From the Guidelines
The MELD score is a crucial tool used in TIPS procedures to assess a patient's risk of mortality and determine candidacy for the procedure, with a score above 18-20 generally considered a contraindication due to significantly higher mortality rates following TIPS placement 1. The MELD score helps predict short-term survival 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
- TIPS is typically performed to treat complications of portal hypertension such as variceal bleeding or refractory ascites, but the procedure can worsen liver function 1.
- The MELD score provides an objective measure to help clinicians balance the potential benefits of TIPS against the risks of post-procedure hepatic decompensation 1.
- Higher MELD scores indicate more severe liver dysfunction and poorer hepatic reserve, which translates to a reduced ability to tolerate the hemodynamic changes caused by TIPS.
Clinical Decision-Making
- When evaluating patients for TIPS with refractory ascites, the expert opinion is to use scores such as MELD as a guide but not as a definitive rule, considering factors such as age, frailty, and alternative treatment options 1.
- Caution is required if considering TIPSS in patients with age >70 years, serum bilirubin >50 μmol/L, platelet count <75×10^9/L, model for end-stage liver disease (MELD) score ≥18, current hepatic encephalopathy, active infection or hepatorenal syndrome 1.
Evidence-Based Practice
- The most recent and highest quality study recommends a multidisciplinary approach, rather than an absolute MELD cutoff, to assess TIPS candidacy 1.
- The MELD score is the strongest predictor of 90-day mortality after TIPS when compared to MELD-Na and other scoring systems, such as the Child-Turcotte-Pugh (CTP) score 1.
From the Research
MELD Score in TIPS
The Model for End-Stage Liver Disease (MELD) score is used to predict survival after Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedures. The 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 undergoing TIPS for acute variceal hemorrhage 2.
Components of the MELD Score
The four original MELD components have been shown to be significant predictors of mortality on multivariate Cox regression:
- Baseline bilirubin
- Creatinine
- International normalized ratio
- Liver disease etiology These components are used to calculate the MELD score, which has been shown to be an excellent predictor of 90-day mortality in the emergent TIPS population 2.
Comparison with Other Scores
The MELD score has been compared to other scores, such as the MELD-Na score, which includes sodium levels in the calculation. However, studies have shown that the original MELD score is a valid and reliable metric for risk stratification and survival projection after emergent TIPS, and that the MELD-Na score may not provide additional prognostic value 3.
Clinical Applications
The MELD score has been shown to be a useful tool for risk stratification in patients with cirrhosis, including those undergoing TIPS procedures. It can be used to predict mortality and identify patients who may benefit from TIPS 2, 4. Additionally, the MELD score has been shown to be a feasible screening tool for identifying patients with impaired hepatic function at hospital admission 5.
Prognostic Value
The MELD score has been shown to have prognostic value in patients undergoing TIPS procedures, with higher scores indicating a higher risk of mortality 2, 3. The score can be used to predict outcomes and guide clinical decision-making. Other versions of the MELD score, such as the MELD-Albumin score, have also been shown to have prognostic value in certain patient populations 6.