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• W2079361446 abstract "Currently, approximately 3000 patients per year are removed from listing for liver transplantation (LT) in the United States because of the severity of their medical illness or death.1 In part, this outcome is a result of how health-care providers identify and manage the most suitable candidates before LT. Implemented in 2002, the Model for End-Stage Liver Disease (MELD) score is the current instrument broadly used to risk-stratify and prioritize patients for the need for LT.2 Although reasonably successful in predicting short-term mortality in all wait-listed patients, it may not adequately capture or identify high-mortality-risk subgroups with lower MELD scores.3 In this issue of Liver Transplantation, Wedd et al.4 seek to better characterize these potentially underserved populations, namely, patients with MELD scores ≤ 20 who have a higher than expected mortality risk. In particular, the authors examine a host of variables among 41 case subjects matched to 66 case controls with equivalent low MELD scores and other associated features. One key variable is “cirrhotic stage 1-5,” which was defined previously by D'Amico et al.5 but is conceptually new to the field: (1) cirrhosis without varices or ascites, (2) varices without bleeding, (3) variceal bleeding without ascites, (4) ascites with or without nonbleeding varices, and (5) ascites with variceal bleeding. Wedd et al. conclude that an increasing cirrhotic stage was the key variable associated with liver-related death more than other factors in this low-MELD cohort. This type of cirrhotic staging formally resurrects some level of subjectivity in our modern risk assessment, which traditionally was a concern with the Child-Turcotte-Pugh (CTP) score initially devised in the 1970s for reasons other than LT determination. The CTP score is limited by the following: (1) the explicitly subjective nature of 2 of the 5 parameters (ie, severity of ascites and encephalopathy); (2) the ceiling effect, which placed patients with greatly altered “objective” laboratory values into similar classes; and (3) the focus on a snapshot of disease, such as ascites improvement and subsequent CTP score reduction, which perhaps erroneously implied a reduced mortality risk. Indeed, in 1998, such concerns prompted the hybridization of the CTP score with patient location to create status levels (1, 2A, 2B, and 3) as the main instrument of risk assessment.6 Although this policy did reduce wait-list mortality, it was eventually plagued by the vagaries and potential wrongdoings of location placement. Ultimately, the transplant community had to develop a more purely objective system of risk assessment. This led directly to the implementation of the MELD score. However, there are persistent concerns with respect to the appropriateness of the objective parameters, the potential for interassay variability and manipulation, and, as mentioned previously, the underserving of low-score, high-risk patients. Tinkering with the MELD score itself has thus persisted either through exception points [eg, for well-staged hepatocellular carcinoma7 (accepted)] or through modification of the equation itself (in testing). Examples of the latter include (1) serum sodium (MELD-Na), (2) integrated age and sodium (iMELD), (3) changes in the MELD score over time (ΔMELD), and (4) the alteration of the coefficients alone (updated MELD).6 However, for better or worse, the MELD score in its current, unmodified form is here to stay. What does this cirrhosis staging system add to the landscape, and can it provide more of a middle ground between the MELD and CTP scores in balancing objectivity and subjectivity? Cirrhosis staging may have an advantage over the CTP score for a number of reasons. First, while it does not replace the simplicity of the MELD score, it can act as secondary risk-capture mechanism with a wider scope. Second, rather than using a gradient, staging objectifies ascites and varices assessment through dichotomous variables (yes or no) that are additive. Third, staging is progressive, regardless of clinical improvement, and thus preserves the highest mortality risk assessment over time. In summary, the authors state that although LT for patients with MELD scores ≤ 15 may not reduce mortality just on the basis of the MELD score,8 cirrhosis staging might capture an appropriate cohort that does have a survival benefit. However, because of the increasing demand for scarce organs and the consequently rising MELD scores required to obtain LT (share 35), such patients are unlikely to receive and benefit from standard deceased donation outside ad hoc exception points.9 Ultimately, these low-score patients identified as being at high risk on the basis of criteria such as cirrhosis staging may be best served by expanded criteria or living donation allocation pathways." @default.
• W2079361446 created "2016-06-24" @default.
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• W2079361446 date "2014-09-25" @default.
• W2079361446 modified "2023-09-23" @default.
• W2079361446 title "New models to enhance the assessment of mortality risk in low model for end-stage liver disease patients: “Objectifying” the subjective" @default.
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• W2079361446 doi "https://doi.org/10.1002/lt.23963" @default.
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