Model for End-Stage Liver Disease-Lactate and Prediction of Inpatient Mortality in Patients With Chronic Liver Disease

Naveed Sarmast, Gerald O Ogola, Maria Kouznetsova, Michael D Leise, Ranjeeta Bahirwani, Rakhi Maiwall, Elliot Tapper, James Trotter, Jasmohan S Bajaj, Leroy R Thacker, Puneeta Tandon, Florence Wong, K Rajender Reddy, Jacqueline G O'Leary, Andrew Masica, Ariel M Modrykamien, Patrick S Kamath, Sumeet K Asrani, Naveed Sarmast, Gerald O Ogola, Maria Kouznetsova, Michael D Leise, Ranjeeta Bahirwani, Rakhi Maiwall, Elliot Tapper, James Trotter, Jasmohan S Bajaj, Leroy R Thacker, Puneeta Tandon, Florence Wong, K Rajender Reddy, Jacqueline G O'Leary, Andrew Masica, Ariel M Modrykamien, Patrick S Kamath, Sumeet K Asrani

Abstract

Background and aims: Compared to other chronic diseases, patients with chronic liver disease (CLD) have significantly higher inpatient mortality; accurate models to predict inpatient mortality are lacking. Serum lactate (LA) may be elevated in patients with CLD due to both tissue hypoperfusion as well as decreased LA clearance. We hypothesized that a parsimonious model consisting of Model for End-Stage Liver Disease (MELD) and LA at admission may predict inpatient mortality in patients with CLD.

Approach and results: We examined all patients with CLD in two large and diverse health care systems in Texas (North Texas [NTX] and Central Texas [CTX]) between 2010 and 2015. We developed (n = 3,588) and validated (n = 1,804) a model containing MELD and LA measured at the time of hospitalization. We further validated the model in a second cohort of 14 tertiary care hepatology centers that prospectively enrolled nonelective hospitalized patients with cirrhosis (n = 726). MELD-LA was an excellent predictor of inpatient mortality in development (concordance statistic [C-statistic] = 0.81, 95% confidence interval [CI] 0.79-0.82) and both validation cohorts (CTX cohort, C-statistic = 0.85, 95% CI 0.78-0.87; multicenter cohort C-statistic = 0.82, 95% CI 0.74-0.88). MELD-LA performed especially well in patients with specific cirrhosis diagnoses (C-statistic = 0.84, 95% CI 0.81-0.86) or sepsis (C-statistic = 0.80, 95% CI 0.78-0.82). For MELD score 25, inpatient mortality rates were 11.2% (LA = 1 mmol/L), 19.4% (LA = 3 mmol/L), 34.3% (LA = 5 mmol/L), and >50% (LA > 8 mmol/L). A linear increase (P < 0.01) was seen in MELD-LA and increasing number of organ failures. Overall, use of MELD-LA improved the risk prediction in 23.5% of patients compared to MELD alone.

Conclusions: MELD-LA (bswh.md/meldla) is an early and objective predictor of inpatient mortality and may serve as a model for risk assessment and guide therapeutic options.

© 2020 by the American Association for the Study of Liver Diseases.

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