Modified Model for End-Stage Liver Disease eXcluding INR (MELD-XI) Score Predicts Early Death After Pediatric Heart Transplantation

Joshua C. Grimm, J. Trent Magruder, Nhue Do, Joseph A. Spinner, Samuel P. Dungan, Arman Kilic, Nishant Patel, Kristin L. Nelson, Marshall L. Jacobs, Duke E. Cameron, Luca A. Vricella

Research output: Contribution to journalArticlepeer-review


Background We sought to determine the ability of the Model for End-Stage Liver Disease eXcluding INR (MELD-XI) to predict short-term and long-term outcomes in pediatric patients undergoing orthotopic heart transplant. Methods The United Network for Organ Sharing Database was queried for all pediatric patients (aged 1 to 18 years) undergoing orthotopic heart transplant from 2000 to 2012. The logarithmic relationship between the serum creatinine and bilirubin was used to calculate the MELD-XI score. Lowess smoothing plots were referenced, and a score threshold of 12.2 was used to stratify patients into low (75%) and high (25%) MELD-XI cohorts. Patient-specific characteristics, intraoperative variables, and postoperative outcomes were compared between the two cohorts. Differences in survival at 30 days, 1 year, and 5 years between the MELD-XI cohorts were estimated by the Kaplan-Meier method. Cox proportional hazards modeling was used to determine the risk-adjusted effect of a high MELD-XI score on death. Results After patients with missing MELD-XI scores were excluded, 2,939 patients met the inclusion criteria. Unconditional 30-day (93.1% vs 98.0%, p < 0.001), 1-year (85.9% vs 92.9%, p < 0.001), and 5-year (71.2% vs 79.5%, p < 0.001) survivals were significantly worse in the high-score cohort. However, 1-year survival excluding 90-day deaths (94.9% vs 95.8%, p = 0.29) and 5-year survival excluding 1-year deaths (82.8% vs 85.6%, p = 0.09) were statistically equivalent. When modeled as a categoric variable, a high MELD-XI score was an independent predictor of death at 30 days (hazard ratio, 2.86; 95% confidence interval, 1.84 to 4.45; p < 0.001), 1 year (hazard ratio, 1.88; 95% confidence interval, 1.42 to 2.48, p < 0.001), and 5 years (hazard ratio, 1.41; 95% confidence interval, 1.19 to 1.77; p < 0.001). For every 1-point increase in the MELD-XI score, mortality increased 11% at 30 days, 7% at 1 year, and 4% at 5 years (p < 0.001). The MELD-XI was not predictive of conditional mortality at 1 year or 5 years. Conclusions The MELD-XI scoring system can be used in pediatric orthotopic heart transplant to identify patients at risk for poor outcomes. Because long-term survival is largely driven by early death, renal insufficiency and congestive hepatopathy should be optimized before transplant.

Original languageEnglish (US)
Pages (from-to)730-735
Number of pages6
JournalAnnals of Thoracic Surgery
Issue number2
StatePublished - Feb 1 2016

ASJC Scopus subject areas

  • Surgery
  • Pulmonary and Respiratory Medicine
  • Cardiology and Cardiovascular Medicine


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