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Abstract Details
Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology
J Hepatol. 2021 Jul 29;S0168-8278(21)01948-6. doi: 10.1016/j.jhep.2021.07.018.Online ahead of print.
Gennaro D'Amico1, Luigi Maruzzelli2, Aldo Airoldi3, Ioannis Petridis4, Giulia Tosetti5, Antonio Rampoldi6, Mario D'Amico7, Roberto Miraglia2, Stella De Nicola3, Vincenzo La Mura8, Marco Solcia6, Riccardo Volpes4, Giovanni Perricone3, Cristiano Sgrazzutti9, Angelo Vanzulli9, Massimo Primignani5, Angelo Luca2, Giuseppe Malizia10, Alessandro Federico11, Marcello Dallio11, Angelo Andriulli12, Angelo Iacobellis12, Luigi Addario13, Matteo Garcovich14, Antonio Gasbarrini14, Luchino Chessa15, Francesco Salerno16, Giulia Gobbo16, Manuela Merli17, Lorenzo Ridola18, Gianluca Svegliati Baroni19, Giuseppe Tarantino19, Nicola Caporaso20, Filomena Morisco20, Pietro Pozzoni21, Agostino Colli21, Luca Saverio Belli3
Author information
1Gatroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Gastroenterology Unit, Clinica La Maddalena, Palermo, Italy. Electronic address: gedamico@libero.it.
2Radiology Service, Mediterranean Institute for Transplantation and Advanced, Specialized Therapies (IRCCS-ISMETT), Palermo, Italy.
3Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy.
4Hepatology Unit, Mediterranean Institute for Transplantation and Advanced, Specialized Therapies (IRCCS-ISMETT), Palermo, Italy.
5Gastroenterology and Hepatology Unit Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy.
6Interventional Radiology Unit, ASST GOM Niguarda, Milan, Italy.
7Radiology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy; Radiology Unit, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
8Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi Hemophilia and Thrombosis Center, Fondazione Luigi Villa, Milan, Italy.
9Radiology Unit, ASST GOM Niguarda, Milan, Italy.
10Gatroenterology Unit, Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy.
11Department of Hepato-Gastroenterology, Department of Precision Medicine, University of Campania Luigi Vanvitelli, Naples, Italy.
12Department of Gastroenterology and Endoscopy, Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy.
13Hepatology Unit, Cardarelli Hospital, Naples, Italy.
14Department of Internal Medicine and Gastroenterology, Policlinico Gemelli, Rome, Italy.
15Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
16Internal Medicine Unit, IRCCS Policlinico San Donato, Milano, Italy.
17Gastroenterology and Hepatology Unit, Department of Translational and Precision Medicine, Università Sapienza, Roma.
18Gastroenterology Unit, ASL Latina, Department of Translational and Precision Medicine, "Sapienza" University of Rome.
19Liver Injury and Transplant Unit, Polytechnic University of Marche, Ancona, Italy.
20Gastroenterology Unit, "Federico II" University, Naples, Italy.
21General Medicine Unit,Presidio Ospedaliero, Azienda Socio Sanitaria Territoriale di Lecco, Lecco, Italy.
Abstract
Bakground & aims: Although discrimination of the model for end stage liver disease (MELD) is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discrimination and calibration performance of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intra-hepatic portosystemic shunt (TIPS); classic MELD-Mayo; MELD-UNOS, used by United Network for Organ Sharing (UNOS). Recalibration and model updating were also explored.
Methods: 776 patients submitted to elective TIPS (TIPS cohort), and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses.
Results: Major patient characteristics in TIPS/non-TIPS cohorts were: viral etiology 402/188, alcoholic 185/130, NASH 65/33; mean follow-up± SD 25±9/19±21months; 3-6-12 month mortality were respectively, 57-102-142/31-47-99. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post-hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used for a MELD updating.
Conclusions: In this validation study the MELD performance was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for a MELD updating are proposed.
Lay summary: While discrimination performance of the Model for End Stage Liver Disease (MELD) is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in two independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis and propose a validated model recalibration. Candidate variables for a MELD updating are proposed.