Date Published: May 23, 2019
Publisher: Public Library of Science
Author(s): Andrew S. Allegretti, Nathan E. Frenk, Darrick K. Li, Harish Seethapathy, Xavier F. Vela Parada, Joshua Long, Paul Endres, Daniel S. Pratt, Raymond T. Chung, Suvranu Ganguli, Zubin Irani, Kei Yamada, Rudolf E. Stauber.
The MELD score was developed to predict survival after transjugular intrahepatic portosystemic shunt (TIPS) placement. Given changes in practice patterns and development of new prognostic tools in cirrhosis, we aimed to evaluate common models to predict mortality after TIPS placement.
Analysis of consecutive patients who underwent TIPS placement for ascites or bleeding. Performance to predict 90-day mortality was assessed by C statistic for six models (MELD, MELD-Na, CLIF-C ACLF, Child-Pugh, Platelet-Albumin-Bilirubin, and Emory score). Added predictive value to MELD score was assessed for univariate predictors of 90-day mortality. Stratified analysis by TIPS indication, emergent placement status, and TIPS stent type was performed.
413 patients were analyzed (248 with variceal bleeding, 165 with refractory ascites). 90-day mortality was 27% (113/413). Mean MELD score was 15 ± 7.9. MELD score best predicted mortality for all patients (c = 0.779), for variceal bleeding (c = 0.844), and for emergent TIPS (c = 0.817). CLIF-C ACLF score best predicted mortality for refractory ascites (c = 0.707). Addition of sodium to the MELD score did not improve predictive value across multiple strata. Addition of hemoglobin improved MELD score’s predictive value in variceal bleeding. Addition of age improved MELD score’s predictive value in refractory ascites.
MELD score best predicted 90-day mortality. Addition of sodium to the MELD score did not improve its performance, though mortality prediction was improved using Age-MELD for ascites and Hemoglobin-MELD for bleeding. An individualized risk stratification approach may be best when considering candidates for TIPS placement.
Transjugular intrahepatic portosystemic shunt (TIPS) placement has been an established therapy for complications of cirrhosis and portal hypertension dating back to 1989, when the procedure was first described for successful treatment of recurrent bleeding varices. While randomized trials have demonstrated survival advantages for TIPS in patients with refractory ascites and variceal bleeding,[2–4] proper patient selection remains vital due to significant risks of post-procedure hepatic encephalopathy, liver failure, and the high overall morbidity/mortality in this population.
In a large population of 413 patients with cirrhosis who received TIPS for variceal bleeding or refractory ascites, we provide a detailed analysis of six widely available prognostic models for 90-day mortality, including the recently adopted MELD-Na and CLIF-C ACLF scores. To our knowledge, this is the first time CLIF-C ACLF score has been assessed among TIPS recipients. We found that MELD score performed best in predicting post-TIPS mortality, and that the addition of sodium to the MELD score did not significantly improve its prognostic ability. However, in specific subgroups, the prognostic ability of the MELD score could still be improved by adding important clinical variables, such as “Hgb-MELD” in those with variceal bleeding and “Age-MELD” in those with refractory ascites.