MELD score in prediction of early mortality in patients suffering refractory ascites treated by TIPS


Authors: T. Fejfar 1;  V. Šafka 1;  P. Hůlek 3;  T. Vaňásek 1;  A. Krajina 2;  V. Jirkovský 1
Authors‘ workplace: II. interní klinika Lékařské fakulty UK a FN Hradec Králové, přednosta prof. MUDr. Jaroslav Malý, CSc. 1;  Radiologická klinika Lékařské fakulty UK a FN Hradec Králové, přednosta prof. MUDr. Pavel Eliáš, CSc. 2;  Katedra interních oborů Lékařské fakulty UK, Hradec Králové, vedoucí prof. MUDr. Jaroslav Malý, CSc. 3
Published in: Vnitř Lék 2006; 52(9): 771-776
Category: Original Contributions

Overview

Summary:
Transjugular Intrahepatic Portosystemic Shunt (TIPS) is now well established in the treatment of complications of symptomatic portal hypertension such as acute or recurrent variceal bleeding, refractory ascites and Budd-Chiari syndrome. In some patients with refractory ascites who belong to group C according to Child-Pugh classification (score around 12), the indication of the procedure could be very questionable and early mortality is quite high. However, in some cases, the subgroup of such risky patients can profit from TIPS. Child-Pugh classification is used for the stratification of the patients routinely. During the last decade other scoring systems occured to bring a better prognostic value. MELD (Model for End stage Liver Disease) score, based only on laboratory values is one of them. Comparison of these two scoring systems in patients treated by TIPS in previous trials brought certain discrepancy, but MELD score seems to be better in predicting early mortality.

The aim of our study
was to determine retrospectively the predictive accuracy of MELD score for the early mortality in comparison to Child-Pugh score in patients treated for refractory ascites by TIPS.

Methods:
We evaluated 110 patients (mean age 55 years) with liver cirrhosis (61 % of patients with alcoholic etiology), who underwent TIPS for refractory ascites in our center from September 1992 to December 2003. MELD and Child-Pugh score was calculated and then compared between groups with early (one month), three month and one year mortality, and those who survived over this period (one, three and twelve months ), comparing MELD and Child-Pugh score (ROC analysis and Student´s T test were used).

Results:
Mean follow up was 23 months. Average MELD score in the whole group was (16). In patients, who died within one month the score before TIPS was 21, three months 20 and 18 one year. Comparing MELD score between subgroups and then Child-Pugh score, only for MELD score there was a statistically significant difference (p < 0.05) in one month. Using ROC (AUC) analysis, discriminant power of MELD score was superior to Child-Pugh score for one (0.73 vs 0.63) and three month (0.73 vs 0.67) mortality. The discriminant power for one year mortality was low in both scores.

Conclusion:
MELD scoring system is a better tool to predict the risk of early mortality in patients with refractory ascites treated by TIPS than Child-Pugh classification. The discriminant power was low in both scores in one year horizon.

Key words:
TIPS - prediction of mortality - MELD


Sources

1. Angermayr B, Cejna M, Karnel F et al. Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt. Gut 2003; 52: 879-885.

2. Azoulay D, Castaing D, Majno P et al. Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decopensated cirrhosis. J Hepatol 2001; 35: 590-597.

3. Banares R, Casado M, Rodriguez-Laiz JM et al. Urgent transjugular intrahepatic portosystemic shunt for control of acute variceal bleeding. Am J Gastroenterol 1998; 93: 75-79.

4. Brensing KA, Raab P, Textor J et al. Prospective evaluation of a clinical score for 60-day mortality after transjugular intrahepatic portosystemic stent-shunt: Bonn TIPSS early mortality analysis. Eur J Gastroenterol Hepatol 2002; 14: 723-731.

5. Edwards EB, Harper AM Application of a continuous disease severity score to the OPTN liver waiting list. Clin Transpl 2001; 5: 19-24.

6. Encarnacion CE, Palmaz JC, Rivera FJ et al Transjugular intrahepatic portosystemic shunt placement for variceal bleeding: predictor of mortality. J Vasc Interv Radiol 1995; 6: 687-694.

7. Fejfar T, Hulek P, Stefankova J et al. TIPS in the treatment of alcoholic liver cirrhosis. Alcohol and Alcoholism 2003; 38: S04-S04.

8. Ferral H, Gamboa P, Postoak DW et al. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end stage liver disease score. Radiology 2004; 231: 231-236.

9. Ferral H, Patel NH Selection Criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol 2005; 16: 449-455.

10. Forman LM, Lucey MR Predicting the prognosis of chronic liver disease: An evolution from Child to MELD. Hepatology 2001; 33: 473-475.

11. Hůlek P, Krajina A (eds). Current practice of TIPS, 1. ed. Hradec Králové: Olga Štambergová 2001.

12. Chalasani N, Clark WS, Martin LG et al. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology 2000; 118: 138-144.

13. Child CG 3rd, Turcotte JG Surgery and portal hypertension. In: Child CG 3rd (ed). The Liver and Portal Hypertension. Philadelphia: WB Saunders 1964; 50.

14. Kamath PS, Wiesner RH, Malinchoc M et al A Model to Predict Survival in Patients With End Stage Liver disease. Hepatology 2001; 33: 464-470.

15. Pugh RN, Murray-Lyon IM, Dawson JL et al. Transection of the oesophagus for bleeding oesophageal varices Br J Surg 1973; 60: 646-649.

16. Rajan DK, Haskal ZJ, Clark TW. Serum bilirubin and early mortality after transjugular intrahepatic portosystemic shunts: results of multivariate analysis. J Vasc Interv Radiol 2002; 13: 155-161.

17. Richter GM, Noeldge G, Palmaz JC et al. The transjugular intrahepatic portosystemic stent-shunt (TIPSS): result of a pilot study. Cardiovasc Intervent Radiol 1990; 13: 200-207.

18. Richter GM, Noeldge G, Palmaz JC el al. Transjugular intrahepatic portocaval stent shunt: preliminary clinical results Radiology 1990; 1974: 1027-1030.

19. Rubin RA, Haskal ZJ, O´Brien CB et al. Transjugular intrahepatic portosystemic shunting: decreased survival for patients with APACHE II scores. Am J Gastroenterol 1995; 90: 556-563.

20. Salerno F, Merli M, Cazzaniga M et al. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosytemic shunt. J Hepatol 2002; 36: 494-500.

21. Sherlock S, Dooley J (eds). Diseases of the Liver and Biliary System. 11th ed. Oxford: Blackwell Science 2002.

22. Schepke M, Roth F, Fimmers R et al. Comparison of MELD, Child Pugh and Emory model for prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting. Am J Gastroenterol 2003; 98: 1167-1174.

23. Wiesner RH, McDiarmid SV, Kamath PS et al. MELD and PELD: application of survival models to liver allocation. Liver Transpl 2001; 7: 256-580.

Labels
Diabetology Endocrinology Internal medicine
Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account