Stage of cirrhosis predicts the risk of liver-related death in patients with low model for End-Stage liver disease scores and cirrhosis awaiting liver transplantation

Abstract

MELD has reduced predictive ability in cirrhotic patients with MELD ≤ 20. We aimed to assess whether a 5-stage clinical model identifies liver transplant (LT) candidates with low MELD who are at increased risk for death. We conducted a case-control study of cirrhotic subjects with MELD ≤ 20 awaiting LT at a single academic medical center from 2/2002-5/2011. Conditional logistic regression was used to evaluate the risk of liver-related death based on cirrhosis stage. We identified 41 case subjects who died from liver-related causes with a MELD ≤ 20 within 90 days of death while waiting for LT. Cases were matched with up to 3 controls, totaling 66 controls, based on listing year, age, gender, liver disease etiology, hepatocellular carcinoma, and MELD. Cirrhosis stage (1=no varices or ascites, 2=varices, 3=variceal bleed, 4=ascites, 5=ascites and variceal bleed) was assessed for all subjects. MELD scores were similar for cases and controls. Clinical states contributing to death in cases were: sepsis 48%, spontaneous bacterial peritonitis 42%, variceal bleeding 24%, and hepatorenal syndrome 21%. In univariate analyses, variceal bleed (OR 5.6, p= 0.003), albumin (OR 0.5, p=0.041), increasing cirrhosis stage (p=0.003) and reaching stage 2, 3, or 4 cirrhosis versus lower stages (OR 3.6, p=0.048; OR 7.4, p<0.001; OR 4.1, p=0.008; respectively), sodium < 135 (OR 3.4, p=0.006), and hepatic encephalopathy (OR 2.3, p=0.082) were associated with liver-related death. In a multivariable model including cirrhosis stage, albumin, sodium, and hepatic encephalopathy, increasing cirrhosis stage (p=0.010) was independently associated with liver-related death. In conclusion, assessing the cirrhosis stage in low MELD patients awaiting LT may help select candidates for more aggressive monitoring or for living donor or extended criteria donation.

Child-Turcotte-Pugh Class is Best at Stratifying Risk in Variceal Hemorrhage

“…ascites and encephalopathy). Ascites has consistently been shown to improve mortality risk prediction in patients who have low MELD scores 15, 16 .…”

Defining Long-term Outcomes With Living Donor Liver Transplantation in North America

“…Both improved pre- and post-transplant survival in experienced centers suggests that in a patient with a suitable living donor, LDLT should be considered the preferred procedure performed prior to the progressive deterioration of liver disease, similar to the benefits offered to kidney patients when transplantation is performed prior to the initiation of dialysis (36, 37). We also know that the MELD score, while an excellent tool to risk stratify candidates on the waitlist, has its limitations and many patients with lower MELD scores with decompensated cirrhosis have an elevated risk of death as well (38–41). Waiting too long for a deceased donor offer at a higher MELD score often results in death on the waitlist and potentially a higher risk of graft failure and/or death after transplant.…”

Outcomes for liver transplant candidates listed with low model for end‐stage liver disease score

“…Various scoring symptoms for patients with low MELD have been proposed and validated in order to predict the longer-term risk of waitlist dropout or liver-related death, incorporating variables such as sodium, albumin, bilirubin, renal function, hepatic encephalopathy, ascites, or varices with or without bleeding (17, 18). …”