MELD 3.0: The Model for End-Stage Liver Disease Updated for the Modern Era.
MELD 3.0: The Model for End-Stage Liver Disease Updated for the Modern Era.
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DOI：
10.1053/j.gastro.2021.08.050
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发表时间：
2021-12
期刊：
影响因子：
29.4
通讯作者：
Kwong AJ
中科院分区：
文献类型：
--
作者：
Kim WR;Mannalithara A;Heimbach JK;Kamath PS;Asrani SK;Biggins SW;Wood NL;Gentry SE;Kwong AJ
终末期肝病(MELD)模型已被建立为终末期肝病患者短期生存的可靠指标。目前的版本(MELDNa)，由INR和血清胆红素、肌酐和钠组成，已被用于确定美国(US)肝移植的器官分配优先顺序。目标是通过考虑其他变量和用当代数据更新系数，进一步优化MELD。2016年1月至2018年12月在美国国家登记处登记的肝脏移植等待名单上登记的所有候选人都被包括在内。单变量和多变量COX模型被用来预测等待登记后90天内的存活率。模型拟合用一致性统计和重分类进行检验，肝脏模拟分配模型(LSAM)用来估计新模型取代MELDNa的影响。最终的多变量模型包括：(1)女性性别和血清白蛋白的附加变量；(2)胆红素与钠、白蛋白与肌酐之间的相互作用；(3)肌酐的上限为3.0 mg/dL。最终的模型(MELD3.0)比MELDNa有更好的判别力(一致性统计0.869对0.862，p<；0.01)。重要的是，MELD 3.0正确地将8.8%的死者重新归类到更高的MELD级别，为他们提供了显著更高的移植机会，特别是在女性中。在LSAM分析中，与MELDNa相比，MELD 3.0导致的等待死亡人数较少(7,788对7,850，p=0.02)。MELD 3.0总体上比MELDNa提供了更准确的死亡率预测，并解决了包括性别差异在内的候补结果的决定因素。
The model for end-stage liver disease (MELD) has been established as a reliable indicator of short-term survival in patients with end-stage liver disease. The current version (MELDNa), consisting of INR and serum bilirubin, creatinine, and sodium, has been used to determine organ allocation priorities for liver transplantation in the United States (US). The objective was to optimize MELD further by taking into account additional variables and updating coefficients with contemporary data. All candidates registered on the liver transplant waitlist in the US national registry from Jan 2016 – Dec 2018 were included. Uni- and multivariable Cox models were developed to predict survival up to 90 days after waitlist registration. Model fit was tested using the concordance statistic and reclassification, and the liver simulated allocation model (LSAM) was used to estimate the impact of replacing MELDNa with the new model. The final multivariable model was characterized by (1) additional variables of female sex and serum albumin, (2) interactions between bilirubin and sodium and between albumin and creatinine, and (3) an upper bound for creatinine at 3.0mg/dL. The final model (MELD 3.0, henceforth), had better discrimination than MELDNa (concordance statistic 0.869 versus 0.862, p<0.01). Importantly, MELD 3.0 correctly reclassified a net of 8.8% of decedents to a higher MELD tier, affording them a meaningfully higher chance of transplant, particularly in women. In the LSAM analysis, MELD 3.0 resulted in fewer waitlist deaths compared to MELDNa (7,788 versus 7,850, p=0.02). MELD 3.0 affords more accurate mortality prediction in general than MELDNa and addresses determinants of waitlist outcomes including the sex disparity.
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