Assessment of Prognosis of Cirrhosis

François Durand, M.D.; Dominique Valla, M.D.


Semin Liver Dis. 2008;28(1):110-122. 

In This Article

Prognosis in the Particular Setting of Transplantation

As it has been clearly shown that waiting time is not an accurate marker of waiting list mortality,[27] the “sickest first” policy has been widely adopted for organ allocation, with the aim of reducing waiting list mortality. Until now, liver transplantation has been the main application for MELD score. The main reasons the MELD score has been widely adopted in this context were discussed above. Briefly, MELD score is a robust marker of early mortality in cirrhotic patients across a wide spectrum of causes. It is a continuous score based on three readily available and relatively objective variables. Patients with particular conditions such as HCC can receive extra points corresponding to a given mortality risk. MELD can be updated in each patient according to the progression of the disease.

The implementation of MELD in the United States has been associated with a reduction in waiting list mortality.[30] In parallel, this “sickest first” policy has been associated with an increasing number of patients with advanced cirrhosis undergoing transplantation. Importantly, this shift in the indications for transplantation did not affect post-transplantation survival. In other words, transplanting patients with high MELD score does not necessarily translate into a significant increased post-transplant mortality, except for extreme values (over 30 to 35).[74,75] As HCC patients receive extra points, the implementation of MELD score also led to a significant decrease in the waiting list dropouts related to excessive tumor growth, without affecting post-transplant survival.[76]

As shown above, MELD score proved highly efficient for prioritizing patients who are at high risk of dying without transplantation. However, an original approach consisting of comparing liver transplant recipients' survival to that of comparable candidates without transplantation offered the possibility of assessing the transplant survival benefit. This comparison showed that transplant survival benefit steadily increased with increasing MELD score.[77] A very important finding is that only patients with a MELD score exceeding 15 to 17 derive a significant benefit from transplantation. Patients with a lower MELD would have a higher risk of dying from transplantation than they have of dying from the complications of cirrhosis. Transplantation would be futile in this subgroup.

However, a subset of patients with low MELD score and uncommon complications such as hepatopulmonary syndrome or mild portopulmonary hypertension are at high risk of dying in the absence of transplantation ( Table 5 ). More studies in these patients are needed for refining the assessment of the prognosis, with and without transplantation.


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