From the Guidelines
The MELD score is a critical tool used in TIPS procedures to assess patient risk and determine candidacy for the intervention, with higher scores (typically above 18-20) indicating increased mortality risk and potentially poor candidacy for TIPS 1. The MELD score helps predict short-term mortality in patients with advanced liver disease by calculating a numerical value based on three laboratory values: serum bilirubin, serum creatinine, and INR (International Normalized Ratio).
Key Considerations for TIPS Candidacy
- The MELD score is the strongest predictor of 90-day mortality after TIPS when compared to MELD-Na and other scoring systems 1.
- A multidisciplinary approach, rather than an absolute MELD cutoff, is recommended to assess TIPS candidacy 1.
- Patients with higher MELD scores have significantly increased mortality risk following the procedure, making them potentially poor candidates 1.
- The decision to proceed with TIPS should take into consideration the relative risk and benefit of TIPS creation, considering the TIPS indication, patient comorbidities, and alternative treatment options 1.
Clinical Implications
- Patients with lower MELD scores generally have better outcomes following TIPS placement, while those with very high scores might be better directed toward liver transplantation evaluation rather than TIPS 1.
- Caution is required if considering TIPS in patients with age >70 years, serum bilirubin >50 μmol/L, platelet count <75×10^9/L, MELD score ≥18, current hepatic encephalopathy, active infection, or hepatorenal syndrome 1.
From the Research
MELD Score in TIPS
The Model for End-Stage Liver Disease (MELD) score is used to predict survival in patients undergoing Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedures. The MELD score is calculated based on three laboratory values:
- Bilirubin
- Creatinine
- International normalized ratio (INR) The MELD score has been validated as a predictor of mortality in patients with cirrhosis, including those undergoing TIPS procedures 2, 3.
Components of the MELD Score
The original MELD score consists of three components:
- Baseline bilirubin
- Creatinine
- International normalized ratio (INR) These components have been shown to be significant predictors of mortality in patients with cirrhosis 2, 4. Some studies have suggested that adding additional parameters, such as serum sodium level or albumin level, may improve the prognostic accuracy of the MELD score 3, 5, 6.
Use of the MELD Score in TIPS
The MELD score is used to risk-stratify patients prior to TIPS procedures. A higher MELD score is associated with an increased risk of mortality after TIPS 2, 5. The decision to pursue TIPS should be based on the original MELD score, as the MELD-Na score alone may exclude patients with refractory ascites who may benefit from TIPS 5.
Prognostic Value of the MELD Score
The MELD score has been shown to be a reliable predictor of mortality in patients undergoing TIPS procedures. The area under the receiver operator characteristic (AUROC) curve for the MELD score in predicting 90-day mortality after TIPS is 0.842 (95% CI 0.755-0.928) 2. The MELD score is also an independent predictor of long-term mortality in patients undergoing elective percutaneous coronary intervention (PCI) 6.
Key Points
- The MELD score is a predictor of mortality in patients with cirrhosis, including those undergoing TIPS procedures.
- The original MELD score consists of three components: bilirubin, creatinine, and INR.
- The MELD score is used to risk-stratify patients prior to TIPS procedures.
- A higher MELD score is associated with an increased risk of mortality after TIPS.
- The decision to pursue TIPS should be based on the original MELD score.