The new liver allocation system: moving toward evidence-based transplantation policy

Renal failure in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis: value of MELD score

BACKGROUND & AIMS

Although renal failure is a common complication of sepsis and patients with cirrhosis frequently develop sepsis, there have been no studies specifically assessing renal function in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis. The aim of this study was to investigate prospectively the frequency, characteristics, and outcome of renal failure in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis.

METHODS

One hundred six consecutive patients with cirrhosis and sepsis were studied prospectively. Patients with spontaneous bacterial peritonitis were excluded.

RESULTS

Twenty-nine out of 106 patients (27%) with cirrhosis and sepsis developed acute renal failure as compared with only 8 of 100 patients (8%) from a control group of cirrhotic patients without infection (P < .0001). Renal failure in the sepsis group was reversible in 22 (76%; 21% of all patients) patients and nonreversible in 7 (24%; 6% of all patients) patients. Renal failure was associated with impairment of effective arterial blood volume, without evidence of tubular damage. The occurrence and type of renal failure correlated strongly with mortality (mortality at 3 months: nonreversible renal failure, 100%; reversible renal failure, 55%; no renal failure, 13%). Among variables obtained at diagnosis of sepsis, the Model for End-Stage Liver Disease (MELD) score was the only independent predictive factor of mortality.

CONCLUSIONS

Renal failure is common in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis and is associated with arterial underfilling and renal vasoconstriction. Outcome is poor, even in the setting of reversible renal failure. The MELD score is the best prognostic marker of patients with cirrhosis and sepsis.

Systematic review: The model for end-stage liver disease--should it replace Child-Pugh's classification for assessing prognosis in cirrhosis?

BACKGROUND

Prognosis in cirrhotic patients has had a resurgence of interest because of liver transplantation and new therapies for complications of end-stage cirrhosis. The model for end-stage liver disease score is now used for allocation in liver transplantation waiting lists, replacing Child-Turcotte-Pugh score. However, there is debate as whether it is better in other settings of cirrhosis.

AIM

To review studies comparing the accuracy of model for end-stage liver disease score vs. Child-Turcotte-Pugh score in non-transplant settings.

RESULTS

Transjugular intrahepatic portosystemic shunt studies (with 1360 cirrhotics) only one of five, showed model for end-stage liver disease to be superior to Child-Turcotte-Pugh to predict 3-month mortality, but not for 12-month mortality. Prognosis of cirrhosis studies (with 2569 patients) none of four showed significant differences between the two scores for either short- or long-term prognosis whereas no differences for variceal bleeding studies (with 411 cirrhotics). Modified Child-Turcotte-Pugh score, by adding creatinine, performed similarly to model for end-stage liver disease score. Hepatic encephalopathy and hyponatraemia (as an index of ascites), both components of Child-Turcotte-Pugh score, add to the prognostic performance of model for end-stage liver disease score.

CONCLUSIONS

Based on current literature, model for end-stage liver disease score does not perform better than Child-Turcotte-Pugh score in non-transplant settings. Modified Child-Turcotte-Pugh and model for end-stage liver disease scores need further evaluation.

Influence of recent advances in medical management on clinical outcomes of cirrhosis

Cirrhosis and its disease-related complications are the 12th leading cause of mortality among U.S. adults and are the 5th leading cause of death for individuals aged 45 to 54 years. Hospitalization costs for disease-related complications are estimated at 18,000 dollars per episode of care, and 10% of admitted patients die. Despite these ominous findings, the survival rate of patients with cirrhosis has improved during the past 2 decades. This observation coincides with the conducting and reporting of high-quality randomized controlled trials and observational studies. Therefore, the improved prognosis in cirrhosis may be related to the effective translation of research findings to clinical practice for this patient population. Although explicit data to support this claim are not available, this article reviews the reported trends in clinical outcomes for patients with cirrhosis and the existence of evidence-based medical information that is available to care for these chronically ill patients.

Influence of hepatic venous pressure gradient on the prediction of survival of patients with cirrhosis in the MELD Era

Measurements of portal pressure, usually obtained via the hepatic venous pressure gradient (HVPG) may be a prognostic marker in cirrhosis. The aim of this study was to evaluate the impact of HVPG on survival in patients with cirrhosis in addition to the Model for End-Stage Liver Disease (MELD) score. We also examined whether inclusion of HVPG in a model with MELD variables improves its prognostic ability. Retrospective analyses of all patients who had HVPG measurements between January 1998 and December 2002 were considered. Proportional hazards Cox models were developed. Prognostic calibrative and discriminative ability of the model was evaluated. In this period, 693 patients had a hepatic hemodynamic study, and 393 patients were included. Survival was significantly worse in those patients with greater HVPG value (univariate HR, 1.05; 95% CI, 1.02-1.08; P = .001). HVPG remained as an independent variable in a model adjusted by MELD, ascites, encephalopathy, and age (multivariate HR, 1.03; 95% CI, 1.00-1.06; P = .05) so that each 1-mmHg increase in HVPG had a 3% increase in death risk. In addition, HVPG as well as MELD score variables and age, significantly contributes to the calibrative predictive capacity of the prognostic model; however, discriminative ability improved only slightly (overall C statistic [95% CI]; MELD score variables: 0.71 [0.62-0.80], MELD score variables, age, and HVPG 0.76: [0.69-0.83]). In conclusion, HVPG has an independent effect on survival in addition to the MELD score. Although inclusion of HVPG and age in a survival predicting model would improve the calibrative ability of MELD, its discriminative ability is not significantly improved.

Regional variations in peer reviewed liver allocation under the MELD system

The Model for End-Stage Liver Disease (MELD) is used to assign priority for liver transplantation candidates. The Organ Procurement and Transplantation Network (OPTN) approved recognized exceptional diagnoses (RED's) for which MELD fails to accurately measure priority. Centers can request increased MELD points in cases not recognized by this policy (non-RED's). Our aim was to compare regional practices to justify non-RED requests for MELD adjustments. The UNOS/OPTN database was queried to extract all adult cases for which a non-RED MELD adjustment was requested from 2/27/02 until 8/27/03. The data were stratified by region and justification. Data for 29,510 listings were available. 26,947 had complete diagnosis information. There were 827 non-RED requests of which 477 (57.7%) petitions were approved by the regional review boards (RRBs). The approval rate varied significantly among regions (range: 28-75%, p<0.0001). The most common non-RED's were complications of portal hypertension (48%). The percentage of patients listed with non-RED's varied significantly among regions (0.7-8.3 %, p<0.0001), as did the proportion of patients transplanted with non-RED's (2.1-31.9%, p<0.0001). Demographics did not differ among regions requesting non-REDs.Widespread regional variations exist in the handling of requests for non-REDs. These variations point to the need for reform to standard exception criteria.

Regional variation and use of exception letters for cadaveric liver allocation in children with chronic liver disease

The Pediatric End-Stage Liver Disease (PELD) score was designed to reduce subjectivity in liver allocation and to advantage patients with a higher probability of waiting list mortality. The aims of this study were to determine the impact of PELD implementation for children with chronic liver disease and to assess whether PELD met its goal of standardization of liver allocation for children. This study used data reported to the United Network for Organ Sharing (UNOS) registry for children with chronic liver disease receiving primary cadaveric liver transplant between January 2000 and December 2001 (pre-PELD) and March 2002 and July 2003 (PELD). PELD reduced the percentage of children transplanted while in an intensive care unit and as status 1. A calculated PELD score was used for allocation in only 52% of recipients. Thirty percent were status 1 at transplant and PELD scores granted by exception were used for allocation in 18% of patients. There was regional variation in PELD score at allocation and use of exception scores with a significant relationship between PELD score and percentage of exception cases. Regional variation suggests that PELD has not resulted in standardization of listing practices in pediatric liver transplantation.

A comparison of transfusion requirements between living donation and cadaveric donation liver transplantation: relationship to model of end-stage liver disease score and baseline coagulation status

The use of living donation is an important option for patients in need of liver transplant. We retrospectively reviewed the preoperative Model for End-Stage Liver Disease (MELD) score, baseline coagulation laboratory results, and intraoperative transfusion of red blood cells and component therapy for 27 living donation transplants and 69 cadaveric donation transplants during a 3-yr period (2001-2004). Patients undergoing living donation transplantation had significantly lower MELD scores and preserved coagulation function compared with cadaveric donation transplantation recipients (P < 0.001). The living donation transplant patients also received significantly fewer transfusions of red blood cells and component therapy compared with the cadaveric donation transplant patients (P < 0.001). For the combined population of both cadaveric donation transplant and living donation transplant patients, there were significant associations between MELD score and preoperative coagulation tests (P < 0.001) and intraoperative transfusion of blood and component therapy. MELD score and preoperative fibrinogen concentration were identified as independent predictors of transfusion exposure. In conclusion, we detected significant differences in severity of disease at time of transplantation, degree of impairment of coagulation function, and need for transfusion of red blood cells and component therapy between patients undergoing living donation transplantation compared with patients undergoing cadaveric donation transplantation.

Short-term postliver transplant survival after the introduction of MELD scores for organ allocation in the United States

BACKGROUND

It has been suggested that the introduction of model for end-stage liver disease (MELD) for organ allocation may reduce overall graft and patient survival since elevated serum creatinine is an important predictor of poor outcome after liver transplantation.

OBJECTIVE

In this study, we determined the outcomes of liver transplantation before (PreMELD group, 1998-February, 2002) and after (MELD group, March-December, 2002, n = 4642) the introduction of MELD score, and examined the impact of MELD scores on the outcome in the United States (US).

PATIENTS & METHODS

After excluding patients for a variety of reasons (children, live-donor, fulminant liver failure, patients with hepatoma and others who received extra MELD points, multiple organ transplantation, re-transplantation, incomplete data), there were 3227 patients in the MELD group. These patients were compared with 14,593 patients in the preMELD group after applying similar exclusion criteria. The survival was compared using Kaplan-Meier survival analysis and Cox regression survival analysis.

RESULTS

There was no difference in short-term (up to 10 months) graft and patient survival between MELD and preMELD groups. However, graft and patient survival was lower in patients with MELD score > or = 30 when compared with those with MELD score <30 after adjusting for the confounding variables.

CONCLUSION

Introduction of MELD score for organ prioritization has not reduced the short-term survival of patients, but patients with MELD score of 30 or higher had a relatively poor outcome.

MELD score and clinical type predict prognosis in hepatorenal syndrome: relevance to liver transplantation

Important progress has been made recently regarding the pathogenesis and treatment of hepatorenal syndrome (HRS). However, scant information exists about factors predicting outcome in patients with cirrhosis and HRS. Moreover, the prognostic value of the model of end-stage liver disease (MELD) score has not been validated in the setting of HRS. The current study was designed to assess the prognostic factors and outcome of patients with cirrhosis and HRS. The study included 105 consecutive patients with HRS. Forty-one patients had type 1 HRS, while 64 patients had type 2 HRS. Patients with type 1 HRS not only had more severe liver and renal failure than type 2 patients, they also had greater impairment of circulatory function, as indicated by lower arterial pressure and higher activation of vasoconstrictor factors. In the whole series, the median survival was 3.3 months. In a multivariate analysis of survival, only HRS type and MELD score were associated with an independent prognostic value. All patients with type 1 HRS had a high MELD score (> or =20) and showed an extremely poor outcome (median survival: 1 mo). By contrast, the survival of patients with type 2 HRS was longer and dependent on MELD score (> or =20, median survival 3 mo; <20, median survival 11 mo; P < .002). In conclusion, the outcome of patients with cirrhosis and HRS can be estimated by using two easily available variables, HRS type and MELD score. These data can be useful in the management of patients with HRS, particularly for patients who are candidates for liver transplantation.

MELD score and hepatocellular carcinoma identify patients at different risk of short-term mortality among cirrhotics bleeding from esophageal varices

BACKGROUND/AIMS

The role of model for end stage liver disease (MELD) and the presence of hepatocellular carcinoma (HCC) as risk factors of short-term mortality in patients bleeding from oesophageal varices were evaluated.

METHODS

From February 2002 to August 2003, 172 cirrhotic patients admitted for the first episode of bleeding from oesophageal varices received vasoactive and endoscopic therapy. Patients' survival was evaluated at 6 weeks and 3 months. The role of MELD and HCC as independent risk factors of mortality was evaluated.

RESULTS

In the 172 patients, the overall mortality was 21.5% at 6 weeks and 30.2% at 3 months. MELD score resulted a good predictor of mortality either at 6 weeks or 3 months. Fifty-four patients (31.3%) had HCC. The presence of advanced HCC was an independent risk factor of mortality at 3 months. Patients with MELD score>15 and advanced HCC had a significantly worse survival than patients with MELD<or=15 and without HCC or with early HCC either at 6 weeks or 3 months

CONCLUSIONS

MELD score and the presence of HCC allow to identify patients at different risk of short-term mortality among cirrhotic patients at first episode of bleeding from oesophageal varices.

Liver transplant recipient selection: MELD vs. clinical judgment

Minimization of death while waiting for liver transplantation involves accurate prioritization according to clinical status and appropriate allocation of donor livers. Clinical judgment in the Liver Transplant Unit Victoria (LTUV) was compared with Model for End-Stage Liver Disease (MELD) in a retrospective analysis of the LTUV database over the 2-year period August 1, 2002, through July 31, 2004. A total of 1,118 prioritization decisions occurred. Decisions were concordant in 758 (68%), comparing priorities assigned by clinical judgment with those assigned by MELD, P < 0.01. A total of 263 allocation decisions occurred. Decisions were concordant in 190 (72%) and 203 (77%) of the cases, comparing donor liver allocation with prioritization by MELD and clinical judgment, respectively. Of the 52 patients allocated a liver, only 23 would have been allocated on the basis of MELD while 29 had been prioritized on the waiting list in the week prior to transplantation. A total of 10 patients died on the waiting list in the 2-year period (annual adult waiting list mortality is 9.3%). Patients who subsequently died waiting were 3 times as likely to be prioritized by MELD as clinical judgment (29% vs. 9%, respectively). One half (3 of 6) of the patients who could have received a donor liver but who died waiting would have been allocated the organ on the basis of MELD. In conclusion, an allocation process based on MELD rather than clinical judgment would significantly alter organ allocation in Australia and may reduce waiting list mortality.

PELD Score and Posttransplant Outcome in Pediatric Liver Transplantation: A Retrospective Study of 100 Recipients

BACKGROUND

Pediatric End-stage Liver Disease (PELD) score is proposed as an objective tool to prioritize children awaiting liver transplantation (LT), higher PELD being associated with increased pre-LT mortality. This study investigated whether PELD may also impact on post-LT results.

METHODS

PELD was retrospectively analyzed in 100 pediatric recipients of a primary LT from living-related (n = 49) or postmortem donors (PMD, n = 51). The main pre-LT diagnosis was biliary atresia (n = 64), hepatic malignancy and fulminant hepatitis cases being excluded. PELD was calculated in all patients at the time of pre-LT assessment. Considering the median delay of 117 days between listing and LT in the PMD subgroup, a second PELD was calculated at the time of LT, allowing the determination of a delta PELD during the waiting period. PMD grafts were allocated using an allocation system taking into account waiting times as well as medical urgency, operative at EuroTransplant.

RESULTS

Overall 5-year actuarial patient and graft survivals were 96% and 91%, respectively. PELD at listing (13.3 +/- 9.7) showed a normal statistical distribution. PELD scores at listing and at LT were not found to significantly impact on post-LT outcome (NS). In contrast, higher delta PELD might be associated with lower posttransplant patient survival (p = 0.094).

CONCLUSIONS

The results of this retrospective analysis suggest that giving priority to high PELD recipients may not result in worsening post-LT outcome. Accordingly, these data support such "sickest children first" allocation policy, which should contribute to reduce pre-LT mortality without worsening post-LT results and increasing organ waste.

Liver transplantation for hepatocellular carcinoma: is expansion of criteria justified?

Hepatocellular carcinoma (HCC) is a major health problem worldwide, involving more than a half million new cases yearly, with an age-adjusted incidence of 5.5 to 14.9 per 10(5) population. In some areas of Asia and the Middle East, HCC ranks as the first cause of death due to cancer. The incidence of HCC is increasing in Europe and the United States, and it is currently the leading cause of death among cirrhotic patients. It is estimated that by the year 2010, the number of patients with HCC awaiting liver transplant in the United States will outnumber the supply of cadaver organs.

Predictors of death on the waiting list for liver transplantation characterized by a long waiting time

The number of patients dying while on the liver transplantation (LT) waiting list (WL) has continued to increase in recent years as a result of severe shortage of organs. Therefore, it is important to evaluate the existing models that predict death on the WL and to determine the independent predictors of death. The study cohort comprised 152 adult patients listed for LT in our centre over a period of 2 years (January 2001 to January 2003). The 12-month survival rate has been calculated by Kaplan-Meier method. The survival analysis performed by Cox proportional hazard model has evaluated the three parameters which compose the model for end-stage liver disease (MELD) score. Forty-four patients (28.9%) died while listed for LT. The survival rate was 92% at 3 months, 80% at 6 months and 69% at 12 months. Median survival was not reached. MELD score was found to be an excellent predictor of death at 12 months on our WL--c-statistic (area under curve) 0.84. In our survival analysis, only international normalized (prothrombin) ratio (INR) and serum creatinine were identified as an independent predictors of death (P < 0.0001). A new simplified version of the MELD score, which does not include serum bilirubin, is proposed and its c-statistic as predictor for death on the WL at 12 months is 0.86, as good as the original MELD score, when evaluated on our list. There is a fourfold increase in mortality on our WL for LT between 3 and 12 months after the inclusion. A simplified version of the MELD score, using only serum creatinine and INR might be taken into account when predicting 12 months mortality on WL with longer waiting time, but it has to be confirmed by other prospective studies.

Predictive models in cirrhosis: correlation with the final results and costs of liver transplantation in Chile

Medical scores for predicting survival are essential to stratify patients with end-stage liver disease (ESLD) for prioritization for liver transplantation (OLT). Recently the UNOS has adopted the Mayo Model for End-stage Liver Disease (MELD) score as the basis for liver allocation in the United States. We retrospectively evaluated and assessed the prognostic impact, the length of stay (LOS), and hospital charges for OLT using two severity scores (Child-Turcotte-Pugh [CTP] versus MELD) to stratify cirrhotic patients before OLT. Twenty-six consecutive adult cirrhotic patients (11 women, mean age 46 years) underwent LT between 2000 and 2002. The main causes for transplantation were alcohol and primary biliary cirrhosis. The mean CTP and MELD scores at the moment of listing for OLT were 8.9 and 16.3 points, respectively. The best discriminative values with prognostic impact in terms of outcome and costs of OLT were a Child Pugh score >/=11 points or a MELD score >/=20 points. Patients in these strata showed a significant increase in LOS in the hospital (from a mean of 12 to 22 days) and intensive care stay (from a mean of 4 to 14 days) post-OLT when compared with patients with a lower CTP or MELD score (P <.05). There was also a trend toward higher hospital charges (P =.06). Organ allocation by MELD score will probably adversely affect the LOS and hospital charges of patients being transplanted due to ESLD.

Impact of pretransplant MELD score on posttransplant outcome in living donor liver transplantation

It is not clear whether pretransplantation MELD (model for End-Stage Liver Disease) score can foresee posttransplant outcome. We retrospectively evaluated 80 adult patients (55 men, 25 women) who underwent living donor liver transplantation between September 1998 and March 2003. Five other patients with fulminant hepatitis were excluded. The UNOS-modified MELD scores were calculated to stratify patients into three groups: group 1) MELD score less than 15 (n = 13); group 2) MELD score 15 to 24 (n = 36); and group 3) MELD score 25 and higher (n = 26). The patients were predominantly men (n = 52, 69.3%) with overall mean age of 43.9 years (range, 17-62 years). The mean follow-up was 15.7 months (range, 1-47; median = 14 months). The mean MELD score was 22.7 (range, 9-50; median = 21). The overall 1- and 2-year patient survivals were 87% and 78.7%, respectively. The 1-year patient survivals for groups 1, 2, and 3 were 100%, 87%, and 79%; respectively. 2-year survivals, 100%, 79%, and 61%, respectively. Survivals stratified by MELD showed no statistically remarkable differences in 1-year and 2-year patient survival (P = .08). In contrast, 1-year and 2-year patient survival rates for UNOS status 2A, 2B, and 3 were 73%-50%, 95%-91%, and 91%-91%, statistically significant difference (P = .002). Finally, to date preoperative MELD score showed no significant impact on 1- and 2-year posttransplant outcomes in adult-to-adult living donor liver transplantation recipients, but we await longer-term follow-up with greater numbers of patients.

Excellent Liver Transplant Survival Rates Under the MELD/PELD System

The MELD/PELD (M/P) system for liver allocation was implemented on February 27, 2002, in the United States. Since then sufficient time has elapsed to allow for assessment of posttransplant survival rates under this system. We analyzed 4163 deceased donor liver transplants performed between February 27, 2002, and December 31, 2003, for whom follow-up reporting was 95% and 67% complete at 6 and 12 months, respectively. Kaplan-Meier survival analysis revealed 1-year patient and graft survival rates for status 1 of 76.9% and 70.4%, respectively, and 87.3% and 82.9% for patients prioritized by M/P (P < .0001 for status 1 vs M/P). When adult candidates were stratified by MELD score quartile at transplant, 1-year survival rates were 89.5%, 88.3%, 86.6%, and 78.1% for lowest to highest quartile (P = .0002) and graft survival rates were similarly distributed (85.0%, 84.5%, 82.7%, 73.0%, P < .0001). Candidates with hepatocellular cancer (89.6%) and other MELD score exceptions (88.8%) had slightly higher 1-year survival rates compared with standard MELD recipients (86.0%), which did not reach statistical significance (P = .089). Pediatric recipients had slightly better patient (88.7%) and graft (86.5%) survival rates at 1 year than adults but there were no significant differences among the PELD strata due to small numbers of patients in each PELD quartile. We conclude that patient and graft survival have remained excellent since implementation of the MELD/PELD system. Although recipients with MELD scores in the highest quartile have reduced survival compared with other quartiles, their 1-year survival rate is acceptable when their extreme risk of dying without a transplant is taken into consideration.

MELD fails to measure quality of life in liver transplant candidates

Previous studies have demonstrated an association between Child Turcotte-Pugh (CTP) class and impaired quality of life. However, the relationship between the model for end-stage liver disease (MELD) score and quality of life (QOL) has not been well studied. In this study, quality of life questionnaires (Medical Outcomes Short Form 36 [SF-36] and the Chronic Liver Disease Questionnaire [CLDQ]) were administered to 150 adult patients awaiting liver transplantation. We also collected demographic data and laboratory results and recorded manifestations of hepatic decompensation. The study found that all domains of the SF-36 and CLDQ were significantly lower in our patient cohort than in normal controls (P < .001). There was a moderate negative correlation between CPT class and physical components of the SF-36 (r = -.30), while there was a weak negative correlation (r = -.10) between CPT class and the mental component. There was a negative moderate correlation between CPT class and overall CLDQ (r = -.39, P < .001) and a weak correlation (r = -.20) between MELD score and overall CLDQ score. Both encephalopathy (correlation coefficient = -.713, P = .004) and ascites (correlation coefficient = -.68, P = .006) were predictive of the QOL using CLDQ (adjusted R(2) = .1494 and f = 0.000). In conclusion, in liver transplant candidates, the severity of liver disease assessed by the MELD score was not predictive of QOL. The presence of ascites and/or encephalopathy was significantly associated with poor quality of life. CTP correlates better to QOL, probably because it contains ascites and encephalopathy.

Surgical advances in liver and bowel transplantation

Liver and intestinal transplantation are currently the treatments of choice for life-threatening hepatic and gastrointestinal failure. These technologies have evolved through contributions from the fields of immunology, anatomy, physiology, surgery, anesthesiology, critical care, ethics, epidemiology, and public health. Transplantation now accounts for the treatment of over 5,000 recipients per year who are in a state of organ failure. The available donor population, however, is not increasing to meet the demands of the faster growing recipient population. This discrepancy has led to the rapid development of novel strategies that require critical evaluation to build on the success rates in recent years. This article presents the most salient advances in liver and intestinal transplantation in the last 15 years.

Serum sodium predicts mortality in patients listed for liver transplantation

With the implementation of the model for end-stage liver disease (MELD), refractory ascites, a known predictor of mortality in cirrhosis, was removed as a criterion for liver allocation. Because ascites is associated with low serum sodium, we evaluated serum sodium as an independent predictor of mortality in patients with cirrhosis who were listed for liver transplantation and whether the addition of serum sodium to MELD was superior to MELD alone. This is a single-center retrospective cohort of all adult patients with cirrhosis listed for transplantation from February 27, 2002, to December 26, 2003. Listing laboratories were those nearest the listing date +/-2 months. Of the 513 patients meeting inclusion criteria, 341 were still listed, while 172 were removed from the list (105 for transplantation, 56 for death, 11 for other reasons). The median serum sodium and MELD scores were 137 mEq/L (range, 110-155) and 15 (range, 6-51), respectively, at listing. Median follow-up was 201 (range, 1-662) days. The risk of death with serum sodium <126 mEq/L at listing or while listed was increased, with hazard ratios of 7.8 (P < .001) and 6.3 (P < .001), respectively, and the association was independent of MELD. The c-statistics of receiver operating characteristic curves for predicting mortality at 3 months based upon listing MELD with and without listing serum sodium were 0.883 and 0.897, respectively, and at 6 months were 0.871 and 0.905, respectively. In conclusion, serum sodium <126 mEq/L at listing or while listed for transplantation is a strong independent predictor of mortality. Addition of serum sodium to MELD increases the ability to predict 3- and 6-month mortality in patients with cirrhosis.

Treatment of hepatocellular carcinoma

Hepatocellular carcinoma is the fifth leading cause of cancer worldwide and its incidence is increasing. Surveillance programs allow doctors to identify patients at early stages of the disease, when the tumor may be curable by radical treatments such as resection, liver transplantation, or local ablation. In the West, these treatments can be applied to 30% to 40% of patients. Resection yields favorable results in patients with single tumors and a well-preserved liver function (5-year survival rate is 60%). Recurrence complicates two thirds of the cases, and there is no effective adjuvant treatment. Liver transplantation is the best treatment for patients with single tumors that are less than 5 cm in diameter and liver failure, or in those presenting with three nodules less than 3 cm, but organ shortage greatly limits its applicability. Long-term survival is expected to be around 50% to 70% at 5 years depending upon the drop-out rate of patients on the waiting list. Chemoembolization and local ablation are the neo-adjuvant treatments applied to patients on the waiting list to prevent tumor progression; no controlled study proving their efficacy has yet been published. In nonsurgical candidates, percutaneous treatments (ethanol injection or radiofrequency ablation) are the best therapeutic approach and improve survival in Child-Pugh A class patients with small tumors that achieve initial complete response (5-year survival rate is 40% to 50%). At more advanced stages, chemoembolization, a technique combining intra-arterial chemotherapy and selected ischemia, has shown to slightly improve survival in a meta-analysis of randomized trials. No survival advantages have been demonstrated with intra-arterial or systemic chemotherapy, hormonal compounds, or radiation. New agents, such as inhibitors of the tyrosine kinase receptors of growth factors and antiangiogenic agents, are currently being tested in phase II/III trials.

Hepatocellular carcinoma: current surgical management

Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world, responsible for 500,000 deaths globally every year. Although HCC is a slow-growing tumor, it is often rapidly fatal because it is usually not discovered until the disease is advanced. HCC occurs primarily in individuals with cirrhosis, a condition that increases the risk of performing potentially curative surgical therapy. Over the last 2 decades, however, the safety of surgical resections has greatly improved because of advances in radiologic assessment, patient selection, and perioperative care. As such, the operative mortality rate for hepatectomy has decreased from the 10%-20% level seen in the 1980s to less than 5% today. The ultimate goal of treatment of HCC is to prolong the quality of life by eradicating the malignancy while preserving hepatic function. For treatment with a curative intent, the gold standard remains surgical resection, by either partial hepatectomy or total hepatectomy followed by liver transplantation. Resectability and choice of procedure depend on many factors, including baseline liver function, absence of extrahepatic metastases, size of residual liver, availability of resources including liver graft, and expertise of the surgical team. Patients without cirrhosis can tolerate extensive resections, and partial hepatectomy should be considered first. For Child class B and C patients with a small HCC, liver transplantation offers the best results, whereas partial liver resection is indicated in patients with well-compensated cirrhosis. Living donor liver transplantation should be considered using the same criteria as that used for cadaveric transplantation.

How will patients be selected for transplantation in the future?

1. The model for end-stage liver disease has become a selection tool for recipients for liver transplantation. 2. The present selection / allocation system does not recognize distinctions in "donor organ quality." 3. Many studies have shown that donor factors such as age, gender, fat content, and heart beating versus non-heart beating status influence outcome of the liver transplantation. 4. Efforts to increase organ donation are likely to provide more "expanded-criteria donors." 5. Future selection practices may attempt to match specific recipients to specific donors.

When is a patient too well and when is a patient too sick for a liver transplant?

1. Liver transplantation is currently offered as a therapeutic option for patients with a wide range of end-stage liver diseases. 2. Conventional wisdom suggests that patients who receive a liver transplant have a greater expected lifetime when compared to comparable candidates on the waiting list. 3. The model for end-stage liver disease (MELD) scoring system is an excellent predictor of mortality on the waiting list and also predicts mortality after liver transplantation. 4. The combination of waiting list mortality risk and posttransplant mortality risk assessed by MELD and other factors can be used to estimate whether candidates are likely to derive a survival benefit from a liver transplant.

Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death

Despite the adoption of "sickest first" liver transplantation, pretransplant death remains common, and many early deaths occur despite initially low Model for End-stage Liver Disease (MELD) scores. From 1997-2003, we studied 507 cirrhotic United States veterans referred for consideration of liver transplantation to identify additional predictors of early mortality. Most of the patients were male (98%) with cirrhosis caused by hepatitis C and/or alcohol (88%). Data for 296 patients referred prior to February 27, 2002 (training group), were analyzed; findings were validated in 211 patients referred subsequently (validation group). In the training group, 61 patients (21%) died within 180 days without transplantation; their median initial MELD score was 21. MELD score, persistent ascites, and low serum sodium (<135 meq/L) were independent predictors of early mortality. In patients with a MELD score of less than 21, only low serum sodium and persistent ascites were independent predictors of mortality; for MELD scores above 21, only MELD was independently predictive. Prognostic significance of persistent ascites and low serum sodium for low MELD score patients was confirmed in the validation group. Risk varied continuously with worsening hyponatremia. Modifying MELD, by including points for persistent ascites and low serum sodium, improved prediction of early pretransplant mortality in low MELD score patients. In conclusion, persistent ascites and low serum sodium identify patients with cirrhosis with high mortality risk despite low MELD scores. Ascites, hyponatremia, and other findings indicative of hemodynamic decompensation merit further prospective study as prognostic indicators in patients awaiting liver transplantation, and should be considered in setting minimal listing criteria.

Can inclusion of serum creatinine values improve the Child-Turcotte-Pugh score and challenge the prognostic yield of the model for end-stage liver disease score in the short-term prognostic assessment of cirrhotic patients?

BACKGROUND

The model for end-stage liver disease (MELD) score is a useful tool to assess prognosis in critically ill cirrhotic patients. However, its short-term prognostic superiority over the traditional Child-Turcotte-Pugh (CTP) score has not been definitely confirmed. The creatinine serum level is an important predictor of survival in patients with liver cirrhosis.

AIMS

To evaluate and compare the short-term prognostic accuracy of the CTP, the creatinine-modified CTP, and the MELD scores in patients with liver cirrhosis.

METHODS

CTP, creatinine-modified CTP, and MELD scores were calculated in a cohort of 145 cirrhotic patients. The creatinine-modified CTP was calculated as follows: we assessed the mean creatinine serum level and standard deviation (SD) of the 145 study patients, then assigned a score of 1 to patients with creatinine serum levels < or = to the mean, a score of 2 to patients with creatinine levels between the mean and the mean+1 SD, and a score of 3 to patients with creatinine levels above the mean+1 SD. The creatinine-modified CTP was then calculated by simply adding each patients' creatinine score to their traditional CTP scores. We calculated and compared the accuracy (c-index) of the three parameters in predicting 3-month survival.

RESULTS

The creatinine-modified CTP score showed better prognostic accuracy as compared with the traditional CTP (P=0.049). However, the MELD score proved to be better at defining patients' prognosis in the short-term as compared with both the traditional CTP score (P=0.012) and the creatinine-modified CTP (P=0.047). The excellent short-term prognostic accuracy of the MELD score was confirmed even when patients with abnormal creatinine serum levels were excluded from the analysis (c-index=0.935).

CONCLUSIONS

Adding creatinine values to the CTP slightly improves the prognostic usefulness of the traditional CTP score alone. The MELD score has a short-term prognostic yield that is better than what is provided by both the CTP and CTP creatinine-modified scores, even in cirrhotic patients who are not critically ill. The positive results obtained by using the MELD score were confirmed even after excluding patients with impaired renal function.

Persistent ascites and low serum sodium identify patients with cirrhosis and low MELD scores who are at high risk for early death

Despite the adoption of "sickest first" liver transplantation, pretransplant death remains common, and many early deaths occur despite initially low Model for End-stage Liver Disease (MELD) scores. From 1997-2003, we studied 507 cirrhotic United States veterans referred for consideration of liver transplantation to identify additional predictors of early mortality. Most of the patients were male (98%) with cirrhosis caused by hepatitis C and/or alcohol (88%). Data for 296 patients referred prior to February 27, 2002 (training group), were analyzed; findings were validated in 211 patients referred subsequently (validation group). In the training group, 61 patients (21%) died within 180 days without transplantation; their median initial MELD score was 21. MELD score, persistent ascites, and low serum sodium (<135 meq/L) were independent predictors of early mortality. In patients with a MELD score of less than 21, only low serum sodium and persistent ascites were independent predictors of mortality; for MELD scores above 21, only MELD was independently predictive. Prognostic significance of persistent ascites and low serum sodium for low MELD score patients was confirmed in the validation group. Risk varied continuously with worsening hyponatremia. Modifying MELD, by including points for persistent ascites and low serum sodium, improved prediction of early pretransplant mortality in low MELD score patients. In conclusion, persistent ascites and low serum sodium identify patients with cirrhosis with high mortality risk despite low MELD scores. Ascites, hyponatremia, and other findings indicative of hemodynamic decompensation merit further prospective study as prognostic indicators in patients awaiting liver transplantation, and should be considered in setting minimal listing criteria.

Selection of pediatric candidates under the PELD system

1. The PELD score accurately predicts the 3 month probability of waiting list death for children with chronic liver disease. 2. Comparing pre and post PELD and MELD implementation, the percent of children receiving deceased donor livers increased and the percent of children dying on the list decreased after PELD/MELD implementation. 3. Excluding children transplanted at status 1, the largest percentage of children are transplanted at a PELD score < 10. 4. Before MELD/PELD 48% of all children receiving deceased donor organs were transplanted at status 1, compared to 41% in the PELD/MELD era. Wide regional variation occurs.

Are physician-derived disease severity indices associated with health-related quality of life in patients with end-stage liver disease?

OBJECTIVES

Model for end-stage liver disease (MELD) score is now often used as an overall indicator of health status for patients with end-stage liver disease. However, there are no data evaluating the associations between MELD scores and patient reports of health-related quality of life (HRQOL).

METHODS

Two hundred-three patients with end-stage liver disease completed a disease-targeted HRQOL instrument (the LDQOL 1.0). Patients also rated the severity of their liver disease and reported number of disability days attributed to their liver disease in the preceding month. MELD and Child Turcott Pugh (CTP) scores were calculated for all patients. Associations of MELD and CTP scores with patient-derived outcomes were estimated.

RESULTS

The mean MELD and CTP scores were 12 and 7, respectively, indicating mild severity of liver disease. HRQOL of patients was generally poor, with the mean SF-36 physical and mental component summary scores of 35 and 40. Seventy percent of patients rated their liver disease symptoms as moderate to severe. Similarly, 70% reported being disabled from their liver disease. MELD was associated with physical functioning scale and the physical component summary (PCS) score in patients with end-stage liver disease. In contrast, CTP score was significantly associated with physical functioning, role limitations due to physical health problems, PCS score, effects of liver disease, sexual functioning, and sexual problems. Both MELD and CTP scores correlated with self-rated severity of liver disease symptoms but not with self-reported disability days.

CONCLUSIONS

Despite objectively mild liver disease, the subjective HRQOL of this cohort was severely impaired. CTP score was more closely associated with patient-reported estimates of HRQOL than the MELD score. CTP or disease-specific HRQOL instruments may compliment MELD by providing insights into outcomes of importance to patients with low risk of mortality.

Older age and liver transplantation: a review

Patients older than 60 are undergoing transplantation with increasing frequency. Reports from several transplant centers document that overall short-term patient survival rates in seniors undergoing liver transplantation are comparable to survival rates of younger adults. However, specific subgroups of older patients may not fare as well. Seniors with far-advanced end-stage liver disease are high-risk for liver transplantation and have poor survival rates. In addition, seniors older than 65 have worse outcomes than those who are 60 to 65, and studies have shown increased mortality with increasing age as a continuous variable. On the other hand, the majority of seniors who survive liver transplantation have full or only minimally limited functional status. Preoperative evaluation of older patients for transplantation requires careful screening to exclude cardiopulmonary disease, malignancy, and other diseases of the aged. Paradoxically, seniors may benefit from a senescent immune system, which results in decreased requirements for immunosuppressive drugs, and possibly a lower rate of acute allograft rejection. Despite good overall short-term survival in the elderly, long-term survival may be worse because of an increased rate of long-term complications, such as malignancy and heart disease. In conclusion, although advanced age is a negative risk factor, advanced age alone should not exclude a patient from liver transplantation; however, it mandates thorough pretransplant evaluation and careful long-term follow-up with attention to usual health maintenance issues in the elderly.

Pretransplant MELD score and post liver transplantation survival in the UK and Ireland

It has been shown that the model for end-stage liver disease (MELD) score is an accurate predictor of survival in patients with liver disease without transplantation. Four recent studies carried out in the United States have demonstrated that the MELD score obtained immediately prior to transplantation is also associated with post-transplant patient survival. Our aim was to evaluate how accurately the MELD score predicts 90-day post-transplant survival in adult patients with chronic liver disease in the UK and Ireland. The UK and Ireland Liver Transplant Audit has data on all liver transplants since 1994. We studied survival of 3838 adult patients after first elective liver transplantation according to United Network for Organ Sharing categories of their MELD scores (< or = 10, 11-18, 19-24, 25-35, > or =36). The overall survival at 90-days was 90.2%. The 90-day survival varied according to the United Network for Organ Sharing MELD categories (92.6%, 91.9%, 89.7%, 89.7%, and 70.8%, respectively; P < 0.01). Therefore, only those patients with a MELD score of 36 or higher (3% of the patients) had a survival that was markedly lower than the rest. As a consequence, the ability of the MELD score to discriminate between patients who were dead or alive was poor (c-statistic 0.58). Re-estimating the coefficients in the MELD regression model, even allowing for nonlinear relationships, did not improve its discriminatory ability. In conclusion, in the UK and Ireland the MELD score is significantly associated with post-transplant survival, but its predictive ability is poor. These results are in agreement with results found in the United States. Therefore, the most appropriate system to support patient selection for transplantation will be one that combines a pretransplant survival model (e.g., MELD score) with a properly developed post-transplant survival model.

Impact of liver transplantation on HRQOL in children less than 5 years old

Our primary goal was to assess health related quality of life (HRQOL) at transplantation and 1 yr after transplantation in pediatric liver transplant patients aged less than 5 years. We conducted a prospective longitudinal study of HRQOL in pediatric liver transplant recipients, aged less than 5 years to define the impact of liver transplantation on HRQOL and identify factors that predict HRQOL after transplantation. The infant toddler health status questionnaire (ITHQ) was completed at the time of listing for liver transplantation and at 6 and 12 months after liver transplantation. The primary outcome measures were the subscale scores that comprise ITHQ. The mean age (+/-s.e.m.) of the enrolled patients (n = 45) at transplantation was 1.4 (+/-1.2) yr. Thirty-eight (84%) of the enrolled patients completed the study. The highest mean baseline scores of 78.6 (+/-3.3) were for global mental health (GlobalMH). ITHQ subscale scores increased steadily after transplantation. The greatest increase was in the first 6 months after transplant. At 1 yr after transplantation, there were significant increases in all of the ITHQ subscale scores except for GlobalMH. ITHQ subscales were similar for patients who received LDLT compared with those who received cadaver donor liver transplantation (CDLT) at baseline and a year after transplant. Time elapsed as transplantation was a significant predictor of functional health in all of the models generated. Scores for general health (GH), global health (GGH), parental time-impact (PT) and parental time-emotion (PE) were higher for male children. Family cohesion (FC) improved with time elapsed since transplant and increased number of inpatient days. HRQOL improves after transplantation in all of our patients irrespective of the donor type. Functional health scores were higher in patients with normal serum bilirubin at 1 yr post-transplant. Assessment of HRQOL should be an integral part of care for liver transplant patients and their caregivers.

Solid organ transplantation in HIV-infected recipients

HIV is generally regarded as an acceptable reason to exclude a potential recipient from consideration for transplantation. Most of the data in the literature regarding transplantation of HIV sero-positive individuals pertains to the time prior to the administration of Highly Active Anti-Retroviral Therapy (pre-HAART). This data, therefore, provides little guidance for the management of HIV-positive individuals in the current era. The development of HAART has resulted in a decreased mortality. With prolonged survival more HIV-infected individual are developing end stage organ disease from co-existing conditions such as HCV and HBV, and diseases common in the general population such as diabetes mellitus and hypertension. This has lead to clinicians, researchers and patients to actively investigate the role of solid organ transplantation in HIV-infected individuals. In this article We review the literature to date in liver and renal transplantation, including more recent data in patients receiving HAART.

New national liver transplant allocation policy: is the regional review board process fair?

Experienced transplant professionals may predict mortality better, in highly selected cirrhotic patients referred for accelerated listing to regional review boards, than the (Pediatric) Model for End-Stage Liver Disease score. However, these requests are often denied. We wished to establish if (1) such denials increase mortality and (2) referring physicians predict mortality better than the score. We analyzed 1,965 non-status 1 requests made between February and November 2002 from the United Network for Organ Sharing (UNOS) national scientific registry. Kaplan-Meier survival and time to transplant were compared between denied and approved patients. Cox proportional hazards analysis was used to establish if referring physicians predicted mortality better than the score. More requests were denied for patients with nonsanctioned conditions (45.7%) than for those with sanctioned conditions (13.3%); P less than.0001). Fewer patients denied accelerated listing had a transplant (46.6% vs. 63.8%; P <.0001); time to transplant was similar (P =.2). However, nonsanctioned cirrhotic cases denied accelerated listing had lower mortality than approved cases (P <.04). Referring physicians predict mortality poorly (P =.23), whereas the Model for End-Stage Liver Disease (MELD)-Pediatric Model for End-Stage Liver Disease (PELD) score was highly predictive (P =.0003). In conclusion, regional review boards are fair and can accurately distinguish high- from low-risk patients. Denying requests does not increase mortality. The MELD-PELD score remains the best predictor of mortality, but the review board process adds additional information. Referring physicians predict patient mortality poorly.

Improving liver allocation: MELD and PELD

On February 27, 2002, the liver allocation system changed from a status-based algorithm to one using a continuous MELD/PELD severity score to prioritize patients on the waiting list. Using data from the Scientific Registry of Transplant Recipients, we examine and discuss several aspects of the new allocation, including the development and evolution of MELD and PELD, the relationship between the two scoring systems, and the resulting effect on access to transplantation and waiting list mortality. Additional considerations, such as regional differences in MELD/PELD at transplantation and the predictive effects of rapidly changing MELD/PELD, are also addressed. Death or removal from the waiting list for being too sick for a transplant has decreased in the MELD/PELD era for both children and adults. Children younger than 2 years, however, still have a considerably higher rate of death on the waiting list than adults. A limited definition of ECD livers suggests that they are used more frequently for patients with lower MELD scores.

The Barcelona approach: diagnosis, staging, and treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common neoplasm in the world, and the third most common cause of cancer-related death. It affects mainly patients with cirrhosis of any etiology. Patients with cirrhosis are thus usually included in surveillance plans aiming to achieve early detection and effective treatment. Only patients who would be treated if diagnosed with HCC should undergo surveillance, which is based on ultrasonography and alpha-fetoprotein every 6 months. Upon diagnosis, the patients have to be staged to define tumor extent and liver function impairment. Thereafter, the best treatment option can be indicated and a prognosis estimate can be established. The present manuscript depicts the Barcelona-Clínic Liver Cancer Group diagnostic and treatment strategy. This is based on the analysis of several cohort and randomized controlled studies that have allowed the continuous refinement of treatment indication and application. Surgical resection is considered the first treatment option for early stage patients. It is reserved for patients with solitary tumors without portal hypertension and normal bilirubin. If these conditions are not met, patients are considered for liver transplantation (cadaveric or live donation) or percutaneous ablation if at an early stage (solitary < or =5 cm or up to 3 nodules < or =3 cm). These patients will reach a 5-year survival between 50 and 75%. If patients are diagnosed at an intermediate stage and are still asymptomatic and have preserved liver function, they may benefit from chemoembolization. Their 3-year survival will exceed 50%. There is no effective treatment for patients with advanced disease and thus, in such instances, the patients have to be considered for research trials with new therapeutic options. Finally, patients with end-stage disease should receive only palliative treatment to avoid unnecessary suffering.