Re: My doc says that a study shows transplants done with lower meld score do worse

[Guest guest]

Hi Mike;

My understanding is that the lower the MELD at transplant, the

better the outcome (survival), as indicated in this study from the

UK, which supports results of 4 similar studies in the US:

Liver Transpl. 2004 Jul;10(7):903-7.

Comment in: Liver Transpl. 2004 Jul;10(7):908-10.

Pretransplant MELD score and post liver transplantation survival in

the UK and Ireland.

M, Copley LP, Lewsey JD, Gimson A, Toogood GJ, Rela M, van der

Meulen JH; UK and Ireland Liver Transplant Audit

Clinical Effectiveness Unit, Royal College of Surgeons of England,

London, UK. mjacob@...

It has been shown that the model for end-stage liver disease (MELD)

score is an accurate predictor of survival in patients with liver

disease without transplantation. Four recent studies carried out in

the United States have demonstrated that the MELD score obtained

immediately prior to transplantation is also associated with post-

transplant patient survival. Our aim was to evaluate how accurately

the MELD score predicts 90-day post-transplant survival in adult

patients with chronic liver disease in the UK and Ireland. The UK

and Ireland Liver Transplant Audit has data on all liver transplants

since 1994. We studied survival of 3838 adult patients after first

elective liver transplantation according to United Network for Organ

Sharing categories of their MELD scores (< or = 10, 11-18, 19-24, 25-

35, > or =36). The overall survival at 90-days was 90.2%. The 90-day

survival varied according to the United Network for Organ Sharing

MELD categories (92.6%, 91.9%, 89.7%, 89.7%, and 70.8%,

respectively; P < 0.01). Therefore, only those patients with a MELD

score of 36 or higher (3% of the patients) had a survival that was

markedly lower than the rest. As a consequence, the ability of the

MELD score to discriminate between patients who were dead or alive

was poor (c-statistic 0.58). Re-estimating the coefficients in the

MELD regression model, even allowing for nonlinear relationships,

did not improve its discriminatory ability. In conclusion, in the UK

and Ireland the MELD score is significantly associated with post-

transplant survival, but its predictive ability is poor. These

results are in agreement with results found in the United States.

Therefore, the most appropriate system to support patient selection

for transplantation will be one that combines a pretransplant

survival model (e.g., MELD score) with a properly developed post-

transplant survival model. PMID: 15237375.

This also seems to be true for PSC patients ... a lower MELD score

is a predictor of survival following transplantation for PSC

patients:

Scand J Gastroenterol. 2003 Nov;38(11):1176-83.

Outcome following liver transplantation for primary sclerosing

cholangitis in the Nordic countries.

Brandsaeter B, Friman S, Broome U, Isoniemi H, Olausson M, Backman

L, Hansen B, Schrumpf E, Oksanen A, zon BG, Hockerstedt K,

Makisalo H, Kirkegaard P, Bjoro K

Dept. of Medicine, Rikshospitalet, Oslo, Norway.

bjorn.brandsaeter@...

BACKGROUND: Primary sclerosing cholangitis (PSC) is the most common

indication for liver transplantation in the Nordic countries.

Because these patients are difficult to evaluate with regard to

timing of liver transplantation, it is important to establish

predictors of post-transplant survival. METHODS: Data from two

groups of patients receiving liver allografts during 1982-2001 were

recorded: (a) PSC patients and ( comparison patients. Outcome

following transplantation has been recorded for all patients.

Regression analyses have been performed for PSC patients to analyse

predictors of patient and graft survival. RESULTS: A total of 245

PSC and 618 comparison patients received a first liver allograft in

the period 1982 until the end of the study. The overall 1-, 3- and 5-

year patient survival rates were 82%, 77% and 75%, and 80%, 77% and

74% in the PSC group and comparison group, respectively. Survival

following transplantation has increased with time in both the PSC

and the comparison group. Recent year of transplantation, no

previous hepatobiliary surgery and a lower MELD score were

predictors of survival following transplantation for PSC patients.

PSC patients had a higher rate of re-transplantations (13% versus

8%, P = 0.01). Predictors of re-transplantation in PSC patients were

an episode of early rejection and vascular thrombosis. CONCLUSION:

In PSC patients, year of transplantation, previous hepatobiliary

surgery and MELD score are predictors of survival following

transplantation and these patients are more frequently in need of re-

transplantation compared to the comparison group. PMID: 14686722.

Best regards,

Dave

(father of (21), PSC 07/03; UC 08/03)

>

> He stated that transplants done with scores less than 15 tend to

do worse after the transplant than higher scores.

[Guest guest]

Hi Mike;

My understanding is that the lower the MELD at transplant, the

better the outcome (survival), as indicated in this study from the

UK, which supports results of 4 similar studies in the US:

Liver Transpl. 2004 Jul;10(7):903-7.

Comment in: Liver Transpl. 2004 Jul;10(7):908-10.

Pretransplant MELD score and post liver transplantation survival in

the UK and Ireland.

M, Copley LP, Lewsey JD, Gimson A, Toogood GJ, Rela M, van der

Meulen JH; UK and Ireland Liver Transplant Audit

Clinical Effectiveness Unit, Royal College of Surgeons of England,

London, UK. mjacob@...

It has been shown that the model for end-stage liver disease (MELD)

score is an accurate predictor of survival in patients with liver

disease without transplantation. Four recent studies carried out in

the United States have demonstrated that the MELD score obtained

immediately prior to transplantation is also associated with post-

transplant patient survival. Our aim was to evaluate how accurately

the MELD score predicts 90-day post-transplant survival in adult

patients with chronic liver disease in the UK and Ireland. The UK

and Ireland Liver Transplant Audit has data on all liver transplants

since 1994. We studied survival of 3838 adult patients after first

elective liver transplantation according to United Network for Organ

Sharing categories of their MELD scores (< or = 10, 11-18, 19-24, 25-

35, > or =36). The overall survival at 90-days was 90.2%. The 90-day

survival varied according to the United Network for Organ Sharing

MELD categories (92.6%, 91.9%, 89.7%, 89.7%, and 70.8%,

respectively; P < 0.01). Therefore, only those patients with a MELD

score of 36 or higher (3% of the patients) had a survival that was

markedly lower than the rest. As a consequence, the ability of the

MELD score to discriminate between patients who were dead or alive

was poor (c-statistic 0.58). Re-estimating the coefficients in the

MELD regression model, even allowing for nonlinear relationships,

did not improve its discriminatory ability. In conclusion, in the UK

and Ireland the MELD score is significantly associated with post-

transplant survival, but its predictive ability is poor. These

results are in agreement with results found in the United States.

Therefore, the most appropriate system to support patient selection

for transplantation will be one that combines a pretransplant

survival model (e.g., MELD score) with a properly developed post-

transplant survival model. PMID: 15237375.

This also seems to be true for PSC patients ... a lower MELD score

is a predictor of survival following transplantation for PSC

patients:

Scand J Gastroenterol. 2003 Nov;38(11):1176-83.

Outcome following liver transplantation for primary sclerosing

cholangitis in the Nordic countries.

Brandsaeter B, Friman S, Broome U, Isoniemi H, Olausson M, Backman

L, Hansen B, Schrumpf E, Oksanen A, zon BG, Hockerstedt K,

Makisalo H, Kirkegaard P, Bjoro K

Dept. of Medicine, Rikshospitalet, Oslo, Norway.

bjorn.brandsaeter@...

BACKGROUND: Primary sclerosing cholangitis (PSC) is the most common

indication for liver transplantation in the Nordic countries.

Because these patients are difficult to evaluate with regard to

timing of liver transplantation, it is important to establish

predictors of post-transplant survival. METHODS: Data from two

groups of patients receiving liver allografts during 1982-2001 were

recorded: (a) PSC patients and ( comparison patients. Outcome

following transplantation has been recorded for all patients.

Regression analyses have been performed for PSC patients to analyse

predictors of patient and graft survival. RESULTS: A total of 245

PSC and 618 comparison patients received a first liver allograft in

the period 1982 until the end of the study. The overall 1-, 3- and 5-

year patient survival rates were 82%, 77% and 75%, and 80%, 77% and

74% in the PSC group and comparison group, respectively. Survival

following transplantation has increased with time in both the PSC

and the comparison group. Recent year of transplantation, no

previous hepatobiliary surgery and a lower MELD score were

predictors of survival following transplantation for PSC patients.

PSC patients had a higher rate of re-transplantations (13% versus

8%, P = 0.01). Predictors of re-transplantation in PSC patients were

an episode of early rejection and vascular thrombosis. CONCLUSION:

In PSC patients, year of transplantation, previous hepatobiliary

surgery and MELD score are predictors of survival following

transplantation and these patients are more frequently in need of re-

transplantation compared to the comparison group. PMID: 14686722.

Best regards,

Dave

(father of (21), PSC 07/03; UC 08/03)

>

> He stated that transplants done with scores less than 15 tend to

do worse after the transplant than higher scores.

[Guest guest]

Chew on this for a while. With a MELD score of less than 15, a patient

is probably feeling pretty good, so the first year after transplant

with the subsequent healing and rehabilitation, there is significant

discomfort, compared to the way the patient FELT before the transplant.

But when you hear stories of patients who present with MELDs in the

20s, they probably FEEL pretty miserable. So transplant provides a

significant improvement of quality of life. The level of discomfort and

the numbers in bloodwork might indicate that both the patient with a 15

and the patient with the 23 are in IDENTICAL physical condition but the

23 reports that he/she FEELS much better than the 15.

Maybe this is what the doctor is referring to.

I've also read stories where in living donor transplant, the PSC

patient wakes up from surgery and reports actually feeling better than

immediately before surgery and the donor is the one who suffers. Who's

in more pain? Who's blood counts are worse. Neither. It's just that the

donor was healthy and feeling good before the surgery and the doctor

made a 20 inch incision and removed a lobe of liver and the PSC patient

was fatigued, septic, depressed, basically dying and the doctor puts in

a healthy chunk of liver which immediately starts removing toxins and

being a better contributor to the conversion of food to energy.

Does this help?

-

ERCP 9-02, PSC 12-02, Gallbladder 2-03, right tib/fib fx w/ rod

placement 1-05(this is for another support group), ERCP 4-05, UC 5-06

>

> than the people with high scores. He stated that transplants done

with

> scores less than 15 tend to do worse after the transplant than higher

> scores.

>

> Has anyone heard of such a study as I'd like to know more. This does

> not make sense to me as 1) lower score imply better health and 2)

where

> can get tranplanted with less than 15.

>

> In the meantime, I'll put in a call to my doctor to get more details

on

> this study.

>

> Mike in Houston (still alive)

>

[Guest guest]

As the article that Barb sent in highlights, people who are transplanted

at less that 15 MELD do worse than people with MELD <15 who aren't

transplanted (on average). They probably do as well or better than

people with a MELD over 15 who are transplanted (although the article

doesn't comment on this).

I guess this shows the importance of saying what you're comparing to

when you make a comparison.... sort of like the companies that say their

product is 20% better, but don't say what it's better than!

athan