Utility of preoperative scores for predicting morbidity after cholecystectomy in patients with cirrhosis.

BACKGROUND & AIMS: Patients with cirrhosis have an increased risk for cholelithiasis but also have an increased risk for morbidity and mortality after cholecystectomy. Current preoperative assessment of surgical risk is imprecise. Our aims were to identify preoperative factors that would accurately predict the risk for cholecystectomy in patients with cirrhosis. METHODS: Preoperative clinical or biochemical parameters were determined for 33 patients with cirrhosis and 31 age- and sex-matched patients without cirrhosis. The use of these parameters and of the Child-Pugh and model for end-stage liver disease (MELD) scores as preoperative predictors of outcome after surgery were assessed. RESULTS: There were 2 deaths, both in cirrhotic patients. The overall risk for morbidity or mortality was increased in cirrhotic patients compared with controls. Postoperative morbidity was significantly associated with preoperative increases of international normalized ratio >1.2, bilirubin >1.0 mg/dL, creatinine >1.4 mg/dL, and a decreased platelet count <150 x 10(3) /mL. The MELD and Child-Pugh scores accurately predicted postoperative morbidity, with an area under the curve of 0.938 and 0.839, respectively. A preoperative MELD score of > or =8 had a sensitivity of 91% and a specificity of 77% for predicting postoperative morbidity. Persons with a MELD score of > or =8 had increased 30- and 90-day global charges and increased blood product usage. CONCLUSIONS: Preoperative biochemical parameters, international normalized ratio, bilirubin, platelets, and creatinine can predict increased morbidity in cirrhotic patients. A MELD score of > or =8 identifies a group at high risk for postoperative morbidity after cholecystectomy.     

Use of the Model for End-Stage Liver Disease (MELD) score to predict 1-year survival of Japanese patients with cirrhosis and to determine who will benefit from living donor liver transplantation

BACKGROUND: Consideration of the prognosis of patients with liver cirrhosis is important when determining the appropriate timing of liver transplantation. Especially in Japan, where 99% of liver transplants are from living donors, timing is very important not only for the patient but also for the family, who need time to consider the various factors involved in living donations. METHODS: To clarify the applicability of the Model for End-Stage Liver Disease (MELD) score in Japanese patients with cirrhosis, changes in the MELD score over 24 months were reviewed in 79 patients with cirrhosis who subsequently died of liver failure (n=33) or who survived 24 months (n=46). All patients had Child class B or C cirrhosis at the start of follow-up. We also compared their survival with that of 30 patients treated by living donor liver transplantation (LDLT) in our institute to determine the proper timing of transplantation in patients with cirrhosis. RESULTS: Significant stratification of survival curves was observed for MELD scores of <12, 12-15, 15-18, and >18 (P=0.0018). A significant survival benefit of LDLT was observed in patients with MELD score >or=15 (P=0.0181), and significantly more risk with transplantation was observed in those with MELD score <15 compared with that of patients in whom the disease followed its natural course (P=0.0168). CONCLUSIONS: MELD score is useful for predicting 1-year survival in Japanese patients with cirrhosis. MELD scores of 15 had discriminatory value for indicating a survival benefit to be gained by liver transplantation and thus can be used to help patients and their families by identifying patients who would benefit from LDLT.     

Surgical clearance for the patient with chronic liver disease

Patients with chronic liver disease face greater risk of perioperative morbidity and mortality, with the greatest risk among patients with cirrhosis. Both the Child-Pugh score and the Model for End-Stage Liver Disease have been evaluated as predictors of postoperative mortality. Other comorbidities, age, and American Society of Anesthesiologists physical status classification are also important predictors of these outcomes. In patients with liver disease, elective surgeries should be delayed to allow complete evaluation of the severity of liver disease, including the role of transplantation in the event of hepatic decompensation postoperatively.     

The additive value of sarcopenia,myosteatosis and hepatic encephalopathy in the predictivity of model for end-stage liver disease

BackgroundSince the use of the Model for End-Stage Liver Disease (MELD) score for establishing the prognosis of cirrhotic patients has been introduced, questions have been raised whether complications of liver cirrhosis would provide additional information. Myosteatosis, sarcopenia and hepatic encephalopathy (HE) are frequent in cirrhosis and may affect prognosis.Aim of the study was analyzing if these factors are independently related to survival and may improve the accuracy of MELD.Methods249 cirrhotics that underwent abdominal CT-scan were enrolled. For each patient, information about previous episodes of HE and muscle alterations were obtained. Patients were followed until transplantation or death.ResultsHistory of HE, MELD, sarcopenia and myosteatosis were independently associated with mortality. The MELD-Sarco-Myo-HE score added accuracy to the MELD score alone for 6- and 3-months mortality. By removing HE, as the only not quantifiable parameter of the model, no relevant decrease in accuracy for 6- and 3-months mortality detection was observed.ConclusionsThe accuracy of MELD in predicting 3- and 6-months mortality may be improved by considering the muscle alterations. A model considering the above parameters may classify more accurately over 30% of the patients.     

肝移植术后早期急性肺水肿14例临床相关因素分析

目的 探讨肝移植术后早期急性肺水肿的临床相关因素,为临床合理处理提供线索。方法观察我院行肝移植术后急性肺水肿14例患者的术前终末期肝病模型（MELD）评分、手术前后肾功能（尿量、血肌酐）的变化情况;记录移植术中及术后前3d总入量、总出量和液体平衡量。结果肝移植术后急性肺水肿患者（14例）术前MELD评分较非肺水肿组（127例）显著增高（P〈0．01）,且术后死亡率明显上升（P〈0．01）;急性肺水肿患者术前存在肾功能不全,术后血肌酐、尿量延迟恢复;术中、术后液体正平衡显著增加,与非肺水肿组差异均有统计学意义（P〈0．01）。结论肝移植术后早期急性肺水肿与术前高MELD分值、术前肾功能障碍、术后肾功能延迟恢复及术中大量输液、术后限液不足密切相关,术中、术后严格控制出入量平衡,尽快恢复患者肾功能及相关重要脏器支持是防止肝移植早期急性肺水肿的有效措施。     

急性Stanford A型主动脉夹层患者术后肝功能不全的危险因素及预后分析

目的 探讨急性Stanford A型主动脉夹层患者术后发生肝功能不全(HD)的危险因素和预后.方法 回顾性分析青岛市市立医院2014年5月至2018年5月156例接受外科手术的急性Stanford A型主动脉夹层患者围术期资料.采用终末期肝病模型(MELD)评分评估患者术后肝功能,并分为HD组35例(MELD评分≥15...     

MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study

BACKGROUND: Indices for predicting survival are essential for assessing prognosis and assigning priority for liver transplantation in patients with liver cirrhosis. The model for end stage liver disease (MELD) has been proposed as a tool to predict mortality risk in cirrhotic patients. However, this model has not been validated beyond its original setting. AIM: To evaluate the short and medium term survival prognosis of a European series of cirrhotic patients by means of MELD compared with the Child-Pugh score. We also assessed correlations between the MELD scoring system and the degree of impairment of liver function, as evaluated by the monoethylglycinexylidide (MEGX) test. PATIENTS AND METHODS: We retrospectively evaluated survival of a cohort of 129 cirrhotic patients with a follow up period of at least one year. The Child-Pugh score was calculated and the MELD score was computed according to the original formula for each patient. All patients had undergone a MEGX test. Multivariate analysis was performed on all variables to identify the parameters independently associated with one year and six month survival. MELD values were correlated with both Child-Pugh scores and MEGX test results. RESULTS: Thirty one patients died within the first year of follow up. Child-Pugh and MELD scores, and MEGX serum levels were significantly different among patients who survived and those who died. Serum creatinine, international normalised ratio, and MEGX(60) were independently associated with six month mortality while the same variables and the presence of ascites were associated with one year mortality. MELD scores showed significant correlations with both MEGX values and Child-Pugh scores. CONCLUSIONS: In a European series of cirrhotic patients the MELD score is an excellent predictor of both short and medium term survival, and performs at least as well as the Child-Pugh score. An increase in MELD score is associated with a decrease in residual liver function.     

Validation of a Mayo post‐operative mortality risk prediction model in Korean cirrhotic patients

Background: Patients with cirrhosis have an increased risk of mortality after surgery. In 2007, a new model was suggested to calculate mortality risk at specific time points after surgery at the Mayo clinic. Aims: We investigated the mortality risks in Korean cirrhotic patients who underwent various surgeries and applied the Mayo clinic model to our study populations. Methods: We conducted a retrospective review of the charts of 160 patients with cirrhosis who underwent surgical procedures under general anaesthesia between January 1996 and December 2006 at two hospitals. Results: The overall 30‐, 90‐day and 1‐year mortality rates were 7.5, 9.4 and 10.6% respectively. In multivariate analysis, the Child–Turcotte–Pugh (CTP) score, model for end‐stage liver disease (MELD) and the American Society of Anesthesiologists (ASA) physical status classification and age were significantly associated with mortality. The area under the receiver operating characteristic (AUROC) from the calculated value using Mayo model as a predictor of 30‐, 90‐day and 1‐year mortality was 0.832, 0.803 and 0.822 respectively, of which, 1‐year mortality was significantly different from AUROC of mortality prediction based on our patient's data (P=0.025). In addition, the mean of predicted 1‐year mortality rate (22.6±12.0%) using Mayo model was significantly higher than that from observed (8.9±1.4%, P<0.01). Conclusions: The CTP score or MELD score or ASA physical class and age were found to be significant predictors of post‐operative mortality in cirrhotic patients. The risk prediction model developed at the Mayo clinic showed good performance in Korean cirrhotic patients. However, we found that the model tended to overestimate mortality, especially 1 year after surgery.     

Child-Pugh-Turcott versus Meld score for predicting survival in a retrospective cohort of black African cirrhotic patients

AIM： To compare the performance of the Child-Pugh- Turcott （CPT） score to that of the model for end-stage liver disease （MELD） score in predicting survival of a retrospective cohort of 172 Black African patients with cirrhosis on a short and mid-term basis.
METHODS： Univariate and multivariate （Cox model） analyses were used to identify factors related to mortality. Relationship between the two scores was appreciated by calculating the correlation coefficient. The Kaplan Meier method and the log rank test were used to elaborate and compare survival respectively. The Areas Under the Curves were used to compare the performance between scores at 3, 6 and 12 mo.
RESULTS： The study population comprised 172 patients, of which 68.9% were male. The mean age of the patient was 47.5 ± 13 years. Hepatitis B virus infection was the cause of cirrhosis in 70% of the cases. The overall mortality was 31.4% over 11 years of follow up. Independent factors significantly associated with mortality were： CPT score （HR = 3.3, 95% CI [1.7-6.2]） （P 〈 0.001） （stage C vs stage A-B）; Serum creatine （HR = 2.5, 95% CI [1.4-4.3]） （P = 0.001） （Serum creatine 〉 1.5 mg/dL versus serum creatine 〈 1.5 mg/dL）; MELD score （HR = 2.9, 95% CI [1.63-5.21]） （P 〈 0.001） （MELD 〉 21 vs MELD 〈 21）. The area under the curves （AUC） that predict survival was 0.72 and 0.75 at 3 mo （P = 0.68）, 0.64 and 0.62 at 6 mo （P = 0.67）, 0.69 and 0.64 at 12 mo （P = 0.38） respectively for the CPT score and the MELD score.
CONCLUSION： The CPT score displays the same prognostic significance as does the MELD score in black African patients with cirrhosis. Moreover, its handling appears less cumbersome in clinical practice as compared to the latter.     

Model for end-stage liver disease score versus Child score in predicting the outcome of surgical procedures in patients with cirrhosis

AIM： To determine factors affecting the outcome of patients with cirrhosis undergoing surgery and to compare the capacities of the Child-Turcotte-Pugh （CTP） and model for end-stage liver disease （MELD） score to predict that outcome. METHODS： We reviewed the charts of 195 patients with cirrhosis who underwent surgery at two teaching hospitals over a five-year period. The combined endpoint of death or hepatic decompensation was considered to be the primary endpoint. RESULTS： Patients who reached the endpoint had a higher MELD score, a higher CTP score and were more likely to have undergone an urgent procedure. Among patients undergoing elective surgical procedures, no statistically significant difference was noted in the mean MELD （12.8 ＋ 3.9 vs 12.6 ＋ 4.7, P = 0.9） or in the mean CTP （7.6 ± 1.2 vs 7.7 ± 1.7, P = 0.8） between patients who reached the endpoint and those who did not. Both mean scores were higher in the patients reaching the endpoint in the case of urgent procedures （MELD： 22.4 ± 8.7 vs 15.2 ± 6.4, P = 0.0007; CTP： 9.9 ± 1.8 vs 8.5 ± 1.8, P = 0.008）. The performances of the MELD and CTP scores in predicting the outcome of urgent surgery were only fair, without a significant difference between them （AUC = 0.755 ± 0.066 for MELD vs AUC = 0.696 ± 0.070 for CTP, P = 0.3）. CONCLUSION： The CTP and MELD scores performed equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.equally, but only fairly in predicting the outcome of urgent surgical procedures. Larger studies are needed to better define the factors capable of predicting the outcome of elective surgical procedures in patients with cirrhosis.     

The model for end-stage liver disease (MELD) predicts survival of liver cirrhosis patients after discharge to hospice

AIM: To assess if the Model for End-stage Liver Disease (MELD) score correlates with survival of liver cirrhosis patients after discharge to hospice. METHODS: Patients who were discharged to a hospice program for decompensated liver cirrhosis during a 7-year period were identified. MELD score was calculated for all patients. Medical records and the Social Security Death Index (SSDI) were used to determine the exact date of death and survival after discharge. RESULTS: Fifty patients were identified. Average MELD score was 26.4. Exact date of death was available for 42 of these patients. Average survival after discharge to hospice was 36.83 days. There was a moderate correlation (r=-0.61, P<0.0001) between MELD scores and survival after hospice discharge. The area under the receiver operating characteristic curve for MELD score predicting 30-day mortality was 0.84. MELD score >/=25 predicted 30-day mortality with a sensitivity of 74.19%, a specificity of 90.91%, and an accuracy of 78.58%. The positive predictive value was 95.83% and the negative predictive value 55.56%. CONCLUSIONS: Patients with cirrhosis who are not candidates for liver transplantation are referred to hospice care at a late stage with an average survival of 1 month. The MELD score correlates with survival of cirrhosis patients enrolled in hospice and can be used to estimate 30-day mortality. Further, research is needed to determine a MELD score that predicts a survival of 6 months or less, an important determinant of appropriate hospice referrals.     

Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death

Despite the adoption of "sickest first" liver transplantation, pretransplant death remains common, and many early deaths occur despite initially low Model for End-stage Liver Disease (MELD) scores. From 1997-2003, we studied 507 cirrhotic United States veterans referred for consideration of liver transplantation to identify additional predictors of early mortality. Most of the patients were male (98%) with cirrhosis caused by hepatitis C and/or alcohol (88%). Data for 296 patients referred prior to February 27, 2002 (training group), were analyzed; findings were validated in 211 patients referred subsequently (validation group). In the training group, 61 patients (21%) died within 180 days without transplantation; their median initial MELD score was 21. MELD score, persistent ascites, and low serum sodium (<135 meq/L) were independent predictors of early mortality. In patients with a MELD score of less than 21, only low serum sodium and persistent ascites were independent predictors of mortality; for MELD scores above 21, only MELD was independently predictive. Prognostic significance of persistent ascites and low serum sodium for low MELD score patients was confirmed in the validation group. Risk varied continuously with worsening hyponatremia. Modifying MELD, by including points for persistent ascites and low serum sodium, improved prediction of early pretransplant mortality in low MELD score patients. In conclusion, persistent ascites and low serum sodium identify patients with cirrhosis with high mortality risk despite low MELD scores. Ascites, hyponatremia, and other findings indicative of hemodynamic decompensation merit further prospective study as prognostic indicators in patients awaiting liver transplantation, and should be considered in setting minimal listing criteria.     

Cardiac surgery in patients with liver cirrhosis: Risk factors for predicting mortality

AIM: To evaluate the results of cardiac surgery in cirrhotic patients and to find the predictors of early and late mortality.METHODS: We included 55 consecutive cirrhotic patients undergoing cardiac surgery between 1993 and 2012. Child-Turcotte-Pugh (Child) classification and Model for End-Stage Liver Disease (MELD) score were used to assess the severity of liver cirrhosis. The online EuroSCORE II calculator was used to calculate the logistic EuroSCORE in each patient. Stepwise logistic regression analysis was used to identify the risk factors for mortality at different times after surgery. Multivariate Cox proportional hazard models were applied to estimate the hazard ratios (HR) of predictors for mortality. The Kaplan-Meier method was used to generate survival curves, and the survival rates between groups were compared using the log-rank test.RESULTS: There were 30 patients in Child class A, 20 in Child B, and five in Child C. The hospital mortality rate was 16.4%. The actuarial survival rates were 70%, 64%, 56%, and 44% at 1, 2, 3, and 5 years after surgery, respectively. There were no significant differences in major postoperative complications, and early and late mortality between patients with mild and advanced cirrhosis. Multivariate logistic regression showed preoperative serum bilirubin, the EuroSCORE and coronary artery bypass grafting (CABG) were associated with early and late mortality; however, Child class and MELD score were not. Cox regression analysis identified male gender (HR = 0.319; P = 0.009), preoperative serum bilirubin (HR = 1.244; P = 0.044), the EuroSCORE (HR = 1.415; P = 0.001), and CABG (HR = 3.344; P = 0.01) as independent risk factors for overall mortality.CONCLUSION: Advanced liver cirrhosis should not preclude patients from cardiac surgery. Preoperative serum bilirubin, the EuroSCORE, and CABG are major predictors of early and late mortality.     

MELD score and serum sodium in the prediction of survival of patients with cirrhosis awaiting liver transplantation

BACKGROUND/ AIMS: Serum sodium predicts prognosis in cirrhosis and may improve the prognostic accuracy of the model for end-stage liver disease (MELD) score, but the available information is limited. The aim of the present study was to assess the prognostic value of serum sodium in the prediction of survival at 3 and 12 months after listing in patients with cirrhosis awaiting liver transplantation, and to compare its predictive value with that of the MELD score. PATIENTS AND METHODS: 308 consecutive patients with cirrhosis listed for transplantation during a 5-year period were included in the study. The end-point was survival at 3 and 12 months before transplantation. Variables obtained at the time of listing were analysed for prognostic value using multivariable analysis. Accuracy of prognostic variables was analysed by receiver operating characteristic (ROC) curves. RESULTS: The MELD score and serum sodium concentration were the only independent predictors of survival at 3 and 12 months after listing. Low serum sodium was associated with an increased risk of death in all subpopulations of patients with cirrhosis categorised according to the major complication developed before listing. The area under the ROC curves for serum sodium and MELD score was not significantly different both at 3 months (0.83 vs 0.79, respectively) and at 12 months (0.70 vs 0.77, respectively). The addition of serum sodium did not significantly improve the accuracy of the MELD score in the prediction of survival at 3 and 12 months. CONCLUSION: In patients with cirrhosis awaiting liver transplantation, serum sodium and MELD were found to be independent predictors of survival. Larger studies are needed to determine whether the addition of serum sodium to MELD can improve its prognostic accuracy.     

Prediction of the prognosis in patients with acute-on-chronic hepatitis using the MELD scoring system

AIM: To predict prognosis in patients with acute-on-chronic hepatitis (AOCH) using the model for end-stage liver disease (MELD) scoring system and to study the effects of age, sex, etiology, low serum sodium, and persistent ascites on MELD. METHODS: The MELD scores of 300 patients with AOCH were calculated according to the original formula. The 3-month mortality in patients was measured, and the validity of the models was determined by means of the concordance (c) statistic. The influential factors on MELD were also assessed. RESULTS: The 3-month mortality of AOCH patients with a MELD score of 20-29 was 56.0%, with a score of 30-39 it was 76.5%, and with a score over 40 it was 98.2%. The concordance (c) statistic of 3-month mortality was 0.782. Univariate analysis showed that mortality was significantly related to age (P=0.047), etiology (P=0.039), serum sodium (P=0.029) and ascites (P=0.031) for patients with MELD scores 20-29. In multivariate analysis, in patients with MELD scores 20-29, age (P=0.012), etiology (P=0.024), serum sodium (P=0.005) and ascites (P=0.017) were independent predictors of mortality; for MELD scores above 30, only MELD score (P=0.015) was independently predictive. CONCLUSIONS: The MELD scoring system is a reliable method for predicting mortality in patients with AOCH. In the group with MELD score 20-29, factors including age, etiology, presence of low serum sodium and persistent ascites may influence the MELD scoring system. The MELD score is the decisive predictor of the prognosis of patients with AOCH when the MELD score is over 30.     

How Do Patients Aged 85 and Older Fare with Abdominal Surgery?

OBJECTIVES: To review the outcomes of patients aged 85 and older after abdominal surgery in terms of mortality, morbidity, and change in residential status and to analyze factors predicting such outcomes.
DESIGN: Retrospective clinical cohort study.
SETTING: A tertiary regional hospital in Victoria, Australia.
PARTICIPANTS: One hundred seventy-nine patients aged 85 and older who had abdominal surgery between 1998 and 2008.
MEASUREMENTS: Mortality, complications (morbidity), and change in residential status.
RESULTS: The patient sample had a mean age of 88.6, a mortality rate of 17.3%, and a morbidity rate of 62.8%. Approximately two-thirds (64%) of all abdominal surgeries were emergency surgeries. Factors predicting mortality included American Society of Anesthesiologists (ASA) score and premorbid residential status. Risk factors predicting severity of complications were ASA score and emergency surgery. Significant factors contributing to change in residential status were ASA score and severity of complications. Age, sex, and number of comorbidities were not significant factors.
CONCLUSION: Patients aged 85 and older experienced mortality rates of 17.3% after abdominal surgery. ASA score and premorbid residential status appear to be more important than age in determining risk for abdominal surgery in older persons.     

Assessment of prognosis of cirrhosis

Once patients with cirrhosis experience decompensation, early mortality risk increases sharply. Liver transplantation has transformed the prognosis of decompensated cirrhosis. Child-Pugh score has been the reference for many years for assessing the prognosis of cirrhosis. However, Child-Pugh score has important limitations among which is subjective interpretation of some of its variables, making it difficult to categorize patients according to their own disease severity. The model for end-stage liver disease (MELD) score, which was originally designed for assessing the prognosis of cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS), is a continuous score relying on three objective variables. Along with TIPS, MELD score proved to be a robust marker of early mortality across a wide spectrum of causes of cirrhosis, even though 10 to 20% of patients are still misclassified. MELD is especially useful for prioritizing candidates for transplantation according to a "sickest first" policy. However, MELD is not a universal prognostic marker of cirrhosis and several MELD exceptions require more specific approaches.     

Predicting outcome after cardiac surgery in patients with cirrhosis: a comparison of Child-Pugh and MELD scores.

BACKGROUND & AIMS: This study aims to quantify the risk of cardiac surgery in patients with cirrhosis. METHODS: Records of all adult patients with cirrhosis undergoing cardiac surgery using cardiopulmonary bypass at the Cleveland Clinic (Cleveland, OH) from January 1992 to June 2002 were analyzed for any relationship of Child-Pugh class and/or score and Model for End-Stage Liver Disease (MELD) score with outcome measures of hepatic decompensation and death during the first 3 months after surgery. RESULTS: Forty-four patients underwent coronary artery bypass grafting (16 patients), valve surgery (16 patients), a combination of the 2 procedures (10 patients), or pericardiectomy (2 patients). Twelve patients (27%) developed hepatic decompensation, and 7 patients (16%) died. Proportions of hepatic decompensation were 3 of 31, 8 of 12, and 1 of 1 patients, and death, 1 of 31, 5 of 12, and 1 of 1 patients in Child-Pugh classes A, B, and C, respectively. The association of hepatic decompensation and mortality with Child-Pugh class, Child-Pugh score, and MELD score was significant (P < 0.005). Areas under the receiver operating characteristic curves for mortality were similar for Child-Pugh (0.84 +/- 0.09) and MELD scores (0.87 +/- 0.09). A cutoff Child-Pugh score >7 was found to have a sensitivity and specificity of 86% and 92% for mortality, with a negative predictive value of 97% (95% confidence interval [CI], 83-99) and positive predictive value of 67% (95% CI, 31-91), respectively. However, a similar cutoff value for MELD score could not be established. CONCLUSIONS: Child-Pugh score and/or class and MELD score are significantly associated with hepatic decompensation and mortality after cardiac surgery using cardiopulmonary bypass in patients with cirrhosis. Such surgery can be conducted safely in patients with a Child-Pugh score /=8 have a significant risk for mortality.     

MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation

Important progress has been made recently regarding the pathogenesis and treatment of hepatorenal syndrome (HRS). However, scant information exists about factors predicting outcome in patients with cirrhosis and HRS. Moreover, the prognostic value of the model of end-stage liver disease (MELD) score has not been validated in the setting of HRS. The current study was designed to assess the prognostic factors and outcome of patients with cirrhosis and HRS. The study included 105 consecutive patients with HRS. Forty-one patients had type 1 HRS, while 64 patients had type 2 HRS. Patients with type 1 HRS not only had more severe liver and renal failure than type 2 patients, they also had greater impairment of circulatory function, as indicated by lower arterial pressure and higher activation of vasoconstrictor factors. In the whole series, the median survival was 3.3 months. In a multivariate analysis of survival, only HRS type and MELD score were associated with an independent prognostic value. All patients with type 1 HRS had a high MELD score (> or =20) and showed an extremely poor outcome (median survival: 1 mo). By contrast, the survival of patients with type 2 HRS was longer and dependent on MELD score (> or =20, median survival 3 mo; <20, median survival 11 mo; P < .002). In conclusion, the outcome of patients with cirrhosis and HRS can be estimated by using two easily available variables, HRS type and MELD score. These data can be useful in the management of patients with HRS, particularly for patients who are candidates for liver transplantation.     

三种评分系统在肝硬化食管胃底静脉曲张破裂出血患者风险评估中的应用

目的探讨MELD(model for end-stage liver disease)、GBS(glasgow-blatchford score)、AIMS65评分系统在肝硬化食管胃底静脉曲张破裂出血(esophageal and gastric variceal bleeding,EGVB)患者风险评估中的临床应用价值。方法对天津医科大学总医院消化内科2015年1月1日至2018年3月1日入院的182例肝硬化EGVB患者进行回顾分析,依据MELD、GBS、AIMS65评分系统标准针对每例患者进行评分,评估各评分系统正确将肝硬化EGVB归为"高风险患者"的能力,并绘制受试者工作特征曲线(receiver-operating characteristic curve,ROC),采用曲线下面积(area under curve,AUC)评估各评分系统针对不同临床结局(输血、再出血、住院死亡)的预测能力,AUC>0.7认为有较高准确性。结果临床结局包括输血113例(62.1%)、再出血31例(17.0%)、死亡11例(6.0%)。MELD评分得分为7~25分,其中得分<9分4例(2.2%);GBS评分得分为3~16分;AIMS65评分得分为0~3分,其中得分0~1分139例(76.4%,0分68例、1分71例)。MELD、GBS、AIMS65评分系统预测输血的AUC分别为0.514(95%CI:0.439~0.589)、0.681(95%CI:0.608~0.748)、0.669(95%CI:0.596~0.737);预测再出血的AUC分别为0.525(95%CI:0.449~0.599)、0.528(95%CI:0.453~0.602)、0.580(95%CI:0.505~0.652);预测住院死亡的AUC分别为0.642(95%CI:0.567~0.711)、0.581(95%CI:0.505~0.653)、0.786(95%CI:0.719~0.843),AIMS65优于MELD(P=0.0836)和GBS(P=0.0470)。结论GBS能正确将肝硬化EGVB患者归类为"高风险人群",优于AIMS65和MELD评分系统。对于肝硬化EGVB患者,3种评分系统对输血和再出血的预测价值均不高,AIMS65对住院死亡有较高的预测价值。