Comparison of Child-Pugh, MELD, MELD-Na, and ALBI Scores in Predicting In-Hospital Mortality in Patients with HCC

Background & Objectives: Hepatocellular carcinoma (HCC) leads to high morbidity and mortality. Various models have been proposed for predicting the outcome of patients with HCC. We aim to compare the prognostic abilities of Child-Pugh, MELD, MELD-Na, and ALBI scores for predicting in-hospital mortality of HCC. Methods: We enrolled patients diagnosed with liver cirrhosis and HCC from May 2017 through May 2018. We further divided eligible patients into hepatitis B virus (HBV), patients without ascites, and patients with ascites subgroups. Areas under the characteristic curves (AUCs) were analyzed. Results: A total of 495 patients were included in the study. We collected data on patients at admission. A majority of patients were infected with HBV (91.5%). None of them were complicated with hepatic encephalopathy. Only 14.9% of patients presented with ascites. In the whole population, AUCs with 95% confidence interval (CI) of Child-Pugh, ALBI, MELD, and MELD-Na scores in predicting in-hospital mortality were 0.889 (95% CI: 0.858 - 0.915), 0.849 (95% CI: 0.814 - 0.879), 0.669 (95% CI: 0.626 - 0.711), and 0.721 (95% CI: 0.679 - 0.760), respectively. In the patients without ascites subgroup, Child-Pugh showed better discriminatory ability than ALBI score in predicting in-hospital mortality (P = 0.0002), while there were no significant differences among other comparisons. Conclusions: Child-Pugh and ALBI may be useful predictors for predicting in-hospital mortality in whole patients, in patients with HBV infection, and in patients without ascites. In HCC patients with ascites, MELD-Na may be effective for predicting in-hospital mortality.

Infection within 2 weeks before liver transplantation closely related to prognosis of posttransplant infection:A single-center retrospective observational study in China

Background:Infections still represent the main factors influencing morbidity and mortality following liver transplantation.This study aimed to evaluate the incidence and risk factors for infection and survival after liver transplantation.Methods:We retrospectively examined medical records in 210 liver recipients who underwent liver transplantation between April 2015 and October 2017 in our hospital.Clinical manifestations and results of pathogen detection test were used to define infection.We analyzed the prevalence,risk factors and prognosis of patients with infection.Results:The median follow-up was 214 days;the incidence of infection after liver transplantation was 46.7%(n=98)which included pneumonia(43.4%),biliary tract infection(21.9%),peritonitis(21.4%)and bloodstream infection(7.6%).Among the pathogens in pneumonia,the most frequently isolated was Acinetobacter baumanii(23.5%)and Klebsiella pneumoniae(21.2%).Model for end-stage liver disease(MELD)score(OR=1.083,95%CI:1.045–1.123;P<0.001),biliary complication(OR=4.725,95%CI:1.119–19.947;P=0.035)and duration of drainage tube(OR=1.040,95%CI:1.007–1.074;P=0.017)were independent risk factors for posttransplant infection.All-cause mortality was 11.0%(n=23).The prognostic factors for postoperative infection in liver recipients were prior-transplant infection,especially pneumonia within 2 weeks before transplantation.Kaplan-Meier curves of survival showed that recipients within 2 weeks prior infection had a significantly lower cumulative survival rate compared with those without infection(65.2%vs.90.0%;hazard ratio:4.480;P<0.001).Conclusions:Infection,especially pneumonia within 2 weeks before transplantation,complication with impaired renal function and MELD score after 7 days of transplantation was an independent prognostic factor for postoperative infection in liver transplant recipients.

Development and validation of a prognostic nomogram for decompensated liver cirrhosis

BACKGROUND Decompensated liver cirrhosis(DLC)is a stage in the progression of liver cirrhosis and has a high mortality.AIM To establish and validate a novel and simple-to-use predictive nomogram for evaluating the prognosis of DLC patients.METHODS A total of 493 patients with confirmed DLC were enrolled from The First Affiliated Hospital of Nanchang University(Nanchang,Jiangxi Province,China)between December 2013 and August 2019.The patients were divided into two groups:a derivation group(n=329)and a validation group(n=164).Univariate and multivariate Cox regression analyses were performed to assess prognostic factors.The performance of the nomogram was determined by its calibration,discrimination,and clinical usefulness.RESULTS Age,mechanical ventilation application,model for end-stage liver disease(MELD)score,mean arterial blood pressure,and arterial oxygen partial pressure/inhaled oxygen concentration were used to construct the model.The Cindexes of the nomogram in the derivation and validation groups were 0.780(95%CI:0.670-0.889)and 0.792(95%CI:0.698-0.886),respectively.The calibration curve exhibited good consistency with the actual observation curve in both sets.In addition,decision curve analysis indicated that our nomogram was useful in clinical practice.CONCLUSION A simple-to-use novel nomogram based on a large Asian cohort was established and validated and exhibited improved performance compared with the Child-Turcotte-Pugh and MELD scores.For patients with DLC,the proposed nomogram may be helpful in guiding clinicians in treatment allocation and may assist in prognosis prediction.

Novel Prognostic Models for Predicting the 180-day Outcome for Patients with Hepatitis-B Virus-related Acute-on-chronic Liver Failure

Background and Aims:It remains difficult to forecast the 180-day prognosis of patients with hepatitis B virus-acuteon-chronic liver failure(HBV-ACLF)using existing prognostic models.The present study aimed to derive novel-innovative models to enhance the predictive effectiveness of the 180-day mortality in HBV-ACLF.Methods:The present cohort study examined 171 HBV-ACLF patients(non-survivors,n=62;survivors,n=109).The 27 retrospectively collected parameters included the basic demographic characteristics,clinical comorbidities,and laboratory values.Backward stepwise logistic regression(LR)and the classification and regression tree(CART)analysis were used to derive two predictive models.Meanwhile,a nomogram was created based on the LR analysis.The accuracy of the LR and CART model was detected through the area under the receiver operating characteristic curve(AUROC),compared with model of end-stage liver disease(MELD)scores.Results:Among 171 HBV-ACLF patients,the mean age was 45.17 years-old,and 11.7%of the patients were female.The LR model was constructed with six independent factors,which included age,total bilirubin,prothrombin activity,lymphocytes,monocytes and hepatic encephalopathy.The following seven variables were the prognostic factors for HBV-ACLF in the CART model:age,total bilirubin,prothrombin time,lymphocytes,neutrophils,monocytes,and blood urea nitrogen.The AUROC for the CART model(0.878)was similar to that for the LR model(0.878,p=0.898),and this exceeded that for the MELD scores(0.728,p<0.0001).Conclusions:The LR and CART model are both superior to the MELD scores in predicting the 180-day mortality of patients with HBV-ACLF.Both the LR and CART model can be used as medical decision-making tools by clinicians.

CA-125 Significance in Cirrhosis and Correlation with Disease Severity and Portal Hypertension: A Retrospective Study

Background and Aims:To evaluate the prevalence and significance of elevated cancer antigen-125(CA-125)levels in patients with cirrhosis being treated in a tertiary care liver center and its correlation with objective markers of disease severity.Methods:We retrospectively reviewed medical records of 172 adult patients with cirrhosis(due to any etiology)after obtaining CA-125 serum analysis.Demographics,etiology of cirrhosis,model of end-stage liver disease(MELD)score,Child's Turcotte-Pugh classification,albumin bilirubin(ALBI)score,degree of ascites,presence of esophageal varices,serum CA-125 level and various other parameters were collected.Statistical analysis was performed using SPSS software and descriptive statistics.Results:Elevated CA-125 levels were noted in 147 patients(85%)of the study population.Higher MELD score was associated with higher CA-125 levels(p=0.001).Statistically significant correlation was observed between elevated CA-125 levels and degree of ascites(p<0.001),ALBI score(p<0.001)and Child's Turcotte-Pugh class(p<0.001).No correlation was observed with presence or absence of esophageal varices.Near-normal CA-125 levels were noted in patients with cirrhosis but undetectable ascites on ultrasound imaging.No differences were observed in mean values between male and female patients(p=0.207).Regression analysis confirmed that CA-125 levels had a better correlation with degree of ascites than MELD score or ALBI score.Conclusions:Elevated CA-125 levels were noted in 85%of patients with cirrhosis at our center.Our study establishes that the more advanced the degree of decompensation based on MELD score,Child's Turcotte-Pugh classification and ALBI score,the higher the elevation in CA-125.Absence of ascites was associated with normal CA-125 level,with a direct correlation between high levels and worsening ascites,but there was no statistically significant correlation with esophageal varices,indicating that elevated CA-125 levels could be related to mechanical stretch of the peritoneum rather than portal hypertension itself.Further multi-centered studies are required to confirm and validate these findings.

Change in model for end-stage liver disease score at two weeks,as an indicator of mortality or liver transplantation at 60 days in acute-on-chronic liver failure

Background:Acute-on-chronic liver failure(ACLF)is characterised by a sudden deterioration of underlying chronic liver disease,resulting in increased rates of mortality and liver transplantation.Early prognostication can benefit optimal allocation of resources.Methods:ACLF was defined as per the disease criteria of the Asian Pacific Association for the Study of the Liver.Inpatient discharge summaries from between January 2001 and April 2013 were reviewed.The primary outcome was mortality or liver transplantation within 60 days from onset of ACLF.Absolute‘model for end-stage liver disease’(MELD)score and change in MELD at Weeks 1,2 and 4 were reviewed in order to identify the earliest point for prediction of mortality or liver transplantation.Results:Clinical data were collected on 53 subjects who fulfilled the inclusion and exclusion criteria.At 60 days from presentation,20 patients(37.7%)died and 4(7.5%)underwent liver transplantation.Increased MELD of-2 after 2 weeks was 75.0%sensitive and 75.9%specific for predicting mortality or liver transplantation.If the MELD score did not increase at 2 weeks,predictive chance of survival was 93.8%over the next 60 days.MELD change at 1 week showed poor sensitivity and specificity.Change at 4 weeks was too late for intervention.Conclusion:Change in MELD score at 2 weeks provides an early opportunity for prognostication in ACLF.A MELD score that does not deteriorate by Week 2 would predict 93.8%chance of survival for the next 60 days.This finding warrants further validation in larger cohort studies.

Refining the Role of Simultaneous Liver Kidney Transplantation

Adoption of the model for end-stage liver disease score by Organ Procurement and Transplant Network(OPTN)deceased donor liver allocation policy in 2002 has led to an increase in the number of simultaneous liver kidney(SLK)transplantation.Since kidney function recovery following liver transplantation is difficult to predict,al ocation of the kidney for SLK trans-plantation thus far has not been based on much rationale and evidence.Lack of OPTN policy towards SLK organ allocation has resulted in great variations among transplant centers regarding SLK transplantation.Increasing use of kidneys towards SLK transplantation diverts deceased donor kidneys away from candidates awaiting kidney-alone transplantation.Recently OPTN/United Network of Organ Sharing has imple-mented medical eligibility criteria for adult SLK transplantation which also includes a concept of safety net.Implementation of the new policy is a move in a positive direction,providing consistency in our practice and evidence-based guidelines in selecting candidates for SLK transplantation.This policy needs to be monitored prospectively and modified based on new data that wil emerge over time.This review outlines the literature on SLK transplantation and efforts towards developing rational policy on SLK organ allocation.

Patients with Cirrhosis of Liver Operated for Non-transplant Surgery: A Retrospective Analysis

Background and Aims:Patients with cirrhosis of the liver have high mortality after surgery.We investigated the mortality in patients with cirrhosis of the liver who underwent surgery other than liver transplant and applied the Mayo clinic model to predict mortality and compare with the observed mortality.We also studied the association of the observed mortality with the Child-Turcotte-Pugh(CTP)class and the model for end-stage liver disease(MELD)and model for end-stage liver disease-sodium(MELD-Na)scores.Methods:The electronic records database of our hospital was accessed to analyze the data of 133 cirrhotic patients who underwent various surgeries under general anesthesia from October 2009 to June 2017.The Mayo risk score was applied to each and used to calculate predicted mortality;the MELD and MELD-Na scores were also calculated.Telephonic interview was performed with the patients and or their relative to ascertain survival or time of death after surgery,when the information was not available from the hospital records.Results:The all-cause observed mortality rates at postoperative days 30 and 90 and at 1 year were 12%,20.3%and 26.3%respectively.The area under the receiver operating characteristic curve values for the Mayo model as a predictor of 30-day,90-day and 1-year mortality were 0.836,0.828 and 0.744 respectively.Good correlation was seen for observed mortality with CTP class and with MELD and MELD-Na scores.Conclusions:The Mayo model for predicting postoperative mortality in patients with cirrhosis of the liver demonstrated good correlation in this study.The strength of prediction of mortality by Mayo risk score calculation was similar at postoperative days 30 and 90 but decreased at 1-year after the surgery.Good correlation was seen for the observed mortality with MELD,MELD-Na and CTP scores.

A comprehensive review of prognostic scoring systems to predict survival after transjugular intrahepatic portosystemic shunt placement

Patient prognosis after transjugular intrahepatic portosystemic shunt(TIPS)placement is relatively poor and highly heterogeneous;therefore,a prognostic scoring system is essential for survival prediction and risk stratification.Conventional scores include the Child–Turcotte–Pugh(CTP)and model for end‐stage liver disease(MELD)scores.The CTP score was created empirically and displayed a high correlation with post‐TIPS survival.However,the inclusion of subjective parameters and the use of discrete cut‐offs limit its utility.The advantages of the MELD score include its statistical validation and objective and readily available predictors that contribute to its broad application in clinical practice to predict post‐TIPS outcomes.In addition,multiple modifications of the MELD score,by incorporating additional predictors(e.g.,MELD‐Sodium and MELD‐Sarcopenia scores),adjusting coefficients(recalibrated MELD score),or combined(MELD 3.0),have been proposed to improve the prognostic ability of the standard MELD score.Despite several updates to conventional scores,a prognostic score has been proposed(based on contemporary data)specifically for outcome prediction after TIPS placement.However,this novel score(the Freiburg index of post‐TIPS survival,FIPS)exhibited inconsistent discrimination in external validation studies,and its superiority over conventional scores remains undetermined.Additionally,several tools display potential for application in specific TIPS indications(e.g.,bilirubin‐platelet grade for refractory ascites),and biomarkers of systemic inflammation,nutritional status,liver disease progression,and cardiac decompensation may provide additional value,but require further validation.Future studies should consider the effect of TIPS placement when exploring predictors,as TIPS is a pathophysiological approach that substantially alters systemic hemodynamics and ameliorates bacterial translocation and malnutrition.