Lee YH, Hsu CY, Hsia CY, et al. Defining the severity of liver dysfunction in patients with hepatocellular carcinoma by the model for end-stage liver disease-derived systems

Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Digestive and Liver Disease (Impact Factor: 2.96). 05/2012; 44(10):868-74. DOI: 10.1016/j.dld.2012.04.018
Source: PubMed


The model for end-stage liver disease (MELD) and serum sodium (Na) are important markers for liver functional reserve in patients with hepatocellular carcinoma. We aimed to determine the best model to define the severity of liver dysfunction in terms of outcome prediction among the 4 currently used systems (MELD, MELDNa, MELD-Na and ReFit MELDNa).
A total of 2308 prospectively enrolled patients with hepatocellular carcinoma were analysed. The prognostic ability was compared by the Akaike information criterion.
MELDNa had the best prognostic accuracy overall, and for patients receiving curative and non-curative treatments, followed by MELD-Na, MELD and ReFit MELDNa. When patients were categorized into <8, 8-12, 12-16, 16-20 and >20, the adjusted risk ratios for MELDNa were 1.065 (p=0.46), 0.996 (p=0.973), 1.38 (p=0.048) and 1.563 (p=0.003) for the scores of 8-12, 12-16, 16-20 and >20, respectively, compared to the group with scores <8. The adjusted risk ratio for MELDNa was 1.014 (95% confidence interval, 1.001-1.027; p=0.034) per unit score increment in the Cox model.
The MELDNa is the best marker to define the severity of liver dysfunction in hepatocellular carcinoma patients independent of treatment strategy. The ReFit MELDNa does not enhance the predictive accuracy of the MELD.

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    ABSTRACT: The model for end-stage liver disease (MELD) has replaced the role of the Child-Turcotte-Pugh system as a more commonly used system in evaluating the severity of liver dysfunction in patients with chronic liver disease, owing to its superior ability to predict survival. The United Network of Organ Sharing (UNOS) in the USA has used the MELD system for prioritizing donor grafts in advanced cirrhotic patients awaiting liver transplantation since 2002. Serum sodium level is another important prognostic predictor in cirrhosis. Consequently, by incorporating serum sodium into the original MELD, the MELD-Na, MELDNa, the MELD-to-sodium ratio (MESO) index, and the ReFit MELDNa were proposed in an attempt to improve the predictive ability of the original MELD. Nevertheless, there are some limitations of the MELD-based systems that need to be refined. The MELD-based systems merely use laboratory data as parameters for the equation, therefore, any lack in unification and standardization of laboratory methods will result in inconsistent data that affect the prioritization of liver transplantation. Furthermore, the MELD system includes creatinine as a parameter, and serum creatinine level may represent different degrees of renal dysfunction in men and women. Therefore, these limitations may compromise the fair process of organ allocation for female cirrhotic patients. Currently, the application of the MELD system has been extended to tumor staging of hepatocellular carcinoma. Several studies have replaced the Child-Turcotte-Pugh system with the MELD as a parameter, indicating that the use of different criteria of liver dysfunction in cancer staging may enhance prognostic accuracy. Although the outcome data of the modified staging systems need to be confirmed, the concept of using the MELD as a reference system for evaluating the severity of liver dysfunction has globally become an important issue.
    No preview · Article · Jun 2013 · Journal of the Chinese Medical Association
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    No preview · Article · Oct 2013 · Journal of clinical gastroenterology
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    ABSTRACT: Many liver staging systems that include the tumor stage and the extent of liver function have been developed. However, prognosis assessment for hepatocellular carcinoma (HCC) remains controversial. In this study, the performances of 7 staging systems were compared in a cohort of patients with HCC who underwent non-surgical treatment. A total of 196 consecutive patients with HCC who underwent non-surgical treatment seen between January 1, 2004, and December 31, 2007, were included. Performances of TNM sixth edition, Okuda, Barcelona Clinic Liver Cancer (BCLC), Cancer of the Liver Italian Program (CLIP), Chinese University Prognostic Index (CUPI), Japan Integrated Staging (JIS), and China integrated score (CIS) have been compared and ranked using concordance index (c-index). Predictors of survival were identified using univariate and multivariate Cox model analyses. The median survival time for the cohort was 7.6 months (95% CI 5.6-9.7). The independent predictors of survival were performance status (P<.001), serum sodium (P<.001), alkaline phosphatase (P<.001), tumor diameter greater than 5 cm (P = .001), portal vein invasion (P<.001), lymph node metastasis (P = .025), and distant metastasis (P = .004). CUPI staging system had the best independent predictive power for survival when compared with the other six prognostic systems. Performance status and serum sodium improved the discriminatory ability of CUPI. In our selected patient population whose main etiology is hepatitis B, CUPI was the most suitable staging system in predicting survival in patients with unresectable HCC. BCLC was the second top-ranking staging system. CLIP, JIS, CIS, and TNM sixth edition were not helpful in predicting survival outcome, and their use is not supported by our data.
    Full-text · Article · Mar 2014 · PLoS ONE
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