Modified model for end stage liver disease score accurately predicts death or liver transplantation in acute flares of chronic hepatitis B

Abstract

BACKGROUND AND AIMS: For patients chronically infected with hepatitis B virus, acute flares of chronic hepatitis B (AFOCHB) can be severe and fatal. The decision on whether to transplant or not is often a difficult one. The current study aims to determine the predictive value of short-term outcomes using the MELD score and its modified counterpart in AFOCHB patients. METHODS: Patients admitted with AFOCHB with ALT >5× upper limit of normal and HBVDNA of at least 4 logs IU/mL were included. Laboratory data was collected at the time of admission, at day 7, and at day 14. The MELD-ALT-Platelet (MAP) score was derived by additional points to the MELD score according to the ALT level (+1, +2, and +4 points for ALT ≤2000, 2000–3000, and >3000 respectively) and platelet level (+1, +2, +3, and +7 points for platelets ≥150, 100 to <150, 50 to <100, and <50 respectively). RESULTS: A total of 210 patients with AFOCHB were included. The outcome measured was either death or liver transplantation. Within 30 days, 25 (11.9%) patients died and 91 (43.3%) underwent liver transplantation. The AUROC of INR, MELD, and the MAP score at the time of admission to predict day 7 outcome was 0.935, 0.945, and 0.950 respectively. At day 7, 179 patients survived without the need for liver transplantation. The AUROC of INR, MELD, and MAP score at day 7 to predict day 14 outcomes were 0.869, 0.867, and 0.871 respectively. By day 14, 159 patients remained alive without the need for liver transplantation. The AUROC at day 14 for INR, MELD and MAP to predict day 30 outcomes was 0.834, 0.878, and 0.912 respectively. Although a high AUROC was observed for day 0, 7, and 14 MAP to predict day 7, 14, and 30 events respectively, the accuracy was reduced when day 0 MAP was used to predict events at day 14 and 30, with AUROC of 0.819 and 0.764 respectively. A similar trend was observed when day 7 MAP was used to predict day 30 events, achieving an AUROC of 0.772 (compared to 0.871 for day 14 events). A MAP score of <25 at day 0, day 7, and at day 14 was associated with no events at day 7, 14, and 30 respectively. For those presenting with MAP ≥35, the rate of events by day 7, 14 and 30 was 72%, 88%, and 96% respectively. CONCLUSIONS: Severe AFOCHB can be associated with high rates of mortality and LT. The MAP score at different time points can accurately predict short-term outcome to provide useful prognosis and determine the urgency of LT workup.