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