Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt

Abstract

Background: In patients undergoing transjugular intrahepatic portosystemic shunt (TIPS), prognostic scores may identify those with a poor prognosis or even those with a clear survival benefit. The Child-Pugh score (CPS) is well established but several drawbacks have led to development of the model of end stage liver disease (MELD).

Aim: The aim of the study was to compare the predictive power of CPS and MELD, to validate the original MELD formula, and to assess the predictive value of the determinants used in the two prognostic scores outside of a study setting.

Patients: A total of 501 patients underwent elective TIPS placement and 475 patients fulfilled the inclusion criteria.

Methods: Data of all patients undergoing elective TIPS in one university hospital and four community hospitals in Vienna, Austria, between 1991 and 2001, were analysed retrospectively. The main statistical tests were Cox proportional hazards regression model, the log rank test, Kaplan-Meier analysis, and concordance c statistics.

Results: Median follow up was 5.2 years and median survival was 4.6 years. During follow up, 230 patients died, 75 within three months after TIPS placement. In stepwise proportional hazards analyses, independent predictors of death were creatinine level, bilirubin level, age, and refractory ascites. MELD was better in predicting survival in a stepwise Cox model but both scores were equally predictive in c statistics for one month, three month, and one year survival. Renal function was the strongest independent predictor of survival.

Conclusions: Although MELD was the primary predictor of overall survival in multivariate analysis, c statistics showed that both scores can be used for patients undergoing TIPS with equal accuracy. For assessing prognosis in patients undergoing TIPS implantation, there seems little reason to replace the well established Child-Pugh score.

Figure 1

Survival of all patients (n=475) included in the analysis. Symbols indicate patients who were censored on the last date known to be alive or on the date of liver transplantation.

Figure 2

(A) Survival according to underlying liver disease. Patients with alcohol and virus related disease had similar survival rates (p=0.636). (B) Survival according to indication for transjugular intrahepatic portosystemic shunt (TIPS). Patients undergoing TIPS for prevention of variceal bleeding had a significantly (p=0.032) better survival than patients undergoing TIPS for therapy of refractory ascites.

Figure 3

(A) Kaplan-Meier plot according to Child-Pugh score (CPS) class (A v B v C). CPS divided patients into groups with significantly different survival rates (p=0.0001). (B) Kaplan-Meier plot according to the model for end stage liver disease (MELD) score. Patients with a high risk of death within three months of transjugular intrahepatic portosystemic shunt placement (MELD >18) had highly significant (p=0.002) poorer survival rates than low risk patients (MELD ≤18).

Figure 4

Receiver operating characteristic curve for Child-Pugh score (CPS) and model for end stage liver disease (MELD) for three month survival. The area under the curve (AUC) was 0.7 for CPS and 0.72 for MELD, which was not significantly different.