MODEL FOR END-STAGE LIVER DISEASE (MELD) IN STRATIFIACATION OF IN HOSPITAL PATIENTS WITH TERMINAL LIVER DISEASE

Abstract

INTRODUCTION: Liver cirrhosis is end stage of liver disease where liver transplantation is the only curative treatment. MELD score system is relatively newer system (the last ten years) used as assesment tool for liver disease severity as well as for creating of liver transplantation priority lists. In the contrary of already used system - Child-Turcotte-Pugh, where posibility for subjective assesment of variables as ascites and encephalopathy is existing, this system avoids such posibility. MELD includes another very important variable – renal function assesment as serious prognostic factor. Well-defined formula calculating natural logarithms of bilrubin, creatinin and international normalized ratio (INR) of prothrombin time determined MELD-'s set of points. The aim of this study is to stratify in hospital patients in Clinic of Gastroenterohepatology, Skopje with terminal liver disease using MELD scoring system and easy recognize the real need for transplantation in these patients. MATERIAL AND METHODS: This retrospective study is analyzing medical discharge summary among 192 patients hospitalized at our clinic in the period from 01.01.2011 to 31.12.2011 with diagnosis of liver cirrhosis, who have all the necessary parameters available to calculate the MELD score (patients with the same diagnosis without the necessary parameters were excluded from the study). Patients were aged between 20 and 90 years (average age 55.7 years) with predominance of males (147 males and 45 females). They were analyzed in accordance to cirrhosis etiology, indication for hospitalization, MELD score and the risk of lethal outcome. Descriptive statistics to analyze data was used. RESULTS: Total of 192 patients are analyzed, 76.6% are male, while 23.4% are women. From the etiological point of view the alcohol as cause of cirrhosis dominates in 73 patients (38%), followed by HBV infection in 49 patients (25.5%), undefined etiology has in 24 patients (12.5%), mixed etiology of ethyl and viral origin of hepatitis B in 11 patients (6%), HCV infection in 9 patients (4.7%), immunogenic etiology in 8 patients (4.1%), portal vein thrombosis in 4 patients (2.1%), secondary biliary cirrhosis in 4 patients (2.1%), alcohol and HCV infection in 3 patients (1.5%), mixed HBV and HCV infection in 2 patients (1%), primary biliary cirrhosis in 2 patients (1%), Wilson disease in 2 patients (1%) and nonalcoholic steatohepatitis as a cause of cirrhosis in 1 patient (0.5%). The most common reason for hospitalization is variceal bleeding in 51 patients (26.6%), followed by refractory ascites in 35 patients (18.2%), jaundice in 31 patients (16.1%), portal encephalopathy in 29 patients (15.1%), diagnostic differentiation (liver biopsy) in 28 patients (14.6%), and hepato-renal syndrome in 14 patients (7.3%). In accordance to the MELD score, patients are divided into 5 groups regarding to calculated percentage of three month mortality. Average MELD score for all 192 patients is 15. Under this scoring system 4 patients (2.1%) belong to the group with highest risk (71.3% is the rate of mortality within three months), 14 patients (7.3%) in group having 52.6% mortality rate within three months, 31 patients (16%) belong to a group with 19.6% mortality rate, and the remaining patients in the group with 6% mortality rate (69 patients - 36%) and the group with the lowest mortality of 1.9% (74 patients - 39.5%). The outcome of 20 from 192 patients analyzed was lethal. The reason for this outcome was hepato-renal syndrome in 11 patients (55%), variceal bleeding in 7 patients (35%) and in 2 patients (10%) hepatic coma. DISCUSSION: Liver cirrhosis as an indication for hospitalization is often seen in our daily practice. Especially common reason for hospitalization is the occurrence of complications of cirrhosis (variceal bleeding, refractory ascites, jaundice, portal encephalopathy or hepato-renal syndrome), which caused lethal outcome in some patients. According to our analysis, a significant percentage of patients (39/192 or 25.4%) with MELD score> 20, belong to the group with high short-term risk of lethal outcome (3 months mortality rate). Those patients in developed countries would find themselves on a priority list for liver transplantation. Our commitment (such as internal disease specialists and surgeons) should be to enable these patients equal access to treatment as in those patients with terminal liver failure in developed countries.