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Copyright Information of the Article Published Online

TITLE

Is MELD score failing patients with liver disease and hepatorenal syndrome?

AUTHOR(s)

Lena Sibulesky, Nicolae Leca, Christopher Blosser, Amir A Rahnemai-Azar, Renuka Bhattacharya, Jorge Reyes

CITATION

Sibulesky L, Leca N, Blosser C, Rahnemai-Azar AA, Bhattacharya R, Reyes J. Is MELD score failing patients with liver disease and hepatorenal syndrome? World J Hepatol 2016; 8(27): 1155-1156

URL

http://www.wjgnet.com/1948-5182/full/v8/i27/1155.htm

DOI

http://dx.doi.org/10.4254/wjh.v8.i27.1155

OPEN ACCESS

This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

CORE TIP

The decompensation of patients with cirrhosis is associated with the development of hepatorenal syndrome (HRS) and renal insufficiency. There are several consequences of a high serum creatinine level in cirrhotic patients, including increased post - liver transplant mortality and increased risk of non-reversal of renal insufficiency/renal failure. We propose a change to the MELD scoring that would lead to timely liver transplantation in patients with HRS.

KEY WORDS

MELD; Hepatorenal syndrome; Cirrhosis; Graft survival; Liver allocation

COPYRIGHT

© The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.

NAME OF JOURNAL

World Journal of Hepatology

ISSN

1948-5182 (online)

PUBLISHER

Baishideng Publishing Group Inc, 8226 Regency Drive, Pleasanton, CA 94588, USA

WEBSITE

http://www.wjgnet.com

LETTERS TO THE EDITOR


Is MELD score failing patients with liver disease and hepatorenal syndrome?
Lena Sibulesky, Nicolae Leca, Christopher Blosser, Amir A Rahnemai-Azar, Renuka Bhattacharya, Jorge Reyes
Lena Sibulesky, Amir A Rahnemai-Azar, Jorge Reyes, Department of Surgery, Division of Transplant Surgery, University of Washington, Seattle, WA 98195, United States

Nicolae Leca, Christopher Blosser, Department of Medicine, Division of Nephrology, University of Washington, Seattle, WA 98195, United States

Renuka Bhattacharya, Department of Medicine, Division of Gastroenterology, University of Washington, Seattle, WA 98195, United States

Author contributions: Sibulesky L wrote the paper and designed and conducted research; Leca N, Blosser C, Rahnemai-Azar AA, Bhattacharya R and Reyes J designed research and reviewed the manuscript.

Correspondence to: Lena Sibulesky, MD, Assistant Professor, Department of Surgery, Division of Transplant Surgery, University of Washington, 1959 NE Pacific Street, Box 356410, Seattle, WA 98195, United States. lenasi@uw.edu

Telephone: +1-206-5987797 Fax: +1-206-5984287

Received: May 26, 2016 Revised: July 22, 2016 Accepted: August 6, 2016

Published online: September 28, 2016


Abstract

There is a need to reassess the application of MELD and the impact of renal insufficiency with consideration for developing an algorithm with exception points that would lead to timely allocation of livers to patients with hepatorenal syndrome prior to occurrence of permanent renal damage without jeopardizing post-transplant survival.


Key words: MELD; Hepatorenal syndrome; Cirrhosis; Graft survival; Liver allocation
© The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
Sibulesky L, Leca N, Blosser C, Rahnemai-Azar AA, Bhattacharya R, Reyes J. Is MELD score failing patients with liver disease and hepatorenal syndrome? World J Hepatol 2016; 8(27): 1155-1156 Available from: URL: http://www.wjgnet.com/1948-5182/full/v8/i27/1155.htm DOI: http://dx.doi.org/10.4254/wjh.v8.i27.1155
Core tip: The decompensation of patients with cirrhosis is associated with the development of hepatorenal syndrome (HRS) and renal insufficiency. There are several consequences of a high serum creatinine level in cirrhotic patients, including increased post - liver transplant mortality and increased risk of non-reversal of renal insufficiency/renal failure. We propose a change to the MELD scoring that would lead to timely liver transplantation in patients with HRS.
TO THE EDITOR

The decompensation of patients with cirrhosis is associated with the development of complications. This physiology can lead to renal hypoperfusion which contributes to the development of hepatorenal syndrome (HRS) and renal insufficiency[1,2]. It is rare to develop HRS with well-compensated liver disease.

There are several consequences of a high serum creatinine level in cirrhotic patients.

Serum creatinine is one of the most important independent predictors of waitlist and post-liver transplant (LT) mortality. While having the same MELD score, patients with higher serum creatinine level have a significantly higher mortality rate[3]. Analysis of the Scientific Registry of Transplant Recipients database linked with Centers for Medicare and Medicaid Services’ end-stage renal disease (ESRD) data by Sharma et al[4] demonstrated that post-LT ESRD is associated with higher post-LT mortality (HR = 3.32; P < 0.0001).

Serum creatinine prior to liver transplantation is one of the most significant predictors of post-liver transplantation ESRD[5]. Wong et al[6] recently demonstrated that the only predictor of type 1 HRS non-reversal was the duration of pre-transplant dialysis with a 6% increased risk of non-reversal with each additional day of dialysis. Prolonged ischemic physiology may lead to structural renal damage and thus, prevent renal recovery. This has led many to consider combined liver-kidney transplantation (CLKT) for patients whose HRS has lasted longer than 6 wk because the outcomes for patients who receive CLKT seem to be better than those of patients who receive a liver transplant alone[7,8]. Since the introduction of MELD score, the number of patients treated with CLKT has increased markedly[9]. Almost 1000 kidneys a year are used in a combined transplantation, thus, diminishing the donor pool for patients on the kidney list.

It has also been shown that patients with renal insufficiency have longer hospital and intensive care unit stays and an increased need for dialysis, which likely increases the cost of transplantation. It likely adds to already increased healthcare costs through additional dialysis cases, and increased hospitalization rates secondary to morbidities associated with ESRD[10].

While MELD score is the gold standard for predicting wait list mortality, a notable weakness for liver allocation lies in predicting post transplantation survival, particularly with renal insufficiency[11,12]. In addition to MELD, various scoring systems, including Child Pugh score, the risk, injury, failure, loss, end-stage kidney disease criteria, sequential organ failure assessment (SOFA) score, and the Chronic Liver Failure-SOFA score have been designed to predict outcomes in post liver transplant patients[13]. Without a timely liver transplant for patients with acute kidney injury, the patient mortality is shifting from the waitlist to the post-transplant period[14]. It is time for a conversation within the transplant community to reassess the application of MELD and the impact of renal insufficiency with consideration for developing an algorithm with exception points that would lead to timely allocation of livers to patients with HRS prior to occurrence of permanent renal damage without jeopardizing post-transplant survival.
REFERENCES

1 Garcia-Tsao G, Parikh CR, Viola A. Acute kidney injury in cirrhosis. Hepatology 2008; 48: 2064-2077 [PMID: 19003880 DOI: 10.1002/hep.22605]

2 Angeli P, Ginès P, Wong F, Bernardi M, Boyer TD, Gerbes A, Moreau R, Jalan R, Sarin SK, Piano S, Moore K, Lee SS, Durand F, Salerno F, Caraceni P, Kim WR, Arroyo V, Garcia-Tsao G. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. J Hepatol 2015; 62: 968-974 [PMID: 25638527 DOI: 10.1016/j.jhep.2014.12.029]

3 Sharma P, Schaubel DE, Guidinger MK, Merion RM. Effect of pretransplant serum creatinine on the survival benefit of liver transplantation. Liver Transpl 2009; 15: 1808-1813 [PMID: 19938142 DOI: 10.1002/lt.21951]

4 Sharma P, Schaubel DE, Guidinger MK, Goodrich NP, Ojo AO, Merion RM. Impact of MELD-based allocation on end-stage renal disease after liver transplantation. Am J Transplant 2011; 11: 2372-2378 [PMID: 21883908 DOI: 10.1111/j.1600-6143. 2011.03703.x]

5 Bahirwani R, Reddy KR. Outcomes after liver transplantation: chronic kidney disease. Liver Transpl 2009; 15 Suppl 2: S70-S74 [PMID: 19876956 DOI: 10.1002/lt.21900]

6 Wong F, Leung W, Al Beshir M, Marquez M, Renner EL. Outcomes of patients with cirrhosis and hepatorenal syndrome type 1 treated with liver transplantation. Liver Transpl 2015; 21: 300-307 [PMID: 25422261 DOI: 10.1002/lt.24049]

7 OPTN/UNOS Kidney Transplantation Committee. Simultaneous Liver Kidney (SLK) allocation policy. 2016. Available from: URL: https://optn.transplant.hrsa.gov/governance/public-comment/simultaneous-liver-kidney-allocation/

8 Fong TL, Khemichian S, Shah T, Hutchinson IV, Cho YW. Combined liver-kidney transplantation is preferable to liver transplant alone for cirrhotic patients with renal failure. Transplantation 2012; 94: 411-416 [PMID: 22805440 DOI: 10.1097/TP.0b013e 3182590d6b]

9 Locke JE, Warren DS, Singer AL, Segev DL, Simpkins CE, Maley WR, Montgomery RA, Danovitch G, Cameron AM. Declining outcomes in simultaneous liver-kidney transplantation in the MELD era: ineffective usage of renal allografts. Transplantation 2008; 85: 935-942 [PMID: 18408571 DOI: 10.1097/TP.0b013e318168476d]

10 Brown RS, Lombardero M, Lake JR. Outcome of patients with renal insufficiency undergoing liver or liver-kidney transplantation. Transplantation 1996; 62: 1788-1793 [PMID: 8990364 DOI: 10.1097/00007890-199612270-00018]

11 Klein KB, Stafinski TD, Menon D. Predicting survival after liver transplantation based on pre-transplant MELD score: a systematic review of the literature. PLoS One 2013; 8: e80661 [PMID: 24349010 DOI: 10.1371/journal.pone.0080661]

12 Oberkofler CE, Dutkowski P, Stocker R, Schuepbach RA, Stover JF, Clavien PA, Béchir M. Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients. Crit Care 2010; 14: R117 [PMID: 20550662 DOI: 10.1186/cc9068]

13 Pan HC, Jenq CC, Lee WC, Tsai MH, Fan PC, Chang CH, Chang MY, Tian YC, Hung CC, Fang JT, Yang CW, Chen YC. Scoring systems for predicting mortality after liver transplantation. PLoS One 2014; 9: e107138 [PMID: 25216239 DOI: 10.1371/journal.pone.0107138]

14 Weber ML, Ibrahim HN, Lake JR. Renal dysfunction in liver transplant recipients: evaluation of the critical issues. Liver Transpl 2012; 18: 1290-1301 [PMID: 22847917 DOI: 10.1002/lt.23522]
Footnotes

Conflict-of-interest statement: The authors declare no conflicts of interest. No funding was received for this research.

Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Manuscript source: Unsolicited manuscript

Peer-review started: May 26, 2016

First decision: July 6, 2016



Article in press: August 8, 2016

P- Reviewer: Chamuleau RAFM, Gong ZJ, Kabir A, Rostami K, Silva LD, Tomizawa M S- Editor: Ji FF L- Editor: A E- Editor: Li D



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