February 2, 2014

Gastroenterology. 2014 Feb;146(2):412-419.e3. doi: 10.1053/j.gastro.2013.10.018. Epub 2013 Oct 19.

Reverter E1, Tandon P2, Augustin S3, Turon F4, Casu S4, Bastiampillai R2, Keough A2, Llop E4, González A3, Seijo S4, Berzigotti A4, Ma M2, Genescà J5, Bosch J1, García-Pagán JC1, Abraldes JG6.

Abstract

BACKGROUND & AIMS: Patients with cirrhosis with acute variceal bleeding (AVB) have high mortality rates (15%-20%). Previously described models are seldom used to determine prognoses of these patients, partially because they have not been validated externally and because they include subjective variables, such as bleeding during endoscopy and Child-Pugh score, which are evaluated inconsistently. We aimed to improve determination of risk for patients with AVB.

METHODS: We analyzed data collected from 178 patients with cirrhosis (Child-Pugh scores of A, B, and C: 15%, 57%, and 28%, respectively) and esophageal AVB who received standard therapy from 2007 through 2010. We tested the performance (discrimination and calibration) of previously described models, including the model for end-stage liver disease (MELD), and developed a new MELD calibration to predict the mortality of patients within 6 weeks of presentation with AVB. MELD-based predictions were validated in cohorts of patients from Canada (n = 240) and Spain (n = 221).

RESULTS: Among study subjects, the 6-week mortality rate was 16%. MELD was the best model in terms of discrimination; it was recalibrated to predict the 6-week mortality rate with logistic regression (logit, -5.312 + 0.207 • MELD; bootstrapped R(2), 0.3295). MELD values of 19 or greater predicted 20% or greater mortality, whereas MELD scores less than 11 predicted less than 5% mortality. The model performed well for patients from Canada at all risk levels. In the Spanish validation set, in which all patients were treated with banding ligation, MELD predictions were accurate up to the 20% risk threshold.

CONCLUSIONS: We developed a MELD-based model that accurately predicts mortality among patients with AVB, based on objective variables available at admission. This model could be useful to evaluate the efficacy of new therapies and stratify patients in randomized trials.

Copyright © 2014 AGA Institute. Published by Elsevier Inc. All rights reserved.

KEYWORDS: AUROC, AVB, Cirrhosis, HCC, HVPG, Logistic Regression, MELD, Prognostic Model, ROC, TIPS, acute variceal bleeding, area under receiver operating characteristic curve, hepatic venous pressure gradient, hepatocellular carcinoma, model for end-stage liver disease, receiver operating characteristic, transjugular intrahepatic portosystemic shunt

PMID: 24148622 [PubMed - in process]

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