MELD-XI: a rational approach to "sickest first" liver transplantation in cirrhotic patients requiring anticoagulant therapy
MELD-XI: a rational approach to "sickest first" liver transplantation in cirrhotic patients requiring anticoagulant therapy
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DOI：
10.1002/lt.20906
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发表时间：
2007-01-01
影响因子：
4.6
通讯作者：
Fisher, Robert A.
中科院分区：
文献类型：
--
作者：
Heuman, Douglas M.;Mihas, Anastasios A.;Fisher, Robert A.
在美国，“病情最严重者优先”肝移植（LT）的优先顺序由终末期肝病模型（MELD）决定。MELD是肝硬化短期死亡率的良好预测因子，但当抗凝治疗人为升高国际标准化比值（INR）时，MELD可能高估风险。在这种情况下，需要一个替代的预后指标省略INR。我们回顾性分析了2003年12月1日之前考虑LT的554名退伍军人的生存数据（训练组）。使用逻辑回归，我们得出了一个预测公式，90天移植前死亡率纳入胆红素和肌酐，但省略国际标准化比值。我们使用线性回归将该公式归一化为与MELD相同的尺度。这产生MELD-XI（对于排除INR的MELD）= 5.11Ln（胆红素）+11.76Ln（肌酸酐）+9.44。MELD-XI的准确性在2003年12月1日之后转诊的278名阿尔茨海默病退伍军人中进行了验证，并在2001年5月1日至2001年10月31日期间在美国进行LT的7，203名阿尔茨海默病成年人的独立验证数据集中进行了验证。MELD-XI和MELD在训练、保持和独立验证队列中相关性良好（分别为r = 0.930、0.954和0.902）。在保留队列中，MELD vs. MELD-XI的死亡率c统计量分别为30天时0.939 vs. 0.906; 60天时0.860 vs. 0.841; 90天时0.842 vs. 0.829; 180天时0.795 vs. 0.797。在独立验证数据集中，MELD与MELD-XI作为90天生存期预测因子的c统计量在非胆汁淤积性肝病中分别为0.857与0.843，在胆汁淤积性肝病中分别为0.905与0.894。相似的MELD和MELD-XI评分与相似的预后相关。总之，MELD-XI在预测肝硬化患者短期生存率方面，尽管忽略了INR，但几乎与MELD一样准确。在接受口服抗凝剂治疗的患者中，用MELD-XI替代MELD可能会更准确地评估LT的风险，并更合理地分配“病情最重”的优先级。
Priority for "sickest first" liver transplantation (LT) in the United States is determined by the model for end-stage liver disease (MELD). MELD is a good predictor of short-term mortality in cirrhosis, but it can overestimate risk when international normalized ratio (INR) is artificially elevated by anticoagulation. An alternate prognostic index omitting INR is needed in this situation. We retrospectively analyzed survival data for 554 cirrhotic veterans referred for consideration of LT prior to December 1, 2003 (training group). Using logistic regression we derived a predictive formula for 90-day pretransplant mortality incorporating bilirubin and creatinine but omitting INR. We normalized this formula to the same scale as MELD using linear regression. This yielded MELD-XI (for MELD excluding INR) = 5.11 Ln(bilirubin) + 11.76 Ln(creatinine) + 9.44. Accuracy of MELD-XI was validated in a holdout group of 278 cirrhotic veterans referred after December 1, 2003, and in an independent validation dataset of 7,203 cirrhotic adults listed for LT in the United States between May 1, 2001, and October 31, 2001. MELD-XI and MELD correlated well in training, holdout, and independent validation cohorts (r = 0.930, 0.954, and 0.902, respectively). In the holdout cohort, c-statistics of MELD vs. MELD-XI for mortality were, respectively, 0.939 vs. 0.906 at 30 days;0.860 vs. 0.841 at 60 days; 0.842 vs. 0.829 at 90 days; and 0.795 vs. 0.797 at 180 days. In the independent validation dataset, c-statistics for MELD vs. MELD-XI as predictors of 90-day survival were, respectively, 0.857 vs. 0.843 in noncholestatic liver diseases and 0.905 vs. 0.894 in cholestatic liver diseases. Comparable MELD and MELD-XI scores were associated with comparable prognosis. In conclusion, MELD-XI, despite omission of INR, is nearly as accurate as MELD in predicting short-term survival in cirrhosis. In patients treated with oral anticoagulants, substitution of MELD-XI for MELD may permit more accurate assessment of risk and more rational assignment of "sickest first" priority for LT.