Stage of Cirrhosis Predicts Risk of Liver Related Death in Low MELD Patients with Cirrhosis Awaiting Liver Transplant

MELD has reduced predictive ability in cirrhotic patients with MELD ≤ 20. We aimed to assess whether a 5-stage clinical model identifies liver transplant (LT) candidates with low MELD who are at increased risk for death. We conducted a case-control study of cirrhotic subjects with MELD ≤ 20 awaiting LT at a single academic medical center from 2/2002-5/2011. Conditional logistic regression was used to evaluate the risk of liver-related death based on cirrhosis stage. We identified 41 case subjects who died from liver-related causes with a MELD ≤ 20 within 90 days of death while waiting for LT. Cases were matched with up to 3 controls, totaling 66 controls, based on listing year, age, gender, liver disease etiology, hepatocellular carcinoma, and MELD. Cirrhosis stage (1=no varices or ascites, 2=varices, 3=variceal bleed, 4=ascites, 5=ascites and variceal bleed) was assessed for all subjects. MELD scores were similar for cases and controls. Clinical states contributing to death in cases were: sepsis 48%, spontaneous bacterial peritonitis 42%, variceal bleeding 24%, and hepatorenal syndrome 21%. In univariate analyses, variceal bleed (OR 5.6, p= 0.003), albumin (OR 0.5, p=0.041), increasing cirrhosis stage (p=0.003) and reaching stage 2, 3, or 4 cirrhosis versus lower stages (OR 3.6, p=0.048; OR 7.4, p