The use of MELD scores in critically ill cirrhotic patients
Supannee Rassameehiran MD, Tinsay A. Woreta MD MPH
Correspondence to Supannee Rassameehiran
Email:s.rassameehiran@gmail.com
SWRCCC 2016;4(16):45-50
doi: 10.12746/swrccc2016.0416.219
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Abstract
The Model for End-Stage Liver Disease (MELD)
was originally created to predict survival following transjugular intrahepatic
portosystemic shunt and was subsequently found to accurately predict mortality
in patients with end-stage liver disease. It has been used in the United States
for liver allocation since 2002, and implementation of the MELD score resulted
in a reduction in total number of deaths on the waitlist and a reduction in
waiting time. Critically ill cirrhotic patients have an in-hospital mortality
greater than 50%. Although the MELD score was also found to be an accurate
predictor of in-ICU mortality and in-hospital mortality after ICU admission in
critically ill cirrhotic patients, the Sequential Organ Failure Assessment
(SOFA) score appears to perform better in many studies. The Chronic Liver
Failure Consortium Acute-on-Chronic Liver Failure (CLIF-C ACLF) score was later
developed by using specific cut-points for each organ failure score system in
CLIF patients to predict mortality in patients with ACLF. Neither the MELD nor
SOFA score independently predicts post-liver transplantation mortality in
cirrhotic patients with extrahepatic organ failure and should not be use as a
delisting criterion for these patients. More data are needed to determine the
accuracy of the CLIF-C ACLF score in predicting post-liver transplantation
outcomes. Prospective evaluation of critically ill cirrhotic patients is needed
to optimize liver organ allocation.
Key words-Cirrhosis,
MELD score, SOFA score
Introduction
The Model for End-Stage Liver Disease (MELD) is a
numerical scale, ranging from 6 to 40, that was originally created to predict
survival following transjugular intrahepatic portosystemic shunt (TIPS) for
refractory variceal bleeding or refractory ascites.1
The score is calculated by a formula using serum bilirubin, serum creatinine,
and the International Normalized Ratio (INR). It was later adopted by the United
Network for Organ Sharing (UNOS) to determine priority for liver organ allocation in
the United States in February 2002.2
The MELD score predicts liver transplantation (LT) waitlist mortality with
estimated three-month mortality of 4%, 27%, 76%, 83%, and 100% for MELD scores
of <10, 10-19, 20-29, 30-39, and ≥ 40, respectively.3
Implementation of the MELD score for organ allocation resulted in a reduction in
total number of deaths on the waitlist and a reduction in waiting time.4
In January 2016, the MELD-Na score was implemented for LT allocation, as
hyponatremia also strongly predicts mortality in these patients.5-7
Apart from prioritizing the urgency for LT, the MELD score accurately predicts
outcomes in cirrhotic patients with infection8-10,
variceal bleeding11, 12,
trauma13,
and surgery other than LT, including liver resection.14,
15 It is also used as one of the
liver-specific prognosis scores for critically ill cirrhotic patients in the
intensive care unit (ICU).
Prognostic scoring systems for critically ill cirrhotic patients in ICU
Liver cirrhosis is the 12th
leading cause of death in the United States.16
The prevalence of liver cirrhosis is increasing and is estimated to be present
in approximately 630,000 adults in the United States.17
Cirrhotic patients are at an increased risk for developing decompensation
related to cirrhosis and portal hypertension, including variceal bleeding,
ascites, hepatic encephalopathy, hepato-renal syndrome, spontaneous bacterial
peritonitis, and sepsis. Patients with cirrhosis admitted to the ICU have a
substantially high mortality rate of 50% to 100%.
18
Liver-specific prognosis scores [Child-Turcotte-Pugh (CTP) and MELD] and
ICU-specific prognosis scores [Simplified Acute Physiology Score (SAPS) II,
Acute Physiology and Chronic Health Evaluation (APACHE), and Sequential Organ
Failure Assessment (SOFA)] have been proposed to assess disease severity and
outcomes in these patients.
The MELD score is calculated by the formula
3.8*loge(serum bilirubin [mg/dL]) + 11.2*loge(INR) +
9.6*loge(serum creatinine [mg/dL]) + 6.4. It contains only objective
values that eliminate intra-and inter-observer variability. Unfortunately, other
than renal dysfunction, the MELD score does not directly account for other
complications of portal hypertension, such as ascites, variceal bleeding,
hepatic encephalopathy, hepatopulmonary syndrome, portopulmonary hypertension,
and cirrhotic cardiomyopathy. Thus
patients with significant decompensation from complications of portal
hypertension may have low MELD scores that do not accurately reflect the
severity of their liver disease and are at a disadvantage with our current
method of organ allocation using the MELD score. A system of exception points
has been implemented for those patients with complications of portal
hypertension that are not captured by the MELD score, such as hepatopulmonary
syndrome and portopulmonary hypertension, to increase their waitlist priority.
The MELD score can also be influenced by acute illnesses that alter bilirubin,
creatinine, or INR values (Table 1).
The main cause of death in cirrhotic patients in the
ICU is multisystem organ failure.26
Several studies have shown that besides hepatic failure, cardiovascular system
dysfunction27, 28,
renal failure21, 29,
elevated lactate30-32,
and ascites32
were independent factors for mortality. Unlike
the MELD score which focuses only on hepatic and renal function, ICU-specific
prognosis scores also consider other organ system dysfunction (Table 2).
Many studies have compared MELD scores with
ICU-specific prognosis scores in predicting in-ICU mortality and in-hospital
mortality for cirrhotic patients after ICU admission.
Most studies have shown that SOFA scores
correlate with mortality better than MELD scores31-38,
APACHE II scores 31, 32, 34, 38-41,
and SAPS II scores.37
Das et al reported the presence of five non-hematologic organ failures in the
SOFA score at the admission to the ICU was associated with 100% in-hospital
mortality.33
Moreover, the accuracy of SOFA scores was improved when reassessed at 48 to 72
hours after the admission to the ICU.18,
38
However, Boone et al reported that both SOFA scores and MELD scores did not
perform well in predicting 28-day mortality in the surgical ICU patients.42
Each of the six different organ failures in the
SOFA score has a different weight in cirrhotic patients.43
Hematologic failure in SOFA score defined by platelet count
< 50 k/μL has no
impact on the prognosis in cirrhotic patients33
New cut-off values for SOFA scores dedicated to cirrhotic patients were proposed
resulting in a development of new scoring systems: the Chronic Liver
Failure-SOFA (CLIF-SOFA) score and the Chronic Liver Failure Consortium
Acute-on-Chronic Liver Failure (CLIF-C ACLF) score.
The CLIF-C ACLF score was specifically
developed using data from patients with the diagnosis of ACLF, which was defined
as an acute deterioration in liver function in an individual with pre-existing
chronic liver disease and hepatic and extrahepatic organ failures.44
Validation of the score was confirmed with external single center prospective
cohort study of ACLF patients admitted to the ICU.37
Jalan et al reported that CLIF-C ACLF score correlates with mortality better
than the MELD score, MELD-Na score, CTP score, and CLIF-SOFA score in patients
with ACLF.44
Sequential use of the score also improves the predictive performance and should
be considered as a good prognostic predictor for cirrhotic patients.44
Evidence for the MELD score, SOFA score, and CLIF-C
ACLF score predicting post-LT outcome is lacking. A systematic review by
Cholongitas et al found that the MELD score does not predict post-LT mortality.45
A
recent study by Karvellas et al reported that the SOFA score was not associated
with an increased risk of 90-day post-LT mortality.46
Optimal organ allocation in cirrhotic
patients with extrahepatic organ failure should be prospectively evaluated.
Conclusion
The MELD score predicts liver transplantation waitlist
mortality and has been used in the United States for liver allocation since
2002. Prior studies have compared the MELD score with ICU-specific prognosis
scores in predicting in-ICU mortality and in-hospital mortality of cirrhotic
patients after ICU admission. Although the MELD score was found to be an
accurate predictor of mortality in critically ill cirrhotic patients, the CLIF-C
ACLF score correlates with mortality better than the MELD score, MELD-Na score,
CTP score, and CLIF-SOFA score in patients with ACLF. Thus we recommend the
CLIF-C ACLF score as a prognostic predictor for patients with acute-on-chronic
liver failure.
Table 1
Influencing factors of MELD score
Variable |
Influencing factors |
Bilirubin |
Increased indirect bilirubin
Hemolysis
Blood transfusion
Drug or sepsis-induced cholestasis19, 20
|
Creatinine |
Acute renal failure21, 22
Hepatorenal syndrome
Other causes: shock, hypovolemia, drug-induced nephropathy, and
medication-induced nephropathy
|
INR |
Anticoagulant therapy: warfarin
Hemodilution23
Bleeding-induced coagulopathy24
Disseminated intravascular coagulopathy25
Malnutrition |
INR-
International Normalized Ratio
Table 2
Components of ICU-specific prognosis scores
Organ system |
ICU-specific prognosis scores |
Cardiovascular system
Heart rate
Blood pressure |
SAPS II, APACHE II
SAPS II, APACHE II, SOFA |
Respiratory system
Respiratory rate
PaO2 or PaO2/FiO2 |
APACHE II
SAPS II, APACHE II, SOFA |
Renal function
Serum creatinine
Serum urea
Oliguria |
APACHE II (acute renal failure)
SOFA, APACHE II
SAPS II
SAPS II, SOFA |
Liver function
Bilirubin |
APACHE II (cirrhosis)
SAPS II, SOFA |
Hematologic findings
WBC count
Platelet |
SAPS II, APACHE II
SOFA |
Neurologic function
Consciousness |
SAPS II, APACHE II, SOFA |
SAPS- Simplified Acute Physiology Score;
APACHE- Acute Physiology and Chronic Health Evaluation; SOFA-Sequential Organ
Failure Assessment
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...................................................................................................................................................................................................................................................................................................................................
Received: 04/4/2016
Accepted: 09/23/2016
Reviewer: Thomas Kerr
Published electronically: 10/15/2016
Conflict of Interest Disclosures: none