Predictors of Rebleeding and Mortality Following Acute Variceal Hemorrhage in Patients with Cirrhosis

Kiran Bambha ¹, W. Ray Kim ¹, Rachel A Pedersen ¹, John P Bida ¹, Walter K Kremers ¹ and Patrick S. Kamath ^1*

¹ Mayo Clinic College of Medicine, United States

^* To whom correspondence should be addressed. E-mail: kamath.patrick{at}mayo.edu.

Accepted 17 January 2008

Abstract

Background and Aims: Risk factors for mortality and re-bleeding following acute variceal hemorrhage are incompletely understood. The aim of this study was to determine risk factors for 6-week mortality, and rebleeding within 5-days in patients with cirrhosis and acute variceal hemorrhage.

Methods: Kaplan-Meier and Cox proportional hazards regression analyses were used to determine risk factors among 256 patients with acute variceal hemorrhage entered into a randomized , prospective trial.

Results: Thirty-five patients (14%) died within 6-weeks of AVH; 14 deaths (40%) occurred within 5 days. Only the Model for End Stage Liver Disease (MELD) score and units of packed red blood cells (PRBCs) transfused in the first 24-hours were associated with 6-week mortality univariately (HR-1.11,p<.001; HR 1.22, P<.001) and bivariately (HR MELD=1.10, p<0.001; HR per unit of PRBCs transfused=1.15, p=0.005). Rebleeding within 5-days occurred in 37 patients (15%); MELD score (P = .01)and a clot on a varix (P=.05) predicted rebleeding. Patients with MELD score (18); both MELD score 18 and 4 units PRBCs transfused ; both MELD score 18 and active bleeding at index endoscopy; and variceal re-bleeding had increased risk of death 6-weeks post-AVH (HR=7.4, p<0.001; 11.3, p<0.001; 9.9, P < .0002; 10.2, p< 0.0001 respectively).

Conclusions: Patients with acute variceal hemorrhage and MELD score 18, requiring 4 units PRBCs within the first 24 hours or with active bleeding at endoscopy, are at increased risk of dying within 6-weeks. MELD score 18 is a also strong predictor of variceal rebleeding within the first 5-days.

Keywords: Child-Pugh class, MELD, portal hypertension, survival models, transfusion

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