New Model for End Stage Liver Disease Improves Prognostic Capability After Transjugular Intrahepatic Portosystemic Shunt
published online 29 June 2009.
Background & Aims
Cirrhotic patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) for refractory ascites or recurrent variceal bleeding are at risk for decompensation and death. This study examined whether a new model for end stage liver disease (MELD), which incorporates serum sodium (MELDNa), is a better predictor of death or transplant after TIPS than the original MELD.
Methods
One hundred forty-eight consecutive patients undergoing nonemergent TIPS for refractory ascites or recurrent variceal bleeding from 1997 to 2006 at a single center were evaluated retrospectively. Cox model analysis was performed with death or transplant within 6 months as the end point. The models were compared using the Harrell's C index. Recursive partitioning determined the optimal MELDNa cutoff to maximize the risk:benefit ratio of TIPS.
Results
The predictive ability of MELDNa was superior to MELD, particularly in patients with low MELD scores. The C indices (95% confidence interval [CI]) for MELDNa and MELD were 0.65 (95% CI, 0.55–0.71) and 0.58 (95% CI, 0.51–0.67) using a cut-off score of 18, and 0.72 (95% CI, 0.60–0.85) and 0.62 (95% CI, 0.49–0.74) using a cut-off score of 15. Using a MELDNa >15, 22% of patients were reclassified to a higher risk with an event rate of 44% compared with 10% when the score was ≤15.
Conclusions
MELDNa performed better than MELD in predicting death or transplant after non-emergent TIPS, especially in patients with low MELD scores. A MELD score ≤18 can provide a false positive prognosis; a MELDNa score ≤15 provides a more accurate risk prediction.
⁎Department of Medicine, Division of Gastroenterology, University of California, San Francisco, San Francisco, California
‡Department of GI Health Outcomes, Policy and Economics (HOPE) Research Program, University of California, San Francisco, San Francisco, California
§Department of Epidemiology and Biostatistics, Division of Biostatistics, University of California, San Francisco, San Francisco, California
∥Department of Interventional Radiology, University of California, San Francisco, San Francisco, California
Reprint requests Address requests for reprints to: Jennifer Guy, MD, MAS, 513 Parnassus Avenue S357, San Francisco, California 94143-0538. fax: (415) 476-0659
Conflicts of interest The authors disclose no conflicts.
Funding This work was funded in part by grants from National Institute of Diabetes and Digestive and Kidney Diseases (DK060414) (JG) (DK076565) (SWB), from the National Center for Research Resources (KL2 RR024130) (SWB), from Agency for Healthcare Research and Quality (DK076565) (SWB), from the ASGE Endoscopic Research Award (MS), and P30 DK026743 (UCSF Liver Center).
Amy J. Markowitz, JD provided editorial assistance with funding under grant DK076565.
ABSTRACT
New Model for End Stage Liver Disease Improves Prognostic Capability After Transjugular Intrahepatic Portosystemic Shunt