Karaci er sirozu; karaci er parankiminin yayg n olarak hepatoselüler nekrozu, rejenerasyon nodülleri olu mas ve fibröz doku ile bozularak de i mesi sonucu meydana gelen ilerleyici iltihabi bir hastal kt r. Siroz kronik karaci er hastal n n son evresidir. Klinik olarak hepatoselüler yetersizlik ve portal hipertansiyon bulgular ile seyreden ölümcül bir hastal kt r [120].
Karaci er nakli, dekompanse karaci er sirozuna sahip hastalar için tek kesin tedavi olmas na ra men, karaci er nakli için s rada bekleyen hasta say s potansiyel karaci er donörlerinin say s n n çok üstündedir. Bunu sonucu olarak, bekleme listesindeyken veya zamanla hastal n ilerlemesinden dolay listeden ç kar ld için ölen hasta say s ABD de, Avrupa da ve MELD modelini kullanan ülkelerde gittikçe artmaktad r [2].
Donör karaci erler, hastalara bu bozuklu a yol açan hastal n a rl na göre verilmektedir ve Amerikan Organ Payla m Sistemi (UNOS), nakil için bekleme s ras nda olan yeti kin hastalara öncelik tan mak için CTP skorlamas ndan son dönem karaci er hastal (MELD) modeline geçi yapm t r [3].
Süreç içerisinde ortaya ç kan sirozla ili kili komplikasyonlar n prognostik bir tahmin belirleyici olarak kullan lmas n n yan s ra, MELD skorunun zaman içerisinde de i mesinin ( MELD), bir sefere mahsus elde edilen MELD skoruna oranla karaci er nakli bekleyen siroz hastalar için daha do ru hayatta kalma tahmini yap lmas n sa lad n gösteren ara t rmalarda mevcuttur [7].
MELD skorlama sistemi, donör karaci er tahsisinde yayg n bir kriter olmu tur [121]. Bu sistemin karakteristik özelli i, rahats zl a yol açan hastal n a rl n tespit etmeye yönelik geni çapl bir ölçek olmas d r ve ayr ca, geleneksel Child-Pugh skorlama sistemiyle kar la t r ld nda minumum de i kenlik avantaj na sahiptir [122].
MELD, rezidüel karaci er fonksiyonlar n n dinamik de i imini zaman içerisinde ölçer. MELD in art dekompanse sirozlu hastalarda beklendi i halde de i imlerle ilgili faktörler bilinmeyendi.
Bizim çal mam zda; inisyal CTP skoru ortalama 8 (7-13), inisyal MELD skoru ortalama 9.48 (6-22), MELD/ay ortalama 2.8 (0-23) idi. nisyal MELD ve
Child-Pugh-Turcote skoru kar la t r ld nda CTP skorlama sistemi mortaliteyi predikte etmekte MELD skorlama sisteminden daha üstün bulundu (p<0.05 ). Fakat 6. ve 12. ayda MELD sisteminin daha üstün oldu u saptand .
Giannini G. ve arkada lar taraf ndan yap lan bir çal mada 46 dekompanse sirozlu hasta ortalama 365 gün süreyle takip edilmi . Takip boyunca 13 hasta ölmü , hastalar takip s ras nda ortalama 120 günde bir de erlendirilmi . 1 y ll k takip süresince hayatta kalan ve ölen hastalar aras ndaki MELD (p=0.056) ve MELD (p=0.0027) skoru aras ndaki farkl l k önemliydi. Bu çal man n sonucuna göre MELD skoru MELD skoruna göre prognozu predikte etmede daha üstün oldu u saptanm [123].
F.Botta ve arkada lar taraf ndan yap lan bir çal mada 129 dekompanse sirozlu hasta 1 y l süreyle takip edilmi . Takip süresince 31 hasta ölmü . Ölen hastalarda ve ya ayan hastalarda MELD ve CTP skorlar aras ndaki farkl l k anlaml yd . MELD skoru CTP skorundan mortaliteyi daha iyi tahmin etmi ve bu skorun art rezidüel karaci er fonksiyonunun azal yla koreledir [124].
Salerno F. ve arkada lar taraf ndan yap lan bir çal mada T PS ile tedavi edilen 140 hasta 3. ayda hayatta kalma için MELD skorunu tahmin etme gücü CTP (Child-Pugh-Turcotte) skorundan üstün bulunmu (p=0.038) [125].
Huo T. ve arkada lar taraf ndan yap lan bir çal mada 290 dekompanse sirozlu hastatada sirozla ba lant l komplikasyonlar n zamana ba ml prognostik tahmin belirleyiciler oldu unu ortaya koymu . Ölen hastalarda, hayatta kalan hastalarla kar la t r ld nda daha yüksek bir MELD skoru oldu u gözlemlenmi (14.5±4.5 ye 12.8±3.9, p=0.004). Bununla birlikte komplikasyonlar n ortaya ç kt ve ç kmad hastalar n MELD skorlar aras nda önemli bir fark görülmemi (13.6 ±4.3 ye 12.9±4.0, p=0.0093). Daha çok komplikasyon episodu olan hastalarda önemli bir MELD skoru art e ilimi gözlemlenmi (p<0.0001). Sirozla ba lant l komplikasyonlar n ortaya ç kmas n n, MELD e ek olarak önemli prognostik i aretler oldu u dü ünülmü ve MELD sisiteminin potansiyel kusurunu telafi edip karaci er nakline en çok ihtiyaç duyan hastalar n belirlenebilece ini ortaya koymu [126].
Cholongitas ve arkada lar taraf ndan yap lan bir çal mada MELD 3 ayl k mortaliteyi tahmin etmede CTP den üstün bulunmam . Fakat MELD anlaml olarak farkl bulunmu [127].
Literatürlerin bir k sm nda mortaliteyi predikte etmede MELD skorlama sistemi CTP den üstün bulunmu , bir k sm nda CTP skorlama sistemi MELD den üstün bulunmu . Bizim çal mam zda CTP skorlama sistemi MELD den üstün bulundu. Yine MELD/ay CTP ve MELD ile kar la t rd m zda ikisinden üstün bulundu ve literatürlerle uyumlu bulundu.
Bizim çal mam zda; 3. ayda MELD skoru art için risk faktörü analizi yap ld . Risk faktörleri için de i kenler MELD art lar Tablo 7 de gösterilmi tir. Ortalama MELD at ortalama MELD 1.76±4.85 idi.
Serum albumin i 3 (n=41) ve albumin i>3 (n=21) olan hastalar n inisyal ve 3. aydaki MELD skorlar aras ndaki MELD art s ras yla 13.5±4.2 ve 1.3±3.1 (p=0.039) olarak saptand ve anlaml yd .
HRS u olan (n=3) ve HRS u olmayan (n=59) hastalar n inisyal ve 3. aydaki MELD skorlar aras ndaki MELD art s ras yla 8.3±9.0 ve 2.5±3.5, (p=0.014) olarak saptand ve anlaml yd .
Beslenmesi kötü olan (n=13) ve iyi olan (n=48) hastalar n inisyal ve 3. aydaki MELD skorlar aras ndaki MELD art s ras yla 2.3±3.8 ve 4.9±4.2, (p=0.037) olarak saptand ve anlaml yd .
nisyal MELD skoru >10 (n=13) ve 10 (n=49) olan hastalar n inisyal ve 3. aydaki MELD skorlar aras ndaki MELD art s ras yla 5.3±5.6 ve 2.1±3.2, (p=0.011) olarak saptand ve anlaml yd .
Huo ve arkada lar taraf ndan yap lan bir çal mada 351 dekompanse sirozlu hastada MELD, inisyal MELD ve Child-Turcotte-Pugh (CTP) skorunun mortaliteyi tahmin etme gücü kar la t r lm . 3. ayda MELD skoru art için risk faktör analizi yap lm , asit (p=0.020) ve hepatik ensefalopatinin (p=0.023) MELD skoru art yla ili kisi anlaml olarak bulunmu .
Çal mam zda elde edilen sonuçlar literatürle uyumlu bulunmad , daha önceki çal malarda 3. ayda MELD skoru art ile ili kili risk faktörleri analiz edilmi . Asit ve hepatik ensefalopati ba lang c n n MELD skorunu art rd bulunmu . Bizim çal mam zda asit ve hepatik ensefalopati anlaml bulunmad , ama hepatorenal sendromun varl , serum albumin dü üklü ü, inisyal MELD ve CTP skorlar n n yüksek olmas ve beslenmenin kötü olmas ile MELD skoru art ile
ili kili olarak anlaml bulundu. imdiye kadar MELD skoru art n n hepatorenal sendrom ve beslenme durumu ile ili kili bir çal ma yap lmam t .
Bizim çal mam zda; ROC e risi kullan larak 6. ayda ve 12. ayda mortaliteyi predikte etme gücü kar la t r ld . 6.ayda MELD/ay için 0.839 (%95 CI: 0.716- 0.962), inisyal MELD skoru (p=0.035) için 0.683 (%95 CI: 0.522-0.844) ve CTP skoru (p=0.032) için 0.687 (%95 CI: 0.528-0.845) ile kar la t r ld . 12. ayda ROC e risi alt nda kalan alan MELD/ay için 0,780 (%95 CI: 0.657-0.903), inisyal MELD skoru (p=0.046) için 0.659 (%95 CI: 0,511-0,807) ve CTP skoru (p=0,006) için 0.718 (%95 CI: 0.579-0.856) ile kar la t r ld .
Yine Huo ve arkada lar taraf ndan yap lan çal mada 6.ay ve 12. ayda mortaliteyi tahmin etme gücü kar la t r lm . 6. ayda ROC e risi kullan larak, MELD/ay için 0.779, MELD (p=0.130) için 0.718 ve CTP (p<0.001) için 0.528 ile kar la t r lm ; 12. ayda bu alan s ras yla 0.822, 0.744, ve 0.528 (p=0.018 ve p<0.001) bulunmu [128].
Çal mam zda elde edilen sonuçlar literatürle uyumlu bulundu. 6. ayda ve 12. ayda mortaliteyi predikte etmede MELD/ay MELD ve CTP skorlama sistemlerinden daha üstündü.
Yine çal mam zda inisyal MELD ve CTP skoru aras ndaki de i ikli i ve mortalite oran kar la t r ld . 6. ayda MELD skoru >10 (n=22) için mortalite, (p=0.011) ve 12. ayda, (p<0.001) olarak saptand . 6. ayda CTP skoru child C olan (n=19) hastalar için mortalite, (p=0.032) ve 12. ayda (p<0.001) olarak saptand . MELD skoru ve CTP skoru artt kça kümülatif mortalite oran n n artt görüldü.
Sonuç olarak MELD skoru art albumin dü üklü ü, inisyal MELD ve CTP skorunun yüksekli i ve hepatorenal sendromun varl ile ili kilidir. Zaman içinde MELD skorunun belirlenmesi orta vadede sonuçlar tahmin etmede tek ba na MELD veya CTP skorundan üstündür. MELD skorunun ilerlemi karaci er sirozlu hastalar için ilave bir prognostik prediktör olarak dü ünülmesi gerekir. MELD skorunun dekompamse sirozlu hastalarda uygun bir model olabilmesi için daha ileri çal malara gereksinim vard r. Bu bulgular dekompanse sirotik hastalar n takibinde ve pre-transplantasyon de erlendirmelerinde önemli olabilir
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