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2015, Number 3

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Ann Hepatol 2015; 14 (3)

MELD score for prediction of survival after emergent TIPS for acute variceal hemorrhage: derivation and validation in a 101-patient cohort

Casadaban LC, Parvinian A, Zivin SP, Lakhoo J, Minocha J, Knuttinen MG, Ray Jr CE, Bui JT, Gaba RC

Language: English
References: 29
Page: 380-388
PDF size: 113.37 Kb.


ABSTRACT

Background and rationale for the study. The Model for End Stage Liver Disease (MELD) score has not been derived and validated for the emergent transjugular intrahepatic portosystemic shunt (TIPS) population. We sought to identify predictive factors for survival among emergent TIPS patients, and to substantiate MELD for outcomes prognostication in this population. Results. 101 patients with acute life threatening variceal hemorrhage underwent emergent TIPS (defined by failed endoscopic therapy for active bleeding, acute hemoglobin drop, ≥ 2-unit transfusion requirement, and/or vasopressor need) at between 1998-2013. Demographic, clinical, laboratory, and procedure parameters were analyzed for correlation with mortality using Cox proportional hazards regression to derive the prognostic value of MELD constituents. Area under receiver operator characteristic (AUROC) curves was used to assess the capability of MELD prediction of mortality. TIPS were created 119 ± 167 h after initial bleeding events. Hemodynamic success was achieved in 90%. Median final portosystemic pressure gradient was 8 mmHg. Variceal rebleeding incidence was 21%. The four original MELD components showed significant correlation with mortality on multivariate Cox regression: baseline bilirubin (regression coefficient 0.366), creatinine (0.621), international normalized ratio (1.111), and liver disease etiology (0.808), validating the MELD system for emergent cases. No other significant predictive parameters were identified. MELD was an excellent predictor of 90-day mortality in the emergent TIPS population (AUROC = 0.842, 95% CI 0.755-0.928). Conclusions. Based on independent derivation of prognostic constituents and confirmation of predictive accuracy, MELD is a valid and reliable metric for risk stratification and survival projection after emergent TIPS.


REFERENCES

  1. Malinchoc M, Kamath PS, Gordon FD, Peine CJ, Rank J, ter Borg PC. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology 2000; 31: 864-71.

  2. Angermayr B, Cejna M, Karnel F, Gschwantler M, Koenig F, Pidlich J, Mendel H, et al. Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt. Gut 2003; 52: 879-85.

  3. Ferral H, Gamboa P, Postoak DW, Albernaz VS, Young CR, Speeg KV, McMahan CA. Survival after elective transjugular intrahepatic portosystemic shunt creation: prediction with model for end-stage liver disease score. Radiology 2004; 231: 231-6.

  4. Salerno F, Merli M, Cazzaniga M, Valeriano V, Rossi P, Lovaria A, Meregaglia D, et al. MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt. J Hepatol 2002; 36: 494-500.

  5. Schepke M, Roth F, Fimmers R, Brensing KA, Sudhop T, Schild HH, Sauerbruch T. Comparison of MELD, Child-Pugh, and Emory model for the prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting. Am J Gastroenterol 2003; 98: 1167-74.

  6. Gaba RC, Couture PM, Bui JT, Knuttinen MG, Walzer NM, Kallwitz ER, Berkes JL, et al. Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2013; 24: 411-20, 20 e1-4; quiz 21.

  7. Tzeng WS, Wu RH, Lin CY, Chen JJ, Sheu MJ, Koay LB, Lee C. Prediction of mortality after emergent transjugular intrahepatic portosystemic shunt placement: use of APACHE II, Child-Pugh and MELD scores in Asian patients with refractory variceal hemorrhage. Korean J Radiol 2009; 10: 481-9.

  8. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology 2007; 46: 922-38.

  9. Gaba RC, Omene BO, Podczerwinski ES, Knuttinen MG, Cotler SJ, Kallwitz ER, Berkes JL, et al. TIPS for treatment of variceal hemorrhage: clinical outcomes in 128 patients at a single institution over a 12-year period. J Vasc Interv Radiol 2012; 23: 227-35.

  10. McNaughton DA, Abu-Yousef MM. Doppler US of the liver made simple. Radiographics 2011; 31: 161-88. Casadaban LC, et al. , 2015; 14 (3): 380-388 388

  11. Brown DB, Cardella JF, Sacks D, Goldberg SN, Gervais DA, Rajan D, Vedantham S, et al. Quality improvement guidelines for transhepatic arterial chemoembolization, embolization, and chemotherapeutic infusion for hepatic malignancy. J Vasc Interv Radiol 2006; 17: 225-32.

  12. Haskal ZJ, Martin L, Cardella JF, Cole PE, Drooz A, Grassi CJ, McCowan TC, et al. Quality improvement guidelines for transjugular intrahepatic portosystemic shunts. J Vasc Interv Radiol 2003; 14: S265-S270.

  13. Boyer TD, Haskal ZJ. The role of transjugular intrahepatic portosystemic shunt in the management of portal hypertension. Hepatology 2005; 41: 386-400.

  14. Blei AT, Cordoba J. Hepatic Encephalopathy. Am J Gastroenterol 2001; 96: 1968-76.

  15. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D’Amico G, et al. A model to predict survival in patients with end-stage liver disease. Hepatology 2001; 33: 464-70.

  16. Gaba RC, Couture PM, Bui JT, Knuttinen MG, Walzer NM, Kallwitz ER, Berkes JL, et al. Prognostic capability of different liver disease scoring systems for prediction of early mortality after transjugular intrahepatic portosystemic shunt creation. J Vasc Interv Radiol 2012. In press.

  17. Lopera JE. Role of emergency transjugular intrahepatic portosystemic shunts. Semin Intervent Radiol 2005; 22: 253-65.

  18. Mukund A, Patidar Y, Rajesh S, Arora A, Garg HK, Sarin SK. Survival and Mid-Term Outcomes Following Emergent Transjugular Intrahepatic Portosystemic Shunt for Refractory Variceal Bleeding in advanced cirrhotic patients: Results in 39 Patients. Hepatology 2013; 58: 1001A.

  19. Patch D, Nikolopoulou V, McCormick A, Dick R, Armonis A, Wannamethee G, Burroughs A. Factors related to early mortality after transjugular intrahepatic portosystemic shunt for failed endoscopic therapy in acute variceal bleeding. J Hepatol 1998; 28: 454-60.

  20. Encarnacion CE, Palmaz JC, Rivera FJ, Alvarez OA, Chintapalli KN, Lutz JD, Reuter SR. Transjugular intrahepatic portosystemic shunt placement for variceal bleeding: predictors of mortality. J Vasc Interv Radiol 1995; 6: 687-94.

  21. Azoulay D, Castaing D, Majno P, Saliba F, Ichai P, Smail A, Delvart V, et al. Salvage transjugular intrahepatic portosystemic shunt for uncontrolled variceal bleeding in patients with decompensated cirrhosis. J Hepatol 2001; 35: 590-7.

  22. Chalasani N, Clark WS, Martin LG, Kamean J, Khan MA, Patel NH, Boyer TD. Determinants of mortality in patients with advanced cirrhosis after transjugular intrahepatic portosystemic shunting. Gastroenterology 2000; 118: 138-44.

  23. Yoon CJ, Chung JW, Park JH. Transjugular intrahepatic portosystemic shunt for acute variceal bleeding in patients with viral liver cirrhosis: predictors of early mortality. AJR Am J Roentgenol 2005; 185: 885-9.

  24. Rubin RA, Haskal ZJ, O’Brien CB, Cope C, Brass CA. Transjugular intrahepatic portosystemic shunting: decreased survival for patients with high APACHE II scores. Am J Gastroenterol 1995; 90: 556-63.

  25. Brensing KA, Raab P, Textor J, Gorich J, Schiedermaier P, Strunk H, Paar D, et al. Prospective evaluation of a clinical score for 60-day mortality after transjugular intrahepatic portosystemic stent-shunt: Bonn TIPSS early mortality analysis. Eur J Gastroenterol Hepatol 2002; 14: 723-31.

  26. Ferral H, Patel NH. Selection criteria for patients undergoing transjugular intrahepatic portosystemic shunt procedures: current status. J Vasc Interv Radiol 2005; 16: 449-55.

  27. Garcia-Pagan JC, Caca K, Bureau C, Laleman W, Appenrodt B, Luca A, Abraldes JG, et al. Early use of TIPS in patients with cirrhosis and variceal bleeding. N Engl J Med 2010; 362: 2370-9.

  28. Garcia-Pagan JC, Di Pascoli M, Caca K, Laleman W, Bureau C, Appenrodt B, Luca A, et al. Use of early-TIPS for highrisk variceal bleeding: results of a post-RCT surveillance study. J Hepatol 2013; 58: 45-50.

  29. Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, Keough A, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology 2014; 146: 412-19 e3.




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