Hepatic dysfunction in ambulatory patients with heart failure: application of the MELD scoring system for outcome prediction

Abstract

Objectives: This study evaluated the Model for End-Stage Liver Disease (MELD) score and its modified versions, which are established measures of liver dysfunction, as a tool to assess heart transplantation (HTx) urgency in ambulatory patients with heart failure.

Background: Liver abnormalities have a prognostic impact on the outcome of patients with advanced heart failure.

Methods: We retrospectively evaluated 343 patients undergoing HTx evaluation between 2005 and 2009. The prognostic effectiveness of MELD and 2 modifications (MELDNa [includes serum sodium levels] and MELD-XI [does not include international normalized ratio]) for endpoint events, defined as death/HTx/ventricular assist device requirement, was evaluated in our cohort and in subgroups of patients on and off oral anticoagulation.

Results: The MELD and MELDNa scores were excellent predictors for 1-year endpoint events (areas under the curve: 0.71 and 0.73, respectively). High scores (>12) were strongly associated with poor survival at 1 year (MELD 69.3% vs. 90.4% [p < 0.0001]; MELDNa 70.4% vs. 96.9% [p < 0.0001]). Increased scores were associated with increased risk for HTx (hazard ratio: 1.10 [95% confidence interval: 1.06 to 1.14]; p < 0.0001 for both scores), which was independent of other known risk factors (MELD p = 0.0055; MELDNa p = 0.0083). Anticoagulant use was associated with poor survival at 1 year (73.7% vs. 86.4%; p = 0.0118), and the statistical significance of MELD/MELDNa was higher in patients not receiving oral anticoagulation therapy. MELD-XI was a fair but limited predictor of the endpoint events in patients receiving oral anticoagulation therapy.

Conclusions: Assessment of liver dysfunction according to the MELD scoring system provides additional risk information in ambulatory patients with heart failure.

Figure 1. Kaplan-Meier Survival Curves of All Patients (N = 260) Dichotomized According to MELD Values

Data were dichotomized according to (A) Model for End-Stage Liver Dysfunction (MELD); (B) MELD serum sodium score (MELDNa); and (C) MELD without international normalized ratio score (MELD-XI) by using the average cutoff value (12) derived from the receiver-operating characteristic analysis for 1-year death/heart transplantation (HTx)/ventricular assist device requirement. The survivals are represented by the solid red line for patients with low scores (<12) and the solid blue line for patients with high scores (>12). The p values obtained by the log-rank test were (A) p < 0.0001, (B) p < 0.0001, and (C) p < 0.0001.

Figure 2. Kaplan-Meier Survival Curve of All Patients (N = 260) Stratified According to Anticoagulation Use

The survivals are represented by the solid red line for patients not undergoing anticoagulation treatment (n = 156) and the solid blue line for patients receiving anticoagulation (n = 104). *Statistically significant (log rank test). HTx = heart transplantation.

Figure 3. Kaplan-Meier Survival Curves of Patients Off and On Anticoagulation

Values given for patients off anticoagulation (n = 156; top) and on anticoagulation (n = 104; bottom) further dichotomized by MELD (left), MELDNa (middle), and MELD-XI (right) scores by using the cutoff value of 12. The survivals are represented by the solid red line for patients with low scores (<12) and the solid blue line for patients with high scores (>12). The p value obtained by using the log-rank test in patients off anticoagulation was (A) p < 0.0001, (B) p = 0.0004, and (C) p = 0.0006. The p value obtained by using the log-rank test in patients on anticoagulation was (D) p = 0.5300, (E) p = 0.3236, and (F) p = 0.0136. *Statistically significant (log rank test). Abbreviations as in Figure 1.