title: Combination of liver biopsy with MELD-XI scores for post-transplant outcome prediction in patients with advanced heart failure and suspected liver dysfunction.
abstract: BACKGROUND
  Functional and structural liver abnormalities may be found in patients with advanced heart failure (HF). The Model of End-Stage Liver Disease Excluding INR (MELD-XI) score allows functional risk stratification of HF patients on and off anti-coagulation awaiting heart transplantation (HTx), but these scores may improve or worsen depending on bridging therapies and during time on the waiting list. Liver biopsy is sometimes performed to assess for severity of fibrosis. Uncertainty remains whether biopsy in addition to MELD-XI improves prediction of adverse outcomes in patients evaluated for HTx.
  
  
  METHODS
  Sixty-eight patients suspected of advanced liver disease underwent liver biopsy as part of their HTx evaluation. A liver risk score (fibrosis-on-biopsy + 1) × MELD-XI was generated for each patient.
  
  
  RESULTS
  Fifty-two patients were listed, of whom 14 had mechanical circulatory support (MCS). Thirty-six patients underwent transplantation and 27 patients survived ≥1 year post-HTx (74%, as compared with 88% average 1-year survival in HTx patients without suspected liver disease; p < 0.01). Survivors had a lower liver risk score at evaluation for HTx (31.0 ± 20.4 vs 65.2 ± 28.6, p < 0.01). A cut-point of 45 for liver risk score was identified by receiver-operating-characteristic (ROC) analysis. In the analysis using Cox proportional hazards models, a liver risk score ≥45 at evaluation for HTx was associated with greater risk of death at 1 year post-HTx compared with a score of <45 in both univariable (HR 3.94, 95% CI 1.77-8.79, p < 0.001) and multivariable (HR 4.35, 95% CI 1.77-8.79, p < 0.001) analyses. Patients who died <1 year post-HTx had an increased frequency of acute graft dysfunction (44.4% vs 3.7%, p = 0.009), longer ventilation times (55.6% vs 11.1%, p = 0.013) and severe bleeding events (44.4% vs 11.1%, p = 0.049). The liver risk score at evaluation for HTx also predicted 1-year mortality after HTx listing (p < 0.001).
  
  
  CONCLUSIONS
  Patients with HF and advanced liver dysfunction are high-risk HTx candidates. Liver biopsy in addition to MELD-XI improves risk stratification of patients with advanced HF and suspected irreversible liver dysfunction.
authors: Department of Medicine, Division of Cardiology. Electronic address: maf2171@columbia.edu.
authors: Maryjane
authors: M
authors: Farr
authors: Department of Pathology.
authors: James
authors: J
authors: Mitchell
authors: Department of Medicine, Division of Cardiology.
authors: Matthew
authors: M
authors: Lippel
authors: Department of Medicine, Division of Cardiology.
authors: Tomoko S
authors: TS
authors: Kato
authors: Department of Biostatistics, Mailman School of Public Health.
authors: Zhezhen
authors: Z
authors: Jin
authors: Department of Medicine, Division of Cardiology.
authors: Paul
authors: P
authors: Ippolito
authors: Department of Surgery, Columbia University Medical Center, New York, New York.
authors: Lorna
authors: L
authors: Dove
authors: Department of Medicine, Division of Cardiology.
authors: Ulrich P
authors: UP
authors: Jorde
authors: Department of Surgery, Columbia University Medical Center, New York, New York.
authors: Hiroo
authors: H
authors: Takayama
authors: Department of Surgery, Columbia University Medical Center, New York, New York.
authors: Jean
authors: J
authors: Emond
authors: Department of Surgery, Columbia University Medical Center, New York, New York.
authors: Yoshifumi
authors: Y
authors: Naka
authors: Department of Medicine, Division of Cardiology.
authors: Donna
authors: D
authors: Mancini
authors: Department of Pathology.
authors: Jay H
authors: JH
authors: Lefkowitch
authors: Department of Medicine, Division of Cardiology.
authors: P Christian
authors: PC
authors: Schulze
mesh_terms: D001706:Biopsy / Q000379:methods*; D058625:End Stage Liver Disease / Q000150:complications / Q000473:pathology*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000150:complications* / Q000601:surgery; D016027:Heart Transplantation; D006801:Humans; D008099:Liver / Q000473:pathology*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D018570:Risk Assessment / Q000379:methods*; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors
keywords: congestive hepatopathy; fibrosis; heart failure; liver disease; risk stratification