Liver Transpl. 2020 Oct 6. doi: 10.1002/lt.25913. Online ahead of print.
BACKGROUND: The burden of cirrhosis hospitalizations is increasing. Admission MELD-lactate was recently demonstrated to be a superior predictor of in-hospital mortality as compared to MELD in limited cohorts. We aimed to identify specific classes of hospitalizations where MELD-lactate may be especially useful, and to evaluate the predictive role of lactate clearance.
METHODS: This was a retrospective cohort study of 1,036 cirrhosis hospitalizations for gastrointestinal bleeding, infection, or other portal hypertension-related indications in the Veterans Health Administration where MELD-lactate was measured upon admission. Performance characteristics for in-hospital mortality were compared between MELD-lactate and MELD/MELD-Na, with stratified analyses of MELD categories (≤15, 15-25, ≥25) and reason for admission. We also incorporated day 3 lactate levels into modeling, and tested for an interaction between day 1 MELD-lactate and day 3 lactate clearance.
RESULTS: MELD-lactate had superior discrimination for in-hospital mortality as compared to MELD or MELD-Na (area under the curve [AUC] 0.789 vs. 0.776 vs. 0.760, p<0.001), and superior calibration. MELD-lactate had higher discrimination among hospitalizations with MELD ≤15 (AUC 0.763 vs. 0.608 for MELD, global p=0.01) and hospitalizations for infection (AUC 0.791 vs. 0.674 for MELD, global p<0.001). We found a significant interaction between day 1 MELD-lactate and day 3 lactate clearance; heat maps were created as clinical tools to risk stratify patients based on these clinical data.
CONCLUSION: In comparison to MELD or MELD-Na, MELD-lactate has significantly superior performance in predicting in-hospital mortality among patients hospitalized for infection and/or with MELD ≤15. Incorporating day 3 lactate clearance may further improve prognostication.