Research Article: Model for End-stage Liver Disease excluding INR (MELD-XI) score in critically ill patients: Easily available and of prognostic relevance

Date Published: February 2, 2017

Publisher: Public Library of Science

Author(s): Bernhard Wernly, Michael Lichtenauer, Marcus Franz, Bjoern Kabisch, Johanna Muessig, Maryna Masyuk, Uta C. Hoppe, Malte Kelm, Christian Jung, Gebhard Wagener.

http://doi.org/10.1371/journal.pone.0170987

Abstract

MELD-XI, an adapted version of Model for End-stage Liver Disease (MELD) score excluding INR, was reported to predict outcomes e.g. in patients with acute heart failure. We aimed to evaluate MELD-XI in critically ill patients admitted to an intensive care unit (ICU) for prognostic relevance.

A total of 4381 medical patients (66±14 years, 2862 male) admitted to a German ICU between 2004 and 2009 were included and retrospectively investigated. Admission diagnoses were e.g. myocardial infarction (n = 2034), sepsis (n = 694) and heart failure (n = 688). We divided our patients in two cohorts basing on their MELD-XI score and evaluated the MELD-XI score for its prognostic relevance regarding short-term and long-term survival. Optimal cut-offs were calculated by means of the Youden-Index.

Patients with a MELD-XI score >12 had pronounced laboratory signs of organ failure and more comorbidities.

The easily calculable MELD-XI score is a robust and reliable tool to predict both intra-ICU and long-term mortality in critically ill medical patients admitted to an ICU. Optimal cut-off values for MELD-XI scores seem to depend on the primary disease and need to be validated in future prospective studies. Compared to SAPS2 and APACHE score, MELD-XI lacks precision but might have comparable and even additive value, as it is easily available and independent of subjective values.

Partial Text

Patients admitted to an intensive care unit (ICU) represent a highly heterogeneous population. They largely differ in terms of clinical presentation, age, disease etiology, hemodynamics, treatment response as well as in prognosis. Scoring systems (such as APACHE 2 and SAPS2) have been developed to better stratify the risk profiles of ICU patients and to estimate their potential outcome [1–3].

Risk stratification in critically ill patients admitted to an ICU is of crucial impact with respect to clinical management tending to improved patients’ outcomes as well as health economic aspects. There are few well-established scoring systems for individual risk assessment, e.g. the APACHE or the SAPS2 score. A major disadvantage of these scores is their complexity, which causes a limited feasibility in daily routine clinical practice. The MELD score and also the MELD-XI score, both assessing renal and liver dysfunction, have been originally developed and evaluated for the allocation of organs for patients waiting for liver transplantation. In addition, they could be proven to be appropriate for risk stratification also in other severe disorders like acute heart failure [23, 24]. Moreover, MELD-XI was reported to predict outcomes in patients undergoing heart transplantation as well as implantation of ventricular assist devices [25–27]. It was further shown that MELD-XI score provides additional risk stratification in patients suffering from acute heart failure by assessing renal and liver dysfunction which both are known to be associated with mortality in critically ill patients in general [24]. Abe et al. could show that MELD-XI predicts adverse prognosis in heart failure and high MELD-XI scores are associated with echocardiographic parameters of right ventricular overload such as increased right ventricular dilatation, increased inferior caval vein diameter as well as higher systolic pulmonary artery pressures [28]. A great advantage especially of the MELD-XI score is its simplicity enabling fast bedside risk stratification even in the emergency setting. Motivated by these considerations, the current study was designed to test the value of the MELD-XI score in ICU patients in a real-life setting. To our best knowledge, this is the first study in this vein and therefore of high clinical interest. As a result, patients with a high MELD-XI score were older, had significantly increased markers of multi-organ failure and had more pre-existing illnesses. The finding that patients with MELD<12 have a higher incidence of CVD most probably reflect that patients with myocardial infarction have lower MELD-XI scores. MELD-XI was significantly associated with both increased long-term and short-term (i.e. intra-ICU) mortality in our collective. This remained true even after correction for age, white blood count, oxygenation and lactate levels at admission in a multivariate cox regression analysis, parameters which are known to be associated with mortality [29–31]. This emphasizes how effective MELD-XI mirrors organ failure of two central organ systems: kidneys and liver, which are both sensitive for global hypo-perfusion and hypoxia [32, 33]. Interestingly, serum total bilirubin included in MELD-XI was superior to liver transaminases—which are frequently used to evaluate liver dysfunction—for prediction of mortality. This further supports the notion that increased serum total bilirubin is tightly associated with hepatocellular hypoxia [8–10].   Source: http://doi.org/10.1371/journal.pone.0170987

 

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