MELD Score Kinetics in Decompensated HIV+/HCV+ Patients. A Useful Prognostic Tool (ANRS HC EP 25 PRETHEVIC Cohort Study).
Gelu-Simeon M. et al.
Medicine (Baltimore). 2015 Jul;94(30).

In HIV-uninfected patients the Model for End-Stage liver disease (MELD) score can determine priorities for access to liver transplantation. The MELD score is also an independent predictor of pretransplant mortality in HIV-infected patients. Dynamic predictive factors for mortality have been evaluated in patients with advanced cirrhosis, but not specifically for decompensated cirrhosis after the first episode of decompensation of cirrhosis, in either HIV-infected or HIV-uninfected patients.
The aim of this prospective study was to define prognostic factors for survival in HIV/HCV-coinfected patients after an initial episode of decompensation of cirrhosis and to study the kinetics of MELD scores in this population.
The ANRS PRETHEVIC study is a multicenter prospective cohort of HIV/HCV-coinfected patients, which was set up in 2009. HIV/HCV-coinfected patients were included between 2009 and 2012 if they had experienced an initial episode of decompensation of cirrhosis and/or a diagnosis of hepatocellular carcinoma (HCC) during the 12 months preceding their enrollment. Cirrhosis was diagnosed by histological examination and or noninvasive tests (transient elastography and/or biological markers of fibrosis). Clinical and biological data were collected every 3 months.

In this analysis, only patients enrolled because of an initial episode of liver decompensation were considered. The occurrence of death, due to liver failure or any other cause, after the date of the initial decompensation, was the main endpoint of the survival analysis, using Kaplan–Meier curves. Data were censored at the last visit during the follow-up or the date of liver transplantation, whichever came first. Univariate and multivariate Cox models with late entry were used to assess prognostic factors of survival.
The kinetics of MELD scores starting from the initial hepatic decompensation episode and throughout follow-up was modeled. At least 2 points of MELD score were required to perform the kinetic of MELD from the first decompensation. A 2-slope mixed linear model with a node at 6 months was used to estimate the comparative changes in MELD scores in deceased and non-deceased patients.

Sixty seven patients were included in 32 centers between 2009 and 2012 (72% male; median age: 48 years [interquartile ratio (IQR):45–52], median follow-up: 22.4 months [range: 0.5–65.3]). Overall survival rates were 86%, 78%, and 59% at 6, 12, and 24 months, respectively. Under multivariate analysis, the MELD score at initial decompensation was predictive of survival, adjusted for age, type of decompensation, baseline CD4 counts, and further decompensation during follow-up as a time-dependent variable. The adjusted hazard ratio of death was 1.32 for a score 3 points higher (95% CI: [1.06–1.63], P = 0.012). MELD score kinetics within the 6 months after initial decompensation differed significantly between non-deceased and deceased patients, with a decreased (- 0.49/month; P = 0.016), versus a flat (+ 0.06/month, P = 0.753) mean change in score.

In conclusion, MELD is an effective tool to predict survival in HIV+/HCV+ patients with decompensated cirrhosis. A non-decreasing MELD score within 6 months following this initial decompensation episode may benefit from privileged access to liver transplantation in this poor prognosis population.

Expert's Commentary

« Survival of HIV patients with advanced stages of liver cirrhosis on the transplant list has been shorter than in HIV uninfected individuals with advanced stages of liver disease. This finding in combination with the more unfavourable course of HCV reinfection in HIV/HCV coinfected patients undergoing liver transplantation has overall questioned the role of liver transplantation in HIV because of the significantly lower post-transplantation survival times. With the advent of DAA based all oral therapy and high HCV cure rates in the pre as well as post-transplant setting the reservation towards liver transplantation in HIV/HCV infected individuals deserves to be reconsidered. Obviously, the identification of a scoring system which more specifically would allow to determine further progression of end-stage liver disease and survival on the transplant list would be helpful in optimizing organ allocation. Previous MELD score was demonstrated as an independent predictor of pre-transplant mortality in HIV-infected patients. The current study for the first time describes MELD score kinetics within the 6 months after initial decompensation HIV-infected patients as a useful tool to assess probability of survival. Clearly a non-decreasing MELD score within 6 months following this initial decompensation episode may help to identify the best candidates for privileged access to liver transplantation. In an era of organ shortage and a risk population of shorter survival on the transplant list this could be clinically extremely important in order to select the best candidates for liver transplantation. »

Pr Jürgen Rockstroh, University of Bonn