title: Model for end-stage liver disease excluding international normalized ratio (MELD-XI) score predicts heart transplant outcomes: Evidence from the registry of the United Network for Organ Sharing.
abstract: BACKGROUND
  Hepato-renal function is a valuable predictor of success after left ventricular assist device therapy and heart transplantation. Hence, we analyzed the importance of the Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score to outcomes after heart transplant.
  
  
  METHODS
  Adults undergoing heart transplant from the United Network for Organ Sharing (UNOS) database were identified (1994 to 2014). Individual MELD-XI scores were calculated; patients were stratified by MELD-XI quartiles (Q1 to Q4). Multivariate logistic regression and the Cox proportional hazard model were implemented to determine any association between MELD-XI scores, survival and other outcomes.
  
  
  RESULTS
  From 39,711 patients undergoing OHT during the study period, MELD-XI score [median 10.7 (interquartile range 7.0 to 14.4)] was calculated for 36,005 patients (76% male and 75% white, 34% Status 1A). Higher MELD-XI scores had higher rates of pre-transplant extracorporeal membrane oxygenation, intra-aortic balloon pump, inotrope use and mechanical ventilation (p < 0.001 for all). Adjusted long-term mortality (median follow-up 8.1 years) was associated with MELD-XI score (hazard ratio [HR] 1.021 [1.016 to 1.026], p < 0.001). The highest MELD-XI quartile was associated with an HR 1.364 [1.255 to 1.482] risk of mortality compared with Q1. MELD-XI score was also associated with increased post-transplant infections (adjusted HR Q4 vs Q1: 1.364 [1.153 to 1.614], p < 0.001), stroke (adjusted HR Q4 vs Q1: 1.410 [1.074 to 1.852], p = 0.013), dialysis (adjusted HR Q4 vs Q1: 3.982 [3.386 to 4.683], p < 0.001), rejection (adjusted HR Q4 vs Q1: 1.519 [1.286 to 1.795], p = 0.003) and prolonged hospitalization (adjusted HR Q4 vs Q1: 1.635 [1.429 to 1.871], p < 0.001).
  
  
  CONCLUSIONS
  Hepato-renal dysfunction, measured with MELD-XI score, predicts morbidity and mortality in patients undergoing orthotopic heart transplantation. Etiology of hepato-renal dysfunction should be sought and treated before heart transplantation.
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio; Division of Cardiovascular Surgery, University Hospitals Case Medical Center, Cleveland, Ohio. Electronic address: svd14@case.edu.
authors.forename: Salil V
authors.initials: SV
authors.lastname: Deo
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Sadeer G
authors.initials: SG
authors.lastname: Al-Kindi
authors.affiliation: Queen Alia Heart Institute, Amman, Jordan.
authors.forename: Salah E
authors.initials: SE
authors.lastname: Altarabsheh
authors.affiliation: (d)School of Medicine, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Dustin
authors.initials: D
authors.lastname: Hang
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Sachin
authors.initials: S
authors.lastname: Kumar
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Mahazarin B
authors.initials: MB
authors.lastname: Ginwalla
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Chantal A
authors.initials: CA
authors.lastname: ElAmm
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio; Division of Cardiovascular Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Basar
authors.initials: B
authors.lastname: Sareyyupoglu
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio; Division of Cardiovascular Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Benjamin
authors.initials: B
authors.lastname: Medalion
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Guilherme H
authors.initials: GH
authors.lastname: Oliveira
authors.affiliation: Advanced Heart Failure and Transplantation Center, Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio; Division of Cardiovascular Surgery, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Soon J
authors.initials: SJ
authors.lastname: Park
mesh_terms: D000328:Adult; D005260:Female; D005544:Forecasting; D016027:Heart Transplantation / Q000401:mortality; D006530:Hepatorenal Syndrome; D006801:Humans; D019934:International Normalized Ratio; D008107:Liver Diseases / Q000503:physiopathology*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D016016:Proportional Hazards Models; D012042:Registries; D016896:Treatment Outcome
keywords: MELD-XI; congestive heart failure; heart transplant; hepatic dysfunction; hepato-renal failure; left ventricular assist device