title: A MELD-based model to determine risk of mortality among patients with acute variceal bleeding.
abstract: OBJECTIVE
  Patients with cirrhosis with acute variceal bleeding (AVB) have high mortality rates (15%-20%). Previously described models are seldom used to determine prognoses of these patients, partially because they have not been validated externally and because they include subjective variables, such as bleeding during endoscopy and Child-Pugh score, which are evaluated inconsistently. We aimed to improve determination of risk for patients with AVB.
  
  
  METHODS
  We analyzed data collected from 178 patients with cirrhosis (Child-Pugh scores of A, B, and C: 15%, 57%, and 28%, respectively) and esophageal AVB who received standard therapy from 2007 through 2010. We tested the performance (discrimination and calibration) of previously described models, including the model for end-stage liver disease (MELD), and developed a new MELD calibration to predict the mortality of patients within 6 weeks of presentation with AVB. MELD-based predictions were validated in cohorts of patients from Canada (n = 240) and Spain (n = 221).
  
  
  RESULTS
  Among study subjects, the 6-week mortality rate was 16%. MELD was the best model in terms of discrimination; it was recalibrated to predict the 6-week mortality rate with logistic regression (logit, -5.312 + 0.207 • MELD; bootstrapped R(2), 0.3295). MELD values of 19 or greater predicted 20% or greater mortality, whereas MELD scores less than 11 predicted less than 5% mortality. The model performed well for patients from Canada at all risk levels. In the Spanish validation set, in which all patients were treated with banding ligation, MELD predictions were accurate up to the 20% risk threshold.
  
  
  CONCLUSIONS
  We developed a MELD-based model that accurately predicts mortality among patients with AVB, based on objective variables available at admission. This model could be useful to evaluate the efficacy of new therapies and stratify patients in randomized trials.
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.
authors.forename: Enric
authors.initials: E
authors.lastname: Reverter
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada.
authors.forename: Puneeta
authors.initials: P
authors.lastname: Tandon
authors.affiliation: Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Salvador
authors.initials: S
authors.lastname: Augustin
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
authors.forename: Fanny
authors.initials: F
authors.lastname: Turon
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
authors.forename: Stefania
authors.initials: S
authors.lastname: Casu
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada.
authors.forename: Ravin
authors.initials: R
authors.lastname: Bastiampillai
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada.
authors.forename: Adam
authors.initials: A
authors.lastname: Keough
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
authors.forename: Elba
authors.initials: E
authors.lastname: Llop
authors.affiliation: Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Antonio
authors.initials: A
authors.lastname: González
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
authors.forename: Susana
authors.initials: S
authors.lastname: Seijo
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain.
authors.forename: Annalisa
authors.initials: A
authors.lastname: Berzigotti
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada.
authors.forename: Mang
authors.initials: M
authors.lastname: Ma
authors.affiliation: Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca, Universitat Autònoma de Barcelona, Barcelona, Spain.
authors.forename: Joan
authors.initials: J
authors.lastname: Genescà
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.
authors.forename: Jaume
authors.initials: J
authors.lastname: Bosch
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.
authors.forename: Joan Carles
authors.initials: JC
authors.lastname: García-Pagán
authors.affiliation: Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic, Institut d'Investigacions Biomèdiques August Pi i Sunyer, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; Division of Gastroenterology, Department of Medicine, University of Alberta, Edmonton, Canada. Electronic address: juan.g.abraldes@ualberta.ca.
authors.forename: Juan G
authors.initials: JG
authors.lastname: Abraldes
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D002138:Calibration; D002170:Canada / Q000453:epidemiology; D003131:Combined Modality Therapy; D003661:Decision Support Techniques; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D005260:Female; D006471:Gastrointestinal Hemorrhage / Q000150:complications / Q000175:diagnosis* / Q000401:mortality / Q000628:therapy; D006305:Health Status Indicators; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012372:ROC Curve; D015203:Reproducibility of Results; D018570:Risk Assessment / Q000379:methods; D013030:Spain / Q000453:epidemiology
keywords: AUROC; AVB; Cirrhosis; HCC; HVPG; Logistic Regression; MELD; Prognostic Model; ROC; TIPS; acute variceal bleeding; area under receiver operating characteristic curve; hepatic venous pressure gradient; hepatocellular carcinoma; model for end-stage liver disease; receiver operating characteristic; transjugular intrahepatic portosystemic shunt