title: A new prognostic model to predict dropout from the waiting list in cirrhotic candidates for liver transplantation with MELD score <18.
abstract: OBJECTIVE
  The model for end-stage liver disease (MELD) is used for organ allocation in liver transplantation (LT), but its prognostic performance is less accurate in patients with low score. We assess the outcome of patients with MELD < 18 awaiting LT, finding prognostic variables to identify a high dropout risk.
  
  
  METHODS
  Training set consisted of 277 patients and validation cohort of 292 patients. Competing risk regression analysis, taking into account LT, was used for univariate/multivariate analysis.
  
  
  RESULTS
  Ascites, sodium, bilirubin, albumin and glomerular filtration rate were independently associated with a 12-month dropout risk in the training set. Combining these five prognostic parameters, we calculated a new score named liver-renal-risk (LIRER). In the validation set, the 12-month LIRER concordance index showed a discrimination power [0.798, 95% confidence interval (95% CI) 0.793-0.803] better than MELD (0.582, 95% CI 0.575-0.588), Child-Turcotte-Pugh (0.687, 95% CI 0.681-0.693), MELD-sodium (0.721, 95% CI 0.715-0.727) and MELD-ascites-sodium (0.729, 95% CI 0.724-0.735), with a remarkable calibration (Hosmer-Lemeshow test: P = 0.91; R(2) = 0.911). Considering all study patients, the risk of wait list dropout increased with the rise in LIRER. The survival benefit analysis comparing the wait list dropout risk with the mortality of the 216 transplanted patients with same LIRER showed an important benefit for LT in patients with LIRER > 15.9.
  
  
  CONCLUSIONS
  In patients with low MELD (<18), combination of ascites, sodium, albumin, bilirubin and renal function in a new score (LIRER) discriminates patients at high risk of medium-term adverse outcome from those in whom LT may be safely deferred.
authors.affiliation: Dipartimento di Scienze Mediche e Chirurgiche, University of Bologna, Bologna, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Biselli
authors.forename: Marco
authors.initials: M
authors.lastname: Dall'Agata
authors.forename: Annagiulia
authors.initials: A
authors.lastname: Gramenzi
authors.forename: Stefano
authors.initials: S
authors.lastname: Gitto
authors.forename: Caterina
authors.initials: C
authors.lastname: Liberati
authors.forename: Lucia
authors.initials: L
authors.lastname: Brodosi
authors.forename: Matteo
authors.initials: M
authors.lastname: Ravaioli
authors.forename: Martina
authors.initials: M
authors.lastname: Gambato
authors.forename: Roberto
authors.initials: R
authors.lastname: Montalti
authors.forename: Antonio D
authors.initials: AD
authors.lastname: Pinna
authors.forename: Patrizia
authors.initials: P
authors.lastname: Burra
authors.forename: Giorgio E
authors.initials: GE
authors.lastname: Gerunda
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo
authors.forename: Pietro
authors.initials: P
authors.lastname: Andreone
authors.forename: Mauro
authors.initials: M
authors.lastname: Bernardi
mesh_terms: D001201:Ascites / Q000473:pathology; D001663:Bilirubin / Q000097:blood; D015331:Cohort Studies; D058625:End Stage Liver Disease / Q000209:etiology / Q000601:surgery*; D005919:Glomerular Filtration Rate / Q000502:physiology; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D016031:Liver Transplantation / Q000379:methods / Q000592:standards*; D008962:Models, Theoretical; D011237:Predictive Value of Tests; D011379:Prognosis; D012044:Regression Analysis; D018570:Risk Assessment / Q000379:methods*; D012709:Serum Albumin; D012720:Severity of Illness Index; D012964:Sodium / Q000097:blood; D014850:Waiting Lists
chemical_list: D012709:Serum Albumin; D012964:Sodium; D001663:Bilirubin
keywords: competing risk; liver transplantation; organ allocation; prognosis; scoring system; survival analysis; wait list