Epidemiology

High MELD score, low albumin linked to worse surgery outcomes in cirrhotics

Last Updated: 2010-01-22 13:47:47 -0400 (Reuters Health)

NEW YORK (Reuters Health) - In cirrhotic patients with high MELD (model of end-stage liver disease) scores, serum albumin levels can predict the outcome of abdominal surgery, according to a report in the December 28, 2009 Clinical Gastroenterology and Hepatology.

Determining whether a patient with advanced cirrhosis is a good surgical candidate is difficult, the authors explain, partly because neither the MELD score nor the Child-Turcotte-Pugh (CTP) score accurately predicts operative outcome.

The MELD score is designed to estimate a patient's risk of dying while waiting for a liver transplant, while CTP class indicates the prognosis of chronic liver disease and the necessity of transplantation.

Therefore, senior author Dr. Celia M. Divino and her colleagues at New York City's Mount Sinai Hospital reviewed pre- and postoperative data on 100 patients with advanced cirrhosis who underwent general surgical procedures, in order to identify factors with an impact on outcome. They looked only at patients who had cholecystectomy, hernia repair (ventral, incisional or umbilical), enterectomy, colectomy, or appendectomy.

Sixty-eight of the cases were elective, the authors report, and the overall 30-day morbidity and mortality rates were 43% and 7%, respectively. Overall mortality at a mean of 36 months follow-up was 9%.

Stratified by CTP class, mortality was 2% for CTP A, 12% for CTP B, and 12% for CTP C.

Mortality for patients with MELD scores between 15 and 25 was 29%. (At their hospital, the authors note, patients with a MELD score of 15 or higher are considered to be potential liver transplant candidates.) MELD scores of at least 15 increased postoperative morbidity 5-fold, whereas MELD scores above 17 increased postoperative mortality 6.9-fold.

Independent risk factors for adverse outcomes in a multivariable analysis included intraoperative transfusion, albumin below 3 mg/dL, American Society of Anesthesiology score above 3, total bilirubin above 1.5 mg/dL, emergent procedure, presence of ascites, and blood loss above 150 mL.

Patients with MELD scores of at least 15 and albumin of no more than 2.5 mg/dL had significantly higher rates of death or liver transplant (60%) than did patients with lower MELD scores and higher albumin levels (14%). The combination of high MELD score and low albumin was associated with an 8.4-fold increased probability of adverse outcome.

"Based on this result, we recommend preoperative albumin be considered a criterion for operative decisions in cirrhotic patients with MELD scores of 15 or higher," the investigators say.

Clin Gastroenterol Hepatol 2009.