Performance of the model for end-stage liver disease score for mortality prediction and the potential role of etiology

Gennaro D'Amico, Luigi Maruzzelli, Aldo Airoldi, Ioannis Petridis, Giulia Tosetti, Antonio Rampoldi, Mario D'Amico, Roberto Miraglia, Stella De Nicola, Vincenzo La Mura, Marco Solcia, Riccardo Volpes, Giovanni Perricone, Cristiano Sgrazzutti, Angelo Vanzulli, Massimo Primignani, Angelo Luca, Giuseppe Malizia, Alessandro Federico, Marcello DallioAngelo Andriulli, Angelo Iacobellis, Luigi Addario, Matteo Garcovich, Antonio Gasbarrini, Luchino Chessa, Francesco Salerno, Giulia Gobbo, Manuela Merli, Lorenzo Ridola, Gianluca Svegliati Baroni, Giuseppe Tarantino, Nicola Caporaso, Filomena Morisco, Pietro Pozzoni, Agostino Colli, Luca Saverio Belli

Research output: Contribution to journalArticlepeer-review


Background & Aims: Although the discriminative ability of the model for end-stage liver disease (MELD) score is generally considered acceptable, its calibration is still unclear. In a validation study, we assessed the discriminative performance and calibration of 3 versions of the model: original MELD-TIPS, used to predict survival after transjugular intrahepatic portosystemic shunt (TIPS); classic MELD-Mayo; and MELD-UNOS, used by the United Network for Organ Sharing (UNOS). We also explored recalibrating and updating the model. Methods: In total, 776 patients who underwent elective TIPS (TIPS cohort) and 445 unselected patients (non-TIPS cohort) were included. Three, 6 and 12-month mortality predictions were calculated by the 3 MELD versions: discrimination was assessed by c-statistics and calibration by comparing deciles of predicted and observed risks. Cox and Fine and Grey models were used for recalibration and prognostic analyses. Results: In the TIPS/non-TIPS cohorts, the etiology of liver disease was viral in 402/188, alcoholic in 185/130, and non-alcoholic steatohepatitis in 65/33; mean follow-up±SD was 25±9/19±21 months; and the number of deaths at 3-6-12 months was 57-102-142/31-47-99, respectively. C-statistics ranged from 0.66 to 0.72 in TIPS and 0.66 to 0.76 in non-TIPS cohorts across prediction times and scores. A post hoc analysis revealed worse c-statistics in non-viral cirrhosis with more pronounced and significant worsening in the non-TIPS cohort. Calibration was acceptable with MELD-TIPS but largely unsatisfactory with MELD-Mayo and -UNOS whose performance improved much after recalibration. A prognostic analysis showed that age, albumin, and TIPS indication might be used to update the MELD. Conclusions: In this validation study, the performance of the MELD score was largely unsatisfactory, particularly in non-viral cirrhosis. MELD recalibration and candidate variables for an update to the MELD score are proposed. Lay summary: While the discriminative performance of the model for end-stage liver disease (MELD) score is credited to be fair to good, its calibration, the correspondence of observed to predicted mortality, is still unsettled. We found that application of 3 different versions of the MELD in 2 independent cirrhosis cohorts yielded largely imprecise mortality predictions particularly in non-viral cirrhosis. Thus, we propose a recalibration and suggest candidate variables for an update to the model.

Original languageEnglish
Pages (from-to)1355-1366
JournalJournal of Hepatology
Issue number6
Publication statusPublished - 2021


  • cirrhosis
  • clinical prediction rule
  • MELD
  • TIPS

ASJC Scopus subject areas

  • Hepatology


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