Original articleComparison of the prognostic value of Chronic Liver Failure Consortium scores and traditional models for predicting mortality in patients with cirrhosisComparación del valor pronóstico de los modelos del Chronic Liver Failure Consortium y modelos tradicionales para predecir la mortalidad en pacientes con cirrosis
Introduction
Cirrhosis is the late stage of hepatic fibrosis and it is characterized by the distortion of the hepatic architecture and formation of regenerative nodules. It accounts for approximately 170,000 deaths per year in Europe.1 Patients with cirrhosis are susceptible to a variety of complications (ascites, spontaneous bacterial peritonitis, hepatic encephalopathy, hepatocellular carcinoma, hepatorenal and hepatopulmonary syndrome). When those complications appear, patients are considered to have decompensated cirrhosis and have a worse prognosis than those with compensated cirrhosis.2
The early use of stratification is essential as part of the initial evaluation of cirrhosis, as it provides objective information to the physician, allowing a useful guide to allocate patients according to their needs and prognosis.
Multiple studies were conducted in order to develop prognostic models for patients with cirrhosis, based on clinical and laboratory data. The two traditional used models are the Child-Turcotte-Pugh (CTP) classification and Model for End-Stage Liver Disease (MELD).3, 4, 5 The CTP score has many limitations, namely because of its reliance on subjective interpretation of qualitative parameters and the empirical choice of its variables.6 MELD has also been criticized for several reasons: for instance, different laboratorial methodologies to detect creatinine serum levels cause marked variations in this score, not allowing accurate comparison of scores between different centers; also, the fact that the international normalized ratio (INR) may not reflect the severity of liver disease (alterations in INR may reflect iatrogenic interventions or inherent disease state, not necessarily the severity of cirrhosis).7, 8 Several attempts to improve the predictive accuracy of MELD were made, by adding clinical or laboratory parameters, as well as optimizing the equation by multivariate analysis, which resulted in new models like MELD-Na,9, 10, 11, 12 MELD to serum sodium ratio index (MESO),13 integrated MELD (iMELD),14 Refit MELD, and Refit MELD-Na.15
Recently, from the Chronic Liver Failure (CLIF) Acute-on-Chronic Liver Failure in Cirrhosis (CANONIC) study,16 two new prognostic models were developed, based on the presence or absence of Acute-on-Chronic Liver Failure (ACLF), respectively, the CLIF Consortium ACLF score (CLIF-C ACLFs)17 and the CLIF-C Acute Decompensation score (CLIF-C ADs).18 Both of them demonstrated superiority over the CTP, MELD and MELD-Na at predicting mortality. ACLF is diagnosed using the CLIF Consortium organ failure score (CLIF-C OFs), which evaluates new prognostic determinants, as the presence of extra-hepatic organ failures (cerebral, lung and circulatory dysfunction), which are not taken into account in MELD based models.16, 17, 18, 19
The aim of this study was to compare the accuracy of the new CLIF-C ACLFs and CLIF-C ADs with some of the traditional models used in clinical practice (CTP, MELD, MELD-Na, iMELD, MESO, Refit MELD, Refit MELD-Na), in order to predict 30- and 90-day mortality (in the first 24 h of admission) of cirrhotic patients admitted due to decompensated cirrhosis.
Section snippets
Population
We conducted a retrospective cohort study that evaluated all consecutive admissions to the Gastroenterology and Hepatology department due to decompensated cirrhosis in 2 centers between 2011 and 2014. The diagnosis of cirrhosis was based on conventional histological (when available), clinical, laboratory, endoscopic and imaging tests.
Acute decompensation was defined by new onset of hepatic encephalopathy, large volume ascites, gastrointestinal bleeding, or any combination of the previous.
Patients
Seven hundred and seventy nine consecutive admissions for chronic liver disease were studied. Forty-nine patients were lost to follow-up at 90 days. Patient's characteristics are described in Table 1. The mean age was 59.98 (±11.62) years; 81.5% were male. The major cause of chronic liver disease was alcohol (65.1%), followed by hepatitis C virus (20.7%). At admission, 349 (44.8%) had criteria for infection, 174 (22.3%) presented acute gastrointestinal bleeding and 77 (9.9%) a diagnosis of
Discussion
A good prognostic model should rely on objective data, minimizing the influence of subjective physician evaluation, should be easy to use and have a high predictive ability.
The two most studied models correspond to CTP and MELD. A recent meta-analysis by Peng et al.21 compared the discriminating ability between CTP and MELD for predicting the prognosis of cirrhotic patients. After evaluating 119 papers they concluded that for the prediction of in-hospital, 3- and 6-month mortality, MELD score
Conflict of interests
The authors declare that they have no conflict of interest.
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