Easy prognostic assessment of concomitant organ failure in critically ill patients undergoing mechanical ventilation

Published:October 09, 2019DOI:


      • MELD-XI is associated with mortality.
      • MELD-XI constitutes a useful tool for risk stratification in intensive care medicine.
      • Optimal MELD-XI cut-off is 12 for patients receiving mechanical ventilation.
      • MELD-XI provided information independently SAPS-2.
      • MELD-XI might find a role for early patient assessment due to its easy applicability.



      Acute respiratory distress syndrome (ARDS) is a life-threatening disease. We evaluated the prognostic utility of Model for End-stage Liver Disease excluding INR (MELD-XI) score for predicting mortality in a cohort of critically ill patients on mechanical ventilation.


      In total, 11,091 mechanically ventilated patients were included in our post-hoc retrospective analysis, a subgroup of the VENTILA study (NCT02731898). Evaluation of associations with mortality was done by logistic and Cox regression analysis, an optimal cut-off was calculated using the Youden Index. We divided the cohort in two sub-groups based on their MELD-XI score at the optimal cut-off (12 score points).


      Peak-, plateau- and positive end-expiratory pressure were higher in patients with MELD-XI>12. Patients with MELD-XI>12 had higher driving pressures (14 ± 6 cmH2O versus 13 ± 6; p < 0.001). MELD-XI was associated with 28-day mortality after correction for relevant cofounders including SAPS II and ventilation pressures (HR 1.04 95%CI 1.03–1.05; p < 0.001. Patients with MELD-XI>12 evidenced both increased hospital (46% versus 27%; p < 0.001) and 28-day mortality (39% versus 22%).


      MELD-XI is independently associated with mortality and constitutes a useful and easily applicable tool for risk stratification in critically ill patients receiving mechanical ventilation.
      Trial registration: NCT02731898, registered 4 April 2016.


      MELD (Model for End-stage Liver Disease score), MELD-XI (MELD excluding INR), APACHE2 (Acute Physiology And Chronic Health Evaluation 2), ARDS (Acute Respiratory Distress Syndrome), ICU (Intensive Care Unit), PBW (Predicted Bodyweight), HR (Hazard Ratio), OR (Odds Ratio), 95%CI (95% Confidence Interval), AUC (Area Under the Curve)


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to European Journal of Internal Medicine
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Le Gall JR
        • Lemeshow S
        • Saulnier F
        A new simplified acute physiology score (SAPS II) based on a European/North American multicenter study.
        JAMA. 1993; 270: 2957-2963
        • Knaus WA
        • Zimmerman JE
        • Wagner DP
        • Draper EA
        • Lawrence DE
        APACHE-acute physiology and chronic health evaluation: a physiologically based classification system.
        Crit Care Med. 1981; 9: 591-597
        • Cholongitas E
        • Marelli L
        • Shusang V
        • Senzolo M
        • Rolles K
        • Patch D
        • et al.
        A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation.
        Liver Transpl. 2006; 12: 1049-1061
        • McCaughan GW
        • Crawford M
        • Sandroussi C
        • Koorey DJ
        • Bowen DG
        • Shackel NA
        • et al.
        Assessment of adult patients with chronic liver failure for liver transplantation in 2015: who and when?.
        Intern Med J. 2016; 46: 404-412
        • Kamath PS
        • Kim WR
        • Advanced Liver Disease Study G
        The model for end-stage liver disease (MELD).
        Hepatology. 2007; 45: 797-805
        • Wernly B
        • Lichtenauer M
        • Franz M
        • Kabisch B
        • Muessig J
        • Masyuk M
        • et al.
        Model for End-stage Liver Disease excluding INR (MELD-XI) score in critically ill patients: Easily available and of prognostic relevance.
        PLoS One. 2017; 12e0170987
        • Ortiz-Bautista C
        • Garcia-Cosio MD
        • Lora-Pablos D
        • Ponz-de Antonio I
        • Rodriguez-Chaverri A
        • Moran-Fernandez L
        • et al.
        Predicting short- and long-term outcomes in adult heart transplantation: clinical utility of MELD-XI score.
        Transplant Proc. 2018; 50: 3710-3714
        • Spieker M
        • Hellhammer K
        • Wiora J
        • Klose S
        • Zeus T
        • Jung C
        • et al.
        Prognostic value of impaired hepato-renal function assessed by the MELD-XI score in patients undergoing percutaneous mitral valve repair.
        Catheter Cardiovasc Interv. 2019; 93: 699-706
        • Wernly B
        • Lichtenauer M
        • Vellinga N
        • Boerma C
        • Ince C
        • Kelm M
        • et al.
        Model for End-Stage Liver Disease Excluding INR (MELD-XI) score is associated with hemodynamic impairment and predicts mortality in critically ill patients.
        Eur J Intern Med. 2018; 51: 80-84
        • Webb HH
        • Tierney DF
        Experimental pulmonary edema due to intermittent positive pressure ventilation with high inflation pressures. Protection by positive end-expiratory pressure.
        Am Rev Respir Dis. 1974; 110: 556-565
        • Dreyfuss D
        • Soler P
        • Basset G
        • Saumon G
        High inflation pressure pulmonary edema. Respective effects of high airway pressure, high tidal volume, and positive end-expiratory pressure.
        Am Rev Respir Dis. 1988; 137: 1159-1164
        • Corbridge TC
        • Wood LD
        • Crawford GP
        • Chudoba MJ
        • Yanos J
        • Sznajder JI
        Adverse effects of large tidal volume and low PEEP in canine acid aspiration.
        Am Rev Respir Dis. 1990; 142: 311-315
        • Hickling KG
        • Henderson SJ
        • Jackson R
        Low mortality associated with low volume pressure limited ventilation with permissive hypercapnia in severe adult respiratory distress syndrome.
        Intensive Care Med. 1990; 16: 372-377
        • Esteban A
        • Anzueto A
        • Frutos F
        • Alia I
        • Brochard L
        • Stewart TE
        • et al.
        Characteristics and outcomes in adult patients receiving mechanical ventilation: A 28-day international study.
        JAMA. 2002; 287: 345-355
        • Jung C
        • Bueter S
        • Wernly B
        • Masyuk M
        • Saeed D
        • Albert A
        • et al.
        Lactate clearance predicts good neurological outcomes in cardiac arrest patients treated with extracorporeal cardiopulmonary resuscitation.
        J Clin Med. 2019; 8
        • Masyuk M
        • Wernly B
        • Lichtenauer M
        • Franz M
        • Kabisch B
        • Muessig JM
        • et al.
        Prognostic relevance of serum lactate kinetics in critically ill patients.
        Intensive Care Med. 2019; 45: 55-61
        • He PC
        • Wei XB
        • Luo SN
        • Chen XL
        • Ke ZH
        • Yu DQ
        • et al.
        Risk prediction in infective endocarditis by modified MELD-XI score.
        Eur J Clin Microbiol Infect Dis. 2018; 37: 1243-1250
        • Arai T
        • Yashima F
        • Yanagisawa R
        • Tanaka M
        • Shimizu H
        • Fukuda K
        • et al.
        Prognostic value of liver dysfunction assessed by MELD-XI scoring system in patients undergoing transcatheter aortic valve implantation.
        Int J Cardiol. 2017; 228: 648-653
        • Yamamoto M
        • Hayashida K
        • Mouillet G
        • Hovasse T
        • Chevalier B
        • Oguri A
        • et al.
        Prognostic value of chronic kidney disease after transcatheter aortic valve implantation.
        J Am Coll Cardiol. 2013; 62: 869-877
        • Allen LA
        • Felker GM
        • Pocock S
        • McMurray JJ
        • Pfeffer MA
        • Swedberg K
        • et al.
        Liver function abnormalities and outcome in patients with chronic heart failure: Data from the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) program.
        Eur J Heart Fail. 2009; 11: 170-177
        • Nikolaou M
        • Parissis J
        • Yilmaz MB
        • Seronde MF
        • Kivikko M
        • Laribi S
        • et al.
        Liver function abnormalities, clinical profile, and outcome in acute decompensated heart failure.
        Eur Heart J. 2013; 34: 742-749

      Linked Article

      • Prognostication by concomitant organ failure in mechanically ventilated patients in ICU: Important issue to face with
        European Journal of Internal MedicineVol. 70
        • Preview
          Acute Physiology And Chronic Health Evaluation-2 (APACHE II) and Simplified Acute Physiology Score II (SAPS2) have been developed to assess the risk stratification of patients admitted to the intensive care unit (ICU) and are most commonly used so far. More recently, other simplified scores were tested including the Model for End-Stage Liver Disease (MELD), primarily developed in patients affected by liver disease [1], but subsequently validated as a marker of liver and kidney failure in subjects with multi-organ failure [2].
        • Full-Text
        • PDF