In the present retrospective study, we evaluated the prognostic accuracy of the PELD-MELD score upon hospital admission in a cohort of pediatric patients with ALF. Using the ROC curve, it was determined that a PELD-MELD cutoff value of 33 or higher presented an accurate specificity and sensitivity to discriminate patients with poor outcome, a value identical to that found by Dhiman et al (8) in a study that compared the prognostic value of the MELD score versus the KCH criteria in adult patients. These results suggest that the PELD-MELD score obtained at admission in pediatric patients could be helpful in establishing the optimal moment for LT evaluation and inclusion in the emergency waiting list because it can significantly discriminate patients with poor prognosis. When patients with stage 0 to 2 encephalopathy are evaluated, the use of the PELD score may contribute to identify those patients with poor outcome despite absence of encephalopathy.
The Pediatric Acute Liver Failure Study Group was created in 1999 and developed a database with the purpose of facilitating the comprehension of all of the aspects of ALF in children. By logistic regression analysis, it was shown that serum bilirubin values ≥5 mg/dL, INR ≥2.5, and hepatic encephalopathy were predictive factors of death or LT (9), both variables which are included in the PELD-MELD score. A study of 210 patients made in 2 pediatric LT centers in Argentina concluded that the most significant indicators of death or need for LT were prothrombin time and stage 3 to 4 encephalopathy (19). During the last 2 decades, many static and dynamic scores have been proposed to assess prognosis in patients with ALF such as the liver injury units score (20) and the acute physiology and chronic health evaluation (21); however, none of these models offered advantages over the existing ones. Several other studies suggested different clinical, biochemical, radiological, and histological prognostic markers (prothrombin time (22), factor V and factor VIII (23), serum bilirubin (24), α-fetoprotein (25), serum phosphate (26,27), lactate (28), galactose elimination capacity (29), ammonia (30), and vitamin D–binding protein (31)), images (residual liver value <700 cm3), necrosis extension obtained by transjugular biopsy (32,33), and others such as age, etiology, and encephalopathy stage (16,20). None of the aforementioned has been validated in prospective studies including a large enough cohort of pediatric patients.
Combining in the same group of analysis patients with LT with those that died could introduce a bias because it implies that every patient with LT would have otherwise died under medical treatment. Another limitation was the fact that 10 patients were excluded from the analysis because of the lack of complete laboratory reports to calculate the PELD-MELD score. Clinical characteristics of these 10 patients did not differ from the rest of the studied group. As opposed to chronic patients, the accessory variables of PELD over MELD in terms of weight and height by age would have no value in the acute presentation in which they would not be modified. Age could be of importance, however, because (as seen with the KCH criteria) young patients could present a higher risk of death. In addition, hepatitis A is an infrequent cause of ALF in most countries. Although the predominant cause of ALF in the present study was hepatitis A, we found a high percentage of indeterminate hepatitis (35%), similar to what was described in other geographical areas, and a surprisingly high percentage of autoimmune hepatitis (AIH) (17.5%). Finally, the absence of acetaminophen toxicity limits the generalization of the results.
Determining prognosis in ALF is critical for both LT indication and organ assignment. Future studies to improve these score systems will allow for a better assessment and evaluation, and optimize the organs and resources in adults and children.
The authors thank Dr Fernando Alvarez (CHU, Sainte-Justine, Université de Montréal) and Dr Carlos Lifschitz (Hospital Italiano, Buenos Aires, Argentina) for critical review of and corrections to the manuscript. We also thank the Department of Biostatistics of the Hospital Italiano for support for statistical analysis.
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