MELD Score Successfully Gauges Risk of Poor Surgical Outcomes

BOSTON — A well-established risk-scoring system is turning out to have helpful new uses for gauging the preoperative risk associated with a variety of procedures.

The Model for End-Stage Liver Disease (MELD) score was first devised to assess progression in patients with cirrhotic liver disease. But the MELD score can also be used to integrate noninvasively collected data on a patient's hepatic, renal, and coagulopathy states, making it well suited to quickly assess a patient's risk for multisystem organ dysfunction and other adverse surgical outcomes.

When applied retrospectively in 211 patients receiving a left ventricular assist device (LVAD) at one center, a modified MELD score predicted the risk for death, renal failure, and right ventricular failure following surgery, as well as patients' perioperative and postoperative need for blood products and their hospital length of stay, Dr. Jennifer C. Matthews reported at the annual meeting of the International Society for Heart and Lung Transplantation.

In other recent studies, the MELD score has been used successfully to predict the risk for adverse outcomes in patients undergoing abdominal surgery and certain cardiac procedures such as coronary bypass and valve repair or replacement, said Dr. Matthews, a cardiologist at the University of Michigan, Ann Arbor.

“I stole the score and applied it to a different population and different organ systems,” she said.

MELD scores are determined by plugging patients' serum creatinine and bilirubin levels and their international normalized ratios (INRs) into a formula that's available on the Internet. In her study, Dr. Matthews used values obtained within 24 hours before LVAD placement surgery. She used a version of the MELD score formula that has been modified by the United Network for Organ Sharing.

Her study used data collected on all 211 patients who received an LVAD at the University of Michigan during October 1996-February 2007. Their average age was 50, their average serum values were a creatinine of 1.5 mg/dL and a bilirubin of 1.8 mg/dL, and their average INR was 1.2. Their average MELD score was 13.7. Perioperative deaths occurred in 29 patients.

A multivariate analysis showed that each 1-point rise in patients' MELD scores boosted their risk of operative death by 20%. A MELD score of 17 or greater was seen in the sickest quartile of patients. Patients in this subgroup had a threefold increased risk of death, and about a fivefold increased risk for both renal failure and right ventricular failure, compared with patients whose MELD scores were less than 17.

Each 1-point rise in MELD score was linked with about a half-day longer ICU stay. Higher MELD scores were also linked with a greater need for blood products (including use of red cells, platelets, plasma, or cryoprecipitate) during or within 24 hours following surgery.

In addition to emerging as an effective prognostic tool, the MELD score can guide physicians to take preoperative measures that might improve a patient's score, such as optimizing right ventricular filling pressure, correcting coagulopathy by improved nutrition or vitamin K supplementation, and using mechanical circulatory support early on.

Dr. Matthews cautioned that it's premature to use MELD scoring to assess patients scheduled to receive an LVAD, because she has not yet shown that improving patients' scores preoperatively will yield better outcomes. She has a project underway to further validate the score's prognostic ability in another set of LVAD recipients, she said in an interview.

BOSTON — A well-established risk-scoring system is turning out to have helpful new uses for gauging the preoperative risk associated with a variety of procedures.

The Model for End-Stage Liver Disease (MELD) score was first devised to assess progression in patients with cirrhotic liver disease. But the MELD score can also be used to integrate noninvasively collected data on a patient's hepatic, renal, and coagulopathy states, making it well suited to quickly assess a patient's risk for multisystem organ dysfunction and other adverse surgical outcomes.

When applied retrospectively in 211 patients receiving a left ventricular assist device (LVAD) at one center, a modified MELD score predicted the risk for death, renal failure, and right ventricular failure following surgery, as well as patients' perioperative and postoperative need for blood products and their hospital length of stay, Dr. Jennifer C. Matthews reported at the annual meeting of the International Society for Heart and Lung Transplantation.

In other recent studies, the MELD score has been used successfully to predict the risk for adverse outcomes in patients undergoing abdominal surgery and certain cardiac procedures such as coronary bypass and valve repair or replacement, said Dr. Matthews, a cardiologist at the University of Michigan, Ann Arbor.

“I stole the score and applied it to a different population and different organ systems,” she said.

MELD scores are determined by plugging patients' serum creatinine and bilirubin levels and their international normalized ratios (INRs) into a formula that's available on the Internet. In her study, Dr. Matthews used values obtained within 24 hours before LVAD placement surgery. She used a version of the MELD score formula that has been modified by the United Network for Organ Sharing.

Her study used data collected on all 211 patients who received an LVAD at the University of Michigan during October 1996-February 2007. Their average age was 50, their average serum values were a creatinine of 1.5 mg/dL and a bilirubin of 1.8 mg/dL, and their average INR was 1.2. Their average MELD score was 13.7. Perioperative deaths occurred in 29 patients.

A multivariate analysis showed that each 1-point rise in patients' MELD scores boosted their risk of operative death by 20%. A MELD score of 17 or greater was seen in the sickest quartile of patients. Patients in this subgroup had a threefold increased risk of death, and about a fivefold increased risk for both renal failure and right ventricular failure, compared with patients whose MELD scores were less than 17.

Each 1-point rise in MELD score was linked with about a half-day longer ICU stay. Higher MELD scores were also linked with a greater need for blood products (including use of red cells, platelets, plasma, or cryoprecipitate) during or within 24 hours following surgery.

In addition to emerging as an effective prognostic tool, the MELD score can guide physicians to take preoperative measures that might improve a patient's score, such as optimizing right ventricular filling pressure, correcting coagulopathy by improved nutrition or vitamin K supplementation, and using mechanical circulatory support early on.

Dr. Matthews cautioned that it's premature to use MELD scoring to assess patients scheduled to receive an LVAD, because she has not yet shown that improving patients' scores preoperatively will yield better outcomes. She has a project underway to further validate the score's prognostic ability in another set of LVAD recipients, she said in an interview.

BOSTON — A well-established risk-scoring system is turning out to have helpful new uses for gauging the preoperative risk associated with a variety of procedures.

The Model for End-Stage Liver Disease (MELD) score was first devised to assess progression in patients with cirrhotic liver disease. But the MELD score can also be used to integrate noninvasively collected data on a patient's hepatic, renal, and coagulopathy states, making it well suited to quickly assess a patient's risk for multisystem organ dysfunction and other adverse surgical outcomes.

When applied retrospectively in 211 patients receiving a left ventricular assist device (LVAD) at one center, a modified MELD score predicted the risk for death, renal failure, and right ventricular failure following surgery, as well as patients' perioperative and postoperative need for blood products and their hospital length of stay, Dr. Jennifer C. Matthews reported at the annual meeting of the International Society for Heart and Lung Transplantation.

In other recent studies, the MELD score has been used successfully to predict the risk for adverse outcomes in patients undergoing abdominal surgery and certain cardiac procedures such as coronary bypass and valve repair or replacement, said Dr. Matthews, a cardiologist at the University of Michigan, Ann Arbor.

“I stole the score and applied it to a different population and different organ systems,” she said.

MELD scores are determined by plugging patients' serum creatinine and bilirubin levels and their international normalized ratios (INRs) into a formula that's available on the Internet. In her study, Dr. Matthews used values obtained within 24 hours before LVAD placement surgery. She used a version of the MELD score formula that has been modified by the United Network for Organ Sharing.

Her study used data collected on all 211 patients who received an LVAD at the University of Michigan during October 1996-February 2007. Their average age was 50, their average serum values were a creatinine of 1.5 mg/dL and a bilirubin of 1.8 mg/dL, and their average INR was 1.2. Their average MELD score was 13.7. Perioperative deaths occurred in 29 patients.

A multivariate analysis showed that each 1-point rise in patients' MELD scores boosted their risk of operative death by 20%. A MELD score of 17 or greater was seen in the sickest quartile of patients. Patients in this subgroup had a threefold increased risk of death, and about a fivefold increased risk for both renal failure and right ventricular failure, compared with patients whose MELD scores were less than 17.

Each 1-point rise in MELD score was linked with about a half-day longer ICU stay. Higher MELD scores were also linked with a greater need for blood products (including use of red cells, platelets, plasma, or cryoprecipitate) during or within 24 hours following surgery.

In addition to emerging as an effective prognostic tool, the MELD score can guide physicians to take preoperative measures that might improve a patient's score, such as optimizing right ventricular filling pressure, correcting coagulopathy by improved nutrition or vitamin K supplementation, and using mechanical circulatory support early on.

Dr. Matthews cautioned that it's premature to use MELD scoring to assess patients scheduled to receive an LVAD, because she has not yet shown that improving patients' scores preoperatively will yield better outcomes. She has a project underway to further validate the score's prognostic ability in another set of LVAD recipients, she said in an interview.