Prognostic Value of Hepatorenal Function By Modified Model for End-stage Liver Disease (MELD) Score in Patients Undergoing Tricuspid Annuloplasty

Abstract

Background: The Model for End-stage Liver Disease excluding international normalized ratio (MELD-XI) score and the modified MELD score with albumin replacing international normalized ratio (MELD-Albumin) score, which reflect both liver and renal function, have been reported as predictors of adverse events in liver and heart disease. Nonetheless, their prognostic value in patients undergoing tricuspid annuloplasty has not been addressed.

Methods and results: A total of 394 patients who underwent tricuspid annuloplasty were evaluated. Baseline clinical, laboratory, and echocardiographic parameters were recorded. Adverse outcome was defined as the occurrence of heart failure requiring admission or all-cause mortality. Patients who underwent tricuspid annuloplasty had a high prevalence of preoperative hepatorenal dysfunction that was more common in patients with severe tricuspid regurgitation than those with mild to moderate tricuspid regurgitation. The MELD-XI and MELD-Albumin scores were excellent predictors of 1-year adverse outcome (area under the curve: 0.69 and 0.75, respectively). Kaplan-Meier survival curve demonstrated that a high score on MELD-XI (≥12.0) and MELD-Albumin (≥10.7) was associated with an increased risk of adverse events. During a median follow-up of 40 months, both MELD-XI and MELD-Albumin scores were significantly associated with adverse outcome, even after adjusting for potential confounding factors. Significant improvement of hepatorenal function at 1 year postoperation was noted only in patients who had no adverse events, not in those who experienced an adverse outcome.

Conclusions: Both MELD-XI score and MELD-Albumin score can provide useful information to predict adverse outcome in patients undergoing tricuspid annuloplasty. The present study supports monitoring of modified MELD score to improve preoperative risk stratification of these patients.

Keywords: Model for End‐stage Liver Disease; liver and renal dysfunction; outcome; tricuspid annuloplasty; tricuspid regurgitation.

Figure 1

The formulas for calculating Model for End‐stage Liver Disease (MELD) score and modified MELD scores. To avoid negative scores, a lower limit of total bilirubin and creatinine was set at 1.0 mg/dL. *MELD‐Albumin score was calculated using this formula when serum albumin was ≥4.1 g/dL. ^# MELD‐Albumin score was calculated using this formula when serum albumin was <4.1 g/dL.

Figure 2

Receiver operating characteristic curves to determine the accuracy of baseline liver and renal function parameters most associated with adverse events at 1‐year follow‐up. ALT indicates alanine transaminase; AST, aspartate transaminase; AUC, area under the curve; eGFR, estimated glomerular filtration rate; MELD‐Albumin, Model for End‐stage Liver Disease with albumin replacing international normalized ratio; MELD‐XI, Model for End‐stage Liver Disease excluding international normalized ratio.

Figure 3

Kaplan–Meier curves for adverse events according to Model for End‐stage Liver Disease excluding international normalized ratio (MELD‐XI) score groups (A) and Model for End‐stage Liver Disease with albumin replacing international normalized ratio (MELD‐Albumin) score groups (B) based on the optimal cutoff value from the 1‐year receiver operating characteristic curve analysis.