Chetwood John D, Wells Mark G, Tsoutsman Tatiana, Pulitano Carlo, Crawford Michael D, Liu Ken, Strasser Simone I, McCaughan Geoffrey W, Majumdar Avik
AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.
Central Clinical School, The University of Sydney, Sydney, Australia.
Transplant Direct. 2022 Jun 10;8(7):e1346. doi: 10.1097/TXD.0000000000001346. eCollection 2022 Jul.
Controversy exists regarding the best predictive model of liver transplant waiting list (WL) mortality. Models for end-stage liver disease-glomerular filtration rate assessment in liver disease (MELD-GRAIL) and MELD-GRAIL-Na were recently described to provide better prognostication, particularly in females. We evaluated the performance of these scores compared to MELD and MELD-Na.
Consecutive patients with cirrhosis waitlisted for liver transplant from 1998 to 2017 were examined in this single-center study. The primary outcome was 90-d WL mortality. MELD, MELD-Na, MELD-GRAIL, and MELD-GRAIL-Na at the time of WL registration were compared. Model discrimination was assessed with area under the receiver operating characteristic curves and Harrell's C-index after fitting Cox models. Model calibration was examined with Grønnesby and Borgan's modification of the Hosmer-Lemeshow formula and by comparing predicted/observed outcomes across model strata.
The study population comprised 1108 patients with a median age of 53.5 (interquartile range 48-59) y and male predominance (74.9%). All models had excellent areas under the receiver operating characteristic curves for the primary outcome (MELD 0.89, MELD-Na 0.91, MELD-GRAIL 0.89, MELD-GRAIL-Na 0.89; all comparisons > 0.05). Youden index cutoffs for 90-d mortality were as follows: MELD, 19; MELD-Na, 22; MELD-GRAIL, 18; and MELD-GRAIL-Na, 17. Variables associated with 90-d mortality on multivariable Cox regression were sodium, bilirubin, creatinine, and international normalized ratio. There were no differences in model discrimination using Harrell's C-index. All models were well calibrated; however, divergence between observed and predicted mortality was noted with scores ≥25.
There were no demonstrable differences in discrimination or calibration of GRAIL-based models compared with MELD or MELD-Na in our cohort. This suggests that GRAIL-based models may not have meaningful improvements in discriminatory ability when applied to other settings.
关于肝移植等待名单（WL）死亡率的最佳预测模型存在争议。最近描述的终末期肝病-肝病肾小球滤过率评估模型（MELD-GRAIL）和MELD-GRAIL-Na能提供更好的预后预测，尤其是在女性患者中。我们评估了这些评分与终末期肝病模型（MELD）和MELD-Na相比的性能。
在这项单中心研究中，对1998年至2017年连续列入肝移植等待名单的肝硬化患者进行了检查。主要结局是90天WL死亡率。比较了WL登记时的MELD、MELD-Na、MELD-GRAIL和MELD-GRAIL-Na。在拟合Cox模型后，用受试者工作特征曲线下面积和Harrell's C指数评估模型鉴别能力。用Grønnesby和Borgan对Hosmer-Lemeshow公式的修正方法，并通过比较各模型分层的预测/观察结局来检验模型校准。
研究人群包括1108例患者，中位年龄为53.5岁（四分位间距48 - 59岁），男性占多数（74.9%）。所有模型对于主要结局的受试者工作特征曲线下面积都很出色（MELD为0.89，MELD-Na为0.91，MELD-GRAIL为0.89，MELD-GRAIL-Na为0.89；所有比较P>0.05）。90天死亡率的约登指数临界值如下：MELD为19，MELD-Na为22，MELD-GRAIL为18，MELD-GRAIL-Na为17。多变量Cox回归中与90天死亡率相关的变量有钠、胆红素、肌酐和国际标准化比值。使用Harrell's C指数时，模型鉴别能力没有差异。所有模型校准良好；然而，评分≥25分时，观察到的和预测的死亡率之间存在差异。
在我们的队列中，与MELD或MELD-Na相比，基于GRAIL的模型在鉴别能力或校准方面没有明显差异。这表明基于GRAIL的模型应用于其他情况时，在鉴别能力上可能没有有意义的改善。
