Limitation of the model for end‐stage liver disease for outcome prediction in patients with cirrhosis‐related complications

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Abstract
The model for end‐stage liver disease (MELD) has been used to prioritize cirrhotic patients awaiting liver transplantation. Bleeding esophageal varices, spontaneous bacterial peritonitis and hepatic encephalopathy are major complications of cirrhosis and traditional indications for liver transplantation evaluation. However, these complications are not included in the MELD and it is not clear if these complications correlate with MELD score in terms of outcome prediction. This study aimed to investigate the feasibility of cirrhosis‐related complication as a prognostic predictor in 290 cirrhotic patients. The MELD score and outcome were compared between patients with and without cirrhosis‐related complications. There was no significant difference of the MELD score between patients with (n=67) and without (n=223) complications (11.6±2.9 vs. 12.2±3.2, p=0.184). The area under the receiver operating characteristic curve was 0.687 for MELD vs. 0.604 for complications (p=0.174) at six months, and the area was 0.641 for MELD vs. 0.611 for complications (p=0.522) at 12 months. A high MELD score and presence of complications had a similar profile of predictive accuracy and both were significant predictors of mortality at six and 12 months in multivariate logistic regression analysis. Patients with cirrhosis‐related complications at presentation had a decreased survival compared with those without complications (p<0.0001). In conclusion, the occurrence of cirrhosis‐related complications is a predictor of poor prognosis. While early transplantation referral is recommended, these patients do not necessarily have a higher MELD score and could be down‐staged in the MELD era.