However, multivariate analysis showed that none of the excess mortality was attributable to the high delta-MELD score (p = 0.43 for delta-MELD ≥ 5) and the majority of the excess risk was attributable to absolute MELD score (p < 0.001) at the time of transplantation. Mortality of patients with rapidly worsening chronic liver disease who undergo transplantation depends substantially on absolute MELD score at the time of transplantation but not the rate of change immediately preceding transplant. Allocation policymakers should consider that a high delta-MELD in the immediate pretransplant period does not indicate greater posttransplant mortality.

3-month and 12-month mortality after first liver transplant in adults in Europe: predictive models for outcome

“…Furthermore, the MELD score is primarily used for the assessment of allocation and eligibility for transplantation, and, since it does not take into account operative or donor factors, it is a poor predictor of posttransplantation survival. 20,21 Second, we excluded patients with missing data on key data items, such as recipient sex and donor age and sex, as well as those with insufficient follow-up to assess outcomes at 3-months and 12-months post-transplantation. The former group of patients was largely restricted to transplants done in earlier time periods, and their exclusion should not, therefore, adversely effect the results from the more recently done transplants.…”

High preoperative recipient plasma 7β-hydroxycholesterol is associated with initial poor graft function after liver transplantation

“…At multivariate analysis, the recipient plasma 7␤-hydroxycholesterol level remained independently associated with early graft function even after controlling for recipient MELD score, donor history of cardiac arrest and cause of death, and other parameters demonstrated to predict the quality of early graft function and survival in previous studies, like graft cold ischemia time, donor age, serum sodium concentration, length of intensive care stay, noradrenaline infusion, and preharvest PaO 2 . [1][2][3] In particular, for every 1-ng/mL increase in plasma 7␤-hydroxycholesterol, odds of IPGF increased by 17%. The fact that we found such a strong association between plasma 7␤-hydroxycholesterol and IPGF in a relatively small number of transplants strengthens its power.…”

“…On the other hand, the relatively small number of transplants in the present study could have caused a ␤ type error masking the association with the quality of graft function of the other above-mentioned variables described in larger series. [1][2][3] It is also likely that the effect of some of the variables shown to predict the quality of graft function in transplants performed a few years ago, like graft cold ischemia time, donor serum sodium concentration and length of intensive care stay, has been blunted in the present study by changes in surgical and intensive care unit management in the last years based upon previous studies (i.e., shorter graft cold ischemia times, hypernatriemia treatment, allocation policy minimizing the simultaneous occurrence of negative cofactors).…”

“…1,2 Recently, the severity of recipient liver disease as expressed by the Model for End-Stage Liver Disease (MELD) score also has been shown to be associated with 3-month OLT survival. 3 Oxidative stress at reperfusion is thought to play a major pathogenetic role in hepatic ischemia-reperfusion injury, the underpinning of early graft dysfunction 1,4 ; in fact, in experimental models reactive oxygen species (ROS) released at reperfusion by activated Kupffer cells recruited neutrophils and hepatocytes induced a series of events at a cellular level, culminating with apoptosis and necrosis and production of inflammatory mediators that provoke circulatory disturbances and worsening of liver damage. 1,[4][5][6] We hypothesized that unlike experimental OLT where the recipient is healthy, in human OLT the biochemical machinery that determines the severity of ischemia-reperfusion injury could also be influenced by the pre-existing altered blood oxidative stress/antioxidant status of the recipient, which eventually persists after removal of the liver with cirrhosis.…”

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

“…To date, however, it has not been shown to reliably predict post-liver transplant mortality. In listed patients with small changes in MELD score (delta MELD), there can be appreciable changes in pre-transplant mortality, although studies do not convincingly show this to be a strong predictor for having a bad outcome [19,20].…”