MELD, MELD 3.0, versus Child score to predict mortality after acute variceal hemorrhage: A multicenter US cohort

Abstract

Background: Acute variceal hemorrhage is a major decompensating event in patients with cirrhosis and is associated with high 6-week mortality risk. Many prognostic models based on clinical and laboratory parameters have been developed to risk stratify patients on index bleeding presentation, including those based on the Model for End-Stage Liver Disease (MELD) and Child-Turcotte-Pugh (CTP). However, consensus on model performance remains unclear.

Methods: Using a large US multicenter cohort of hospitalized patients with cirrhosis who presented with acute variceal hemorrhage, this study evaluates, recalibrates, and compares liver severity index-based models, including the more recent MELD 3.0 model, to investigate their predictive performance on 6-week mortality. Models were also recalibrated and externally validated using additional external centers.

Results: All recalibrated MELD-based and CTP-based models had excellent discrimination to identify patients at higher risk for 6-week mortality on initial presentation. The recalibrated CTP score model maintained the best calibration and performance within the validation cohort. Patients with low CTP scores (Class A, score 5-6) were strongly associated with < 5% mortality, while high CTP score (Class C, score > 9) were associated with > 20% mortality.

Conclusion: Use of liver severity index-based models accurately predict 6-week mortality risk for patients admitted to the hospital with acute variceal hemorrhage and supports the utilization of these models in future clinical trials as well as their use in clinical practice.

Graphical abstract

FIGURE 1

Initial assessment of calibration of MELD (A), Fortune CTP (B), and Reverter MELD (C) in the training cohort demonstrates significant miscalibration of both MELD and the previously published recalibration of CTP score. The previously published recalibration of MELD was calibrated in the training cohort. Abbreviations: CTP, Child-Turcotte-Pugh; MELD, Model for End-Stage Liver Disease.

FIGURE 2

Recalibration of MELD (A), MELD 3.0 (B), CTP Score (C) and Child class (D) demonstrated improved performance within the training cohort. Abbreviations: CTP, Child-Turcotte-Pugh; MELD, Model for End-Stage Liver Disease.

FIGURE 3

After recalibration of MELD (A), MELD 3.0 (B), CTP Score (C), and Child Class (D), all predictive models remained technically calibrated within the validation cohort, except for the recalibrated MELD, which was significantly miscalibrated in the validation cohort. Abbreviations: CTP, Child-Turcotte-Pugh; MELD, Model for End-Stage Liver Disease.

FIGURE 4

Locally weighted scatterplot smoothing smoothing and identification of thresholds for CTP Score in training cohort (A), CTP Score in validation cohort (B), MELD 3.0 Score in training cohort (C), and MELD 3.0 Score in validation cohort (D). Locally weighted scatterplot smoothing smoothing uses a robust weighting system to reduce the impact of outliers on a model, instead focusing on density. Plotted against observed outcomes, we have observed approximate mortality thresholds (denoted by the colored lines) which may be useful in clinical risk stratification. Abbreviations: BIDMC, Beth Israel Deaconess Medical Center; BUMC, Boston University Medical Center, MELD, Model for End-Stage Liver Disease; UC Davis, University of California, Davis; UNM, University of New Mexico; WCMC, Weill Cornell Medical Center