Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
Center for Liver Disease and Transplantation, Columbia University, Vagelos College of Physicians and Surgeons, New York, New York, USA.
Hepatology. 2022 Sep;76(3):689-699. doi: 10.1002/hep.32448. Epub 2022 Mar 31.
We investigated the impact of the inclusion of kidney dysfunction type on the discrimination and calibration of the Model for End-Stage Liver Disease with sodium (MELD-Na-KT) score.
We included all adults listed for ≥90 days without exception points from January 1, 2008, through December 31, 2018. We defined kidney dysfunction types as follows: acute kidney disease (AKD; an increase of ≥0.3 mg/dL or ≥50% in serum creatinine in the last 7 days or fewer than 72 days of hemodialysis), chronic kidney disease (CKD; an estimated glomerular filtration rate <60 ml/min/1.73 m for 90 days or ≥72 days of hemodialysis), AKD on CKD (met both definitions), or none (met neither definition). We then developed and validated a multivariable survival model with follow-up beginning at the first assessment after 90 days from waitlist registration and ending at the time of death, waitlist removal, or 90 days from enrollment in this study. The predictor variables were MELD-Na and the derived MELD-Na-KT model. In the derivation cohort, kidney dysfunction type was significantly associated with waitlist mortality after controlling for MELD-Na. There was a significant linear interaction between kidney dysfunction type and MELD-Na score. In the validation cohort, we saw an improvement in the discrimination of the model with an increase in the c-index from 0.76 with MELD-Na to 0.78 with MELD-Na-KT (p = 0.002) and a net reclassification index of 10.8% (95% CI, 1.9%-11.4%). The newly derived MELD-Na-KT model had lower Brier scores (MELD-Na-KT 0.042 vs. MELD-Na 0.053).
This study demonstrates the feasibility and the potential for objectively defined kidney dysfunction types to enhance the prognostication of waitlist mortality provided by the MELD-Na score.
我们研究了纳入肾功能障碍类型对终末期肝病模型钠（MELD-Na-KT）评分的区分度和校准度的影响。
我们纳入了 2008 年 1 月 1 日至 2018 年 12 月 31 日期间无例外点等待时间≥90 天的所有成年人。我们将肾功能障碍类型定义如下：急性肾损伤（AKI；在过去 7 天内血清肌酐增加≥0.3mg/dL 或≥50%，或在 72 天内少于血液透析），慢性肾脏病（CKD；估计肾小球滤过率<60ml/min/1.73m2 持续 90 天或≥72 天血液透析），AKI 合并 CKD（同时符合两种定义），或均不符合（同时不符合两种定义）。然后，我们开发并验证了一个多变量生存模型，随访从等待名单登记后第 90 天的第一次评估开始，直到死亡、等待名单移除或本研究登记后 90 天结束。预测变量为 MELD-Na 和衍生的 MELD-Na-KT 模型。在推导队列中，在控制 MELD-Na 后，肾功能障碍类型与等待名单死亡率显著相关。肾功能障碍类型与 MELD-Na 评分之间存在显著的线性交互作用。在验证队列中，我们发现模型的区分度随着 c 指数从 MELD-Na 的 0.76 增加到 MELD-Na-KT 的 0.78（p=0.002）和净再分类指数 10.8%（95%CI，1.9%-11.4%）而有所提高。新衍生的 MELD-Na-KT 模型的 Brier 评分较低（MELD-Na-KT 0.042 比 MELD-Na 0.053）。
本研究证明了客观定义的肾功能障碍类型增强 MELD-Na 评分预测等待名单死亡率的可行性和潜力。
