Score predicts general surgical outcomes in chronic liver disease patients

Last Updated: 2016-05-23

By Marilynn Larkin

NEW YORK (Reuters Health) - The Model for End-Stage Liver Disease (MELD) score can be used preoperatively to predict mortality risk and when counseling patients on the risks and benefits of general surgery, Massachusetts-based researchers report.

Patients with chronic liver disease (CLD) who undergo emergency surgery for other conditions have comparatively higher rates of surgical complications and death. Long-term outcomes for patients with CLD who undergo emergency general surgery are unknown, and current risk-stratification models don't include CLD severity, write Dr. Joaquim Havens and colleagues at Brigham and Women's Hospital, Boston, in JAMA Surgery, online May 18.

The team sought to determine whether the MELD score (http://bit.ly/1ewquNe), which is used mainly to predict outcomes in patients who undergo liver transplantation, might be associated with the risk of 90-day mortality following admission to the intensive care unit in CLD patients who undergo emergency general surgery.

They reviewed medical records of 13,552 emergency general surgery patients who received critical care and determined that 5% had both CLD and data to determine their MELD score when admitted to the ICU. The patients' median MELD score was 14 (out of 40; lower score is better). Overall 90-day mortality was 30.1%.

They calculated the adjusted odds ratio of 90-day mortality for each 10-point increase in MELD score to be 1.63. They found a decrease in MELD score of more than three in the 48 hours following ICU admission to be associated with a 2.2-fold decrease in 90-day mortality (odds ratio, 0.46).

"We found that emergency general surgery patients with chronic liver disease are at increased risk of death as their MELD score increases," Dr. Havens told Reuters Health by email. "This risk is greater than the risk associated with either emergency general surgery or MELD score alone and the increase in the risk of death is greatest for mild-to-moderate chronic liver disease, not severe liver disease like we expected, although the patients with severe chronic liver disease are at the highest risk of death; it's just that it doesn't get much worse after emergency general surgery, perhaps because it is so high to begin with."

"In the case of chronic liver disease, it is difficult to change that risk. However, we can use this information to help us counsel patients with liver disease on the true risks of surgery and help hospitals and health care systems better 'risk adjust' so they can more accurately measure the quality of their emergency surgical care," he says.

Dr. Ali Zarrinpar of the University of California, Los Angeles, author of an accompanying editorial, told Reuters Health by email, "The advantages of MELD are that it uses three inexpensive tests that are readily available at any modern hospital (serum bilirubin, international normalized ratio, serum creatinine); it is noninvasive (only a blood draw); it uses objective and standardizable parameters; and it can discern gradations of disease within a continuum of risk."

"The disadvantages of MELD are that the score can be affected by kidney-only disease in the absence of liver disease or pharmaceutical anticoagulation by warfarin, for example."

"Furthermore, in the era of electronic health records and massive datasets, the MELD score stands to be revisited. It was devised based on data from a few hundred patients. We now have thousands upon thousands of patients for whom we can collect data," he says.

"Can MELD be revised using the same lab values but with slightly different coefficients? Can MELD incorporate different lab values or clinical factors to improve its predictive function? Are other tests even better? For example, indocyanine green clearance measurement is one quick and noninvasive means of measuring physiologic liver function that has been used to predict ICU mortality," Dr. Zarrinpar continues. "Can this be used to predict outcomes in emergency surgery as well?"

"Other physiologic liver tests are also becoming more readily available and easy to perform. They may help in our attempts to improve ways to deliver the best and more efficacious care to our patients," he concludes.

The authors reported no funding or conflicts of interest.

SOURCE: http://bit.ly/1Rkkfzi and http://bit.ly/1XMWSpC

JAMA Surg 2016.