Elsevier

Journal of Hepatology

Volume 36, Issue 4, April 2002, Pages 494-500
Journal of Hepatology

MELD score is better than Child–Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt

https://doi.org/10.1016/S0168-8278(01)00309-9Get rights and content

Abstract

Background/Aims: Patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) are at risk of early death due to end-stage liver failure. The aim of this study was to compare model of end-stage liver disease (MELD) and Child–Pugh scores as predictors of survival after TIPS.

Methods: We studied 140 cirrhotic patients treated with elective TIPS. Concordance (c)-statistic was used to assess the ability of MELD or Child–Pugh scores to predict 3-month survival. The prediction of overall survivals was estimated by comparing actuarial curves of subgroups of patients stratified according to either Child–Pugh scores or MELD risk scores.

Results: During a median follow-up of 23.7 months, 55 patients died, 14 underwent liver transplantation and seven were lost to follow-up. For 3-month survival, the discrimination power of MELD score was superior to Child–Pugh score (0.84 vs. 0.70, z=2.07; P=0.038). Unlike Pugh score, MELD score identified two subgroups of Child C patients with different overall survivals (P=0.027). The comparison between observed and predicted survivals showed that MELD score overrates death risk.

Conclusions: MELD score is superior to Child–Pugh score as predictor of short-term outcome after TIPS. Its accuracy, however, decreases for long-term predictions.

Introduction

Transjugular intrahepatic portosystemic shunt (TIPS) is a radiological procedure widely used to treat some of the complications of portal hypertension [1]. Several trials demonstrated the effectiveness of TIPS in the prevention of variceal rebleeding and the control of refractory ascites [2], [3]. TIPS does not require surgery and procedure-associated morbidity and mortality rates are therefore lower. Nevertheless, some patients can develop severe liver failure or other serious complications after TIPS implantation and may die shortly after this procedure [4]. Even if negative predictors, such as high serum bilirubin level and Child C class, have been recognized [5], [6], the identification of patients at risk of early death after TIPS is still a matter of research. Bilirubin is a good index of liver function but may be influenced by other variables such as hemolysis. Child–Pugh classification is rather rigid, it does not quantify patient survival, and uses determinants such as ascites and encephalopathy, which are based on subjective assessment and are influenced by therapy. Recently, investigators of the Mayo clinic reported a mathematical model able to predict the individual chance of survival after elective TIPS [7]. This model, called model of end-stage liver disease (MELD), includes serum creatinine, bilirubin, international normalized ratio of prothrombin time (INR) and etiology of the underlying liver disease [8].

The aim of the present study was to compare MELD and Child–Pugh score systems for their accuracy as survival predictors in a population of Italian cirrhotic patients who underwent elective TIPS.

Section snippets

Patients and methods

All consecutive cirrhotic patients selected to undergo TIPS between 1993 and 1999 in the Department of Internal Medicine of the University of Milan and the Gastroenterology Unit of ‘La Sapienza’ Medical School in Rome were included in this retrospective study. Twenty-two patients were excluded. In 18 cases, TIPS was performed for emergency control of ongoing bleeding, and in four the stent was not implanted because of transcapsular puncture with peritoneal bleeding (n=1) or inability to

Clinical outcome

The median follow-up of the 140 patients was 23.7 months (range 0.30–93). During follow-up, 75 patients (53%) had 186 episodes of PSE. Most episodes were mild and easily reversible, while hospital admission was required in 45 cases. Severe PSE persisted in only one patient who, in spite of a successful attempt to reduce the stent caliber, died of terminal liver failure. One hundred and thirty stent stenosis occurred in 85 patients (60.7%); these stenoses were successfully treated in all but six

Discussion

TIPS is widely employed to treat patients with severe portal hypertension. It may benefit patients with recurring variceal bleedings, those with refractory ascites or hydrothorax and those with Budd–Chiari syndrome. However, patient selection is critical to exclude those not likely to tolerate the procedure. Child–Pugh score was developed as a model to predict the success of portacaval shunt and thus it is one of the most widely employed methods to select patients undergoing TIPS, even if it is

Acknowledgements

We thank Dr Lucio Caccamo for giving data of patients with OLT, and Mrs Anna Maria Carrera for secretarial support.

This work was supported in part by a grant of the Ospedale Policlinico IRCCS of Milan from the ‘Ministero Italiano della Sanità’.

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