Limitations of the MELD score in predicting mortality or need for removal from waiting list in patients awaiting liver transplantation.
BACKGROUND
Decompensated cirrhosis is associated with a poor prognosis and liver transplantation provides the only curative treatment option with excellent long-term results. The relative shortage of organ donors renders the allocation algorithms of organs essential. The optimal strategy based on scoring systems and/or waiting time is still under debate.


METHODS
Data sets of 268 consecutive patients listed for single-organ liver transplantation for nonfulminant liver disease between 2003 and 2005 were included into the study. The Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP) scores of all patients at the time of listing were used for calculation. The predictive ability not only for mortality on the waiting list but also for the need for withdrawal from the waiting list was calculated for both scores. The Mann-Whitney-U Test was used for the univariate analysis and the AUC-Model for discrimination of the scores.


RESULTS
In the univariate analysis comparing patients who are still on the waiting list and patients who died or were removed from the waiting list due to poor conditions, the serum albumin, bilirubin INR, and CTP and MELD scores as well as the presence of ascites and encephalopathy were significantly different between the groups (p < 0.05), whereas serum creatinine and urea showed no difference. Comparing the predictive abilities of CTP and MELD scores, the best discrimination between patients still alive on the waiting list and patients who died on or were removed from the waiting list was achieved at a CTP score of >or=9 and a MELD score of >or=14.4. The sensitivity and specificity to identify mortality or severe deterioration for CTP was 69.0% and 70.5%, respectively; for MELD, it was 62.1% and 72.7%, respectively. This result was supported by the AUC analysis showing a strong trend for superiority of CTP over MELD scores (AUROC 0.73 and 0.68, resp.; p = 0.091).


CONCLUSIONS
The long term prediction of mortality or removal from waiting list in patients awaiting liver transplantation might be better assessed by the CTP score than the MELD score. This might have implications for the development of new improved scoring systems.
Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany. daniel_gotthardt@med.uni-heidelberg.de
Daniel
D
Gotthardt
Karl Heinz
KH
Weiss
Melanie
M
Baumgärtner
Alexandra
A
Zahn
Wolfgang
W
Stremmel
Jan
J
Schmidt
Thomas
T
Bruckner
Peter
P
Sauer
D000293:Adolescent; D000328:Adult; D000368:Aged; D000465:Algorithms; D001201:Ascites / Q000175:diagnosis / Q000209:etiology; D001663:Bilirubin / Q000097:blood; D003404:Creatinine / Q000097:blood; D005260:Female; D006501:Hepatic Encephalopathy / Q000175:diagnosis / Q000209:etiology; D006801:Humans; D008107:Liver Diseases / Q000150:complications / Q000401:mortality* / Q000601:surgery*; D016031:Liver Transplantation / Q000639:trends*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D018579:Patient Selection; D011237:Predictive Value of Tests; D011379:Prognosis; D040841:Resource Allocation / Q000379:methods; D012189:Retrospective Studies; D012709:Serum Albumin / Q000378:metabolism; D012720:Severity of Illness Index; D014850:Waiting Lists; D055815:Young Adult
D012709:Serum Albumin; D003404:Creatinine; D001663:Bilirubin