Occurrence of cirrhosis-related complications is a time-dependent prognostic predictor independent of baseline model for end-stage liver disease score

Background: The model for end-stage liver disease (MELD) is used to prioritize cirrhotic patients awaiting liver transplantation. Many cirrhosis-related complications are indications for transplantation but are not included in MELD. This study investigated the impact of these complications on survival and association with MELD. Methods: The mortality risk of cirrhosis-related complications, including bleeding esophageal varices. spontaneous bacterial peritonitis, hepatic encephalopathy, hepatorenal syndrome and hepatic decompensation, was analyzed using a time-dependent Cox regression model in 227 cirrhotic patients. Results: A total of 281 episodes of complications occurred in 142 (63%) patients. Patients who died had a significantly higher baseline MELD score compared with those who survived (14.5 +/- 4.5 vs 12.8 +/- 3.9, P=0.004). There was no significant difference in the MELD score between patients with and without the occurrence of complications (13.6 +/- 4.3 vs 12.9 +/- 4.0, P=0.093). Patients with a higher baseline MELD score tended to develop early complications (rho=-0.598, P<0.001). Using the Cox regression model, the risk ratio of mortality was 4.9 (95% confidence interval: 3.9-6.3, P<0.0001) for each additional episode of complication. Conclusions: The mortality risk increases as the number of complication episodes increases. While patients with repeated complications have a poor outcome, they do not necessarily have a higher baseline MELD score and could be down-staged in the MELD era.