![]() ![]() National implementation of the MELD system has provided a predictable and reproducible means for clinicians to assess the severity of ESLD and to appropriately list patients for transplantation. Attempts have been made to associate the pretransplant MELD score with post-transplant outcomes, but results of these studies have been less clear. Early reviews of the MELD system demonstrate that deaths on the LT wait list have decreased. In 2002, the LT wait list was transitioned from a wait time–based allocation system to a MELD-based system in which wait time was de-emphasized, and disease severity (MELD score) became the primary criterion for organ allocation. It was subsequently found to be a sensitive and specific predictor of short-term mortality for patients with liver failure awaiting transplantation. The MELD score is a continuous variable of disease severity that was developed to assess short-term prognosis in patients with liver failure undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement. Tector MD, PhD, in Practical Hepatic Pathology, 2011 Liver Allograft Allocation Mortality in patients with cirrhosis admitted to the ICU with two or three organ systems failing ranges from 75% to 95%, respectively, 30 much higher than rates seen, for example, in severe sepsis without liver disease. 29įinally, when patients with cirrhosis are admitted to the intensive care unit (ICU) because of multiorgan failure, the prognosis is especially poor. 21 Studies also have suggested that a subset of patients with a low MELD score and refractory ascites and hyponatremia, 22–26 or complications such as hepatopulmonary syndrome, 27, 28 mild portopulmonary hypertension, or ascites with large-volume pleural effusion are at high risk for death in the absence of a liver transplantation. However, the MELD score does overestimate liver disease severity in patients with intrinsic renal disease, patients with hyperbilirubinemia secondary to Gilbert syndrome, and patients on anticoagulation therapy. The strength of the MELD score as a prognostic model lies in its rigorous statistical foundation and its use of objective, readily available parameters. 18 Since its initial development, the MELD score has been validated as a robust marker of early and long-term survival in patients with CLD across a wide spectrum of disease causes and settings ( Table 54-2). Subsequently, a modified model with three of the original variables (bilirubin, creatinine, and international normalized ration) was shown to accurately predict 3-month mortality in patients with cirrhosis listed for liver transplant. 17 Multivariable analysis found four independent variables that had an impact on survival. The MELD score was originally designed to predict 3-month mortality of patients with cirrhosis undergoing transjugular portosystemic intrahepatic shunt (TIPS). Sean Morrison, in Evidence-Based Practice in Palliative Medicine, 2013 The Model for End Stage Liver Disease Although this has been demonstrated for PSC, 107 there are no specific data examining this issue with respect to PBC to date.Īluko Hope, R. 105,106 With over a decade of experience using the MELD score for LT, there are questions about PBC having a disadvantage in terms of waiting list time as compared to non–cholestatic liver disease. However, the influence of liver disease cause on MELD score was eliminated from the model when UNOS implementation was undertaken. It should be noted that the original MELD study recognized that patients with cholestatic liver disease had improved predicted survival as compared to other types of liver disease. Subsequent analysis demonstrated that the MELD score was equivalent to the Mayo PBC risk score for predicting survival in PBC patients. ![]() 104 In this cohort the MELD score was associated with a very high discriminative value of 0.87 (95% confidence interval, 0.71-1.00) for mortality at 3 months that remained at the same (0.87) value when assessing 1-year mortality. The original MELD score was based on a predictive survival model described for patients receiving transjugular intrahepatic portosystemic shunt. 102,103 The MELD score involves three readily available laboratory values: serum total bilirubin, creatinine, and international normalized ratio (INR). The MELD score was adopted in February 2002 by UNOS to guide organ allocation policies. Talwalkar, in Transplantation of the Liver (Third Edition), 2015 MELD Scores in Patients with Primary Biliary Cirrhosis ![]()
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