Model for end-stage liver disease-sodium underestimates 90-day mortality risk in patients with acute-on-chronic liver failure.
Model for end-stage liver disease-sodium underestimates 90-day mortality risk in patients with acute-on-chronic liver failure.
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DOI：
10.1016/j.jhep.2020.06.005
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发表时间：
2020-12
影响因子：
25.7
通讯作者：
Kanwal, Fasiha
中科院分区：
文献类型：
--
作者：
Hernaez, Ruben;Liu, Yan;Kramer, Jennifer R.;Rana, Abbas;El-Serag, Hashem B.;Kanwal, Fasiha
目前尚不清楚终末期肝病模型-钠（MELD-Na）评分是否能反映慢性加急性肝衰竭（ACLF）的临床严重程度。我们将观察到的ACLF患者90天死亡率与基于MELD-Na计算的预期死亡率进行比较，并检查低估临床严重程度的后果。我们确定了2004年1月1日至2014年12月31日期间127家VA医院因肝硬化住院期间的ACLF患者。我们检查了MELD-Na评分ACLF的存在和等级。我们使用实际和观察到的90天死亡率来估计ACLF存在和分级的标准化死亡率（SMR）。我们使用移植中心特异性的移植时MELD-Na中位数（MMaT）来估计仅基于MELD-Na可能优先接受肝移植（LT）的比例。在因失代偿性肝硬化住院的71，894例患者中，18，979例（26.4%）患者在入院时符合ACLF标准。ACLF患者入院时MELD-Na中位数（P25-P75）为26（22-30），而非ACLF患者为15（12-20）; ACLF-1、2和3分别为24（21-27）、27（23-31）和32（26-37）。在90天时，40.0%的ACLF患者死亡（ACLF-1、2和3组分别为30.8%、41.6%和68.8%），而非ACLF患者为21.3%。与基于MELD-Na的预期死亡率相比，ACLF患者的死亡风险更高，SMR（95% CI）：总体ACLF、ACLF-1、-2和-3分别为1.52（1.48-1.52）、1.46（1.41-1.51）、1.50（1.44-1.55）、1.66（1.58-1.74）。只有9.1%的ACLF患者达到了全国中位数MELD-Na 35，17.3%至35.1%的患者超过了任何中心的MMaT。在索引入院期间，589例（0.8%）ACLF患者被考虑进行LT评估，16例（0.1%）被列为LT。在美国失代偿期肝硬化住院患者队列中，MELD-Na未捕获ACLF患者的90天死亡风险。ACLF患者在当前基于MELD-Na的系统中处于不利地位。慢性加急性肝衰竭（ACLF）是一种以肝硬化患者多器官功能衰竭为特征的疾病，与死亡风险高相关。肝移植可能是这些患者唯一的治愈性治疗方法。在美国，一种称为终末期肝病钠模型（MELD-Na）的评分有助于指导供肝移植的分配。患者的MELD-Na评分越高，患者接受肝移植的可能性越大。我们的研究数据表明，MELD-Na评分低估了ACLF患者90天内的死亡风险。因此，医生需要尽早开始肝移植评估，而不是等待高MELD-Na值。
It is unclear whether the model for end-stage liver disease-sodium (MELD-Na) score captures the clinical severity of acute-on-chronic liver failure (ACLF). We compared observed 90-day mortality in patients with ACLF with expected mortality based on the calculated MELD-Na and examined the consequences of underestimating clinical severity. We identified patients with ACLF during hospitalization for cirrhosis in 127 VA hospitals between 01/01/2004 and 12/31/2014. We examined MELD-Na scores by ACLF presence and grade. We used actual and observed 90-day mortality to estimate a standardized mortality ratio (SMR) by ACLF presence and grade. We used transplant center-specific median MELD-Na at transplantation (MMaT) to estimate the proportion likely to receive priority for liver transplantation (LT) based on MELD-Na alone. Of 71,894 patients hospitalized for decompensated cirrhosis, 18,979 (26.4%) patients met the criteria for ACLF on admission. The median (P25-P75) MELD-Na on admission was 26 (22–30) for ACLF compared to 15 (12–20) for patients without ACLF; it was 24 (21–27), 27 (23–31), and 32 (26–37) for ACLF-1, 2 and 3, respectively. At 90 days, 40.0% of patients with ACLF died (30.8%, 41.6% and 68.8% with ACLF-1, 2 and 3, respectively) compared to 21.3% of patients without ACLF. Compared to the expected death rate based on MELD-Na, mortality risk was higher for patients with ACLF, SMR (95% CI): 1.52 (1.48–1.52), 1.46 (1.41–1.51), 1.50 (1.44–1.55), 1.66 (1.58–1.74) for overall ACLF, ACLF-1, -2 and -3, respectively. Only 9.1% of patients with ACLF reached the national median MELD-Na of 35 and between 17.3% to 35.1% exceeded the MMaT at any center. During index admission, 589 (0.8%) patients with ACLF were considered for LT evaluation and 16 (0.1%) were listed for LT. In a US cohort of hospitalized patients with decompensated cirrhosis, MELD-Na did not capture 90-day mortality risk in patients with ACLF. Patients with ACLF are at a disadvantage in the current MELD-Na-based system. Acute-on-chronic liver failure (ACLF) is a condition marked by multiple organ failures in patients with cirrhosis and is associated with a high risk of death. Liver transplantation may be the only curative treatment for these patients. A score called model for end-stage liver disease-sodium (MELD-Na) helps guide donor liver allocation for transplantation in the United States. The higher the MELD-Na score in a patient, the more likely that a patient receives a liver transplant. Our study data showed that MELD-Na score underestimates the risk of dying at 90 days in patients with ACLF. Thus, physicians need to start liver transplant evaluation early instead of waiting for a high MELD-Na number.
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影响因子：
13.5
作者：
O'Leary, Jacqueline G.;Reddy, K. Rajender;Bajaj, Jasmohan S.
通讯作者：
Bajaj, Jasmohan S.
影响因子：
13.5
作者：
Gustot, Thierry;Fernandez, Javier;Arroyo, Vicente
通讯作者：
Arroyo, Vicente
影响因子：
25.7
作者：
Jalan, Rajiv;Saliba, Faouzi;Arroyo, Vicente
通讯作者：
Arroyo, Vicente
影响因子：
12.6
作者：
Piano, Salvatore;Schmidt, Hartmut H.;Angeli, Paolo
通讯作者：
Angeli, Paolo
DOI：
10.1016/j.cgh.2017.09.012
发表时间：
2018-05
期刊：
Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association
影响因子：
--
作者：
China L;Skene SS;Shabir Z;Maini A;Sylvestre Y;Bennett K;Bevan S;O'Beirne J;Forrest E;Portal J;Ryder S;Wright G;Gilroy DW;O'Brien A
通讯作者：
O'Brien A