Model for end-stage liver disease: end of the first decade

The yesterday, today and tomorrow of liver transplant

With a very long history of setbacks and successes, organ transplantation is one of the greatest medical achievements of the twentieth century. Liver transplantation is currently the most effective method for treating end-stage liver disease. From humble beginnings, improvements in surgical technique, perioperative management, and immunosuppressive therapy have yielded excellent graft and patient outcomes. Most established 'liver transplant' (LT) centres have a 1-year survival rate exceeding 90%, and a 3-year survival rate of over 80%. With immense success, the need for hepatic grafts substantially exceeds their availability. This problem has been partially addressed by using split grafts, living donor liver transplantation (LDLT), and extended criteria grafts (ECG). This article reviews the immense progress made in various aspects of LT including evaluation, increasing donor pool, surgical advances, immunosuppression and anaesthesia related aspects and the way forward. With ongoing cutting edge research in technologies like artificial liver devices, tissue bioengineering and hepatocyte 'farms', the future of LT is more exciting than ever before.

Hyperbilirubinemia in hospitalized patients: Etiology and outcomes

There is little information on the differential diagnosis and prognosis of hospitalized patients with hyperbilirubinemia. Here, we hypothesized that hyperbilirubinemia in hospitalized patients is associated with specific diseases and outcomes. This retrospective cohort analysis included patients admitted to the Medical University of South Carolina with a total bilirubin >3 mg/dL from January 9, 2015 to August 25, 2017. Collected clinical data included demographics, primary diagnosis, Charlson Comorbidity Index (CCI), laboratory data, and clinical outcomes. We separated and analyzed the cohort into seven primary diagnostic groups. We identified 1693 patients with a bilirubin level >3 mg/dL. The cohort was 42% female, had an average age of 54, average CCI of 4.8, and average length of stay of 13 days. The causes of hyperbilirubinemia included the following: primary liver disease (868/1693; 51%) with cirrhosis being most common (385/1693; 23%), benign biliary obstruction (252/1693; 15%), hemolytic anemia (149/1693; 9%), malignant biliary obstruction (121/1693; 7%), unknown etiology (108/1693; 6%), primary liver cancer (74/1693; 4%), and metastatic cancer to the liver (57/1693; 3%). Overall, the mortality/discharge to hospice rate in patients with a bilirubin >3 mg/dL was 30%, and was proportional to the severity of hyperbilirubinemia, including when controlling for the underlying severity of illness. Mortality was highest in patients with primary liver disease and malignancy and was lowest in patients with non-cancerous obstruction or hemolytic jaundice. Hyperbilirubinemia in hospitalized patients is most often due to primary liver disease, and identifies patients with a poor prognosis, particularly when caused by primary liver disease or cancer.

A Validated Composite Score Demonstrates Potential Superiority to MELD-Based Systems in Predicting Short-Term Survival in Patients with Liver Cirrhosis and Spontaneous Bacterial Peritonitis-A Preliminary Study

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a severe complication in cirrhosis patients with ascites, leading to high mortality rates if not promptly treated. However, specific prediction models for SBP are lacking.

AIMS

This study aimed to compare commonly used cirrhotic prediction models (CTP score, MELD, MELD-Na, iMELD, and MELD 3.0) for short-term mortality prediction and develop a novel model to improve mortality prediction.

METHODS

Patients with the first episode of SBP were included. Prognostic values for mortality were assessed using AUROC analysis. A novel prediction model was developed and validated.

RESULTS

In total, 327 SBP patients were analyzed, with HBV infection as the main etiologies. MELD 3.0 demonstrated the highest AUROC among the traditional models. The novel model, incorporating HRS, exhibited superior predictive accuracy for in-hospital in all patients and 3-month mortality in HBV-cirrhosis, with AUROC values of 0.827 and 0.813 respectively, surpassing 0.8.

CONCLUSIONS

MELD 3.0 score outperformed the CTP score and showed a non-significant improvement compared to other MELD-based scores, while the novel SBP model demonstrated impressive accuracy. Internal validation and an HBV-related cirrhosis subgroup sensitivity analysis supported these findings, highlighting the need for a specific prognostic model for SBP and the importance of preventing HRS development to improve SBP prognosis.

A case of mistaken MELD (model for end stage liver disease) score-How an acute hemolytic transfusion reaction falsely altered a patient's transplant status

BACKGROUND

An acute hemolytic transfusion reaction (AHTR) caused by intravascular hemolysis features a decrease in hemoglobin/hematocrit, reduced haptoglobin, and increases in creatinine, and bilirubin. Acute intravascular hemolysis carries its own morbidity and mortality, especially in the setting of a patient liver disease related pre-existing alterations in hemostasis. Additionally, AHTR significantly impacts the laboratory values used in calculating the Model for End Stage Liver Disease (MELD) score and thus liver transplant status.

CASE REPORT

Herein, we present a case of a patient with hepatorenal syndrome due to ESLD on the transplant list who developed an AHTR due to an evolving anti-Jka that initially presented as non-specific reactivity in solid phase adherence testing. This evolving antibody caused intravascular hemolysis and a significant increase in bilirubin from 4.7 to 17.1 mg/dl, thus, raising the MELD score, increasing the predicted short-term mortality risk, and affecting the patient's transplant status.

RESULTS

Acute hemolysis caused significant elevation of bilirubin raising the MELD score which increased both the predicted mortality to 70 percent and the perceived urgency of transplant. The MELD score improved after resolution of the AHTR and clearing of the offending Jka-positive RBCs.

CONCLUSION

This case highlights the effect of AHTR on parameters used in the determination of MELD score which significantly increases the perceived short-term mortality and urgency of liver transplant. Therefore, any nonspecific reactivity in initial workup could be due to developing antibodies, and put the patient at higher risk for an acute hemolytic transfusion reaction.

Plasma human neutrophil peptides as biomarkers of disease severity and mortality in patients with decompensated cirrhosis

BACKGROUND & AIMS

Human neutrophil peptides (HNP)-1, -2 and -3 are the most abundant proteins in neutrophil azurophilic granules and are rapidly released via neutrophil degranulation upon activation. The aims of our study were to assess the role of HNP1-3 as biomarkers of disease severity in patients with decompensated cirrhosis and their value in predicting short-term mortality.

METHODS

In this study, 451 patients with acutely decompensated cirrhosis (AD) were enrolled at the two medical centres. Overall, 281 patients were enrolled as the training cohort from October 2015 to April 2019, and 170 patients were enrolled as the validation cohort from June 2020 to February 2021. Plasma HNP1-3 levels were measured using enzyme-linked immunosorbent assay (ELISA).

RESULTS

Plasma HNP1-3 increased stepwise with disease severity (compensated cirrhosis: 0.3 (0.2-0.4); AD without acute-on-chronic liver failure (ACLF): 1.9 (1.3-4.8); ACLF-1: 2.3 (1.8-6.1); ACLF-2: 5.6 (2.9-12.3); ACLF-3: 10.3 (5.7-17.2) ng/ml). From the multivariate Cox regression analysis, HNP1-3 emerged as independent predictors of mortality at 30 and 90 days. Similar results were observed in the subgroup analysis. On ROC analysis, plasma HNP1-3 showed better predictive accuracy for 30- and 90-day mortality (area under the receiver operating characteristic (AUROC) of 0.850 and 0.885, respectively) than the neutrophil-to-lymphocyte ratio (NLR) and similar accuracy as end-stage liver disease (MELD: 0.881 and 0.874) and chronic liver failure-sequential organ failure (CLIF-SOFA: 0.887 and 0.878).

CONCLUSIONS

Plasma HNP1-3 levels were closely associated with disease severity and might be used to identify patients with AD at high risk of short-term mortality.

Arterial Lactate Concentration at the End of Liver Transplantation is Independently Associated With One-Year Mortality

BACKGROUND

Liver transplant patients who develop hyperlactatemia are at increased risk of postoperative morbidity and short-term mortality, but there are few data on longer-term outcomes. We therefore investigated if arterial lactate concentration obtained immediately after surgery, at the time of admission to the intensive care unit (ICU), was associated with 1-year mortality.

METHODS

In this retrospective cohort study, all patients who underwent liver transplant surgery from a deceased donor between September 2013 and December 2019 were screened for inclusion. Patients who underwent combined transplantation surgery and those with a history of previous liver transplantation (ie, redo surgery) were not included. Logistic regression modeling included univariate and multivariate analyses. Receiver operating characteristic curves and areas under the curves were calculated. Lactate thresholds and association with outcome were analyzed for specificity, sensitivity, and Youden's index.

RESULTS

Of 226 patients included, 18.4% died within 1 year of liver transplantation. Immediate postoperative lactate concentration was independently associated with 1-year mortality with an adjusted odds ratio of 1.35 (95% CI 1.16-1.59; P < .001) per mmol/L increase in lactate and an area under the curve of 0.80 (95% CI 0.72-0.87; P < .001). A lactate concentration of 2.25 mmol/L (cutoff determined using Youden's index) was associated with increased 1-year mortality with a sensitivity of 0.71 and a specificity of 0.72.

CONCLUSIONS

Increased arterial lactate concentration on admission to the intensive care unit immediately after orthotopic liver transplantation is independently associated with increased 1-year mortality.

[Malnutrition management of hospitalized patients with diabetes/hyperglycemia and liver cirrhosis]

Introduction

Liver cirrhosis is a progressive and chronic disease of the liver, of diverse etiology, which is frequently associated with glucose intolerance and in some cases concurs with type 2 diabetes (DM2). DM2 is associated with adverse outcomes in patients with cirrhosis, including a higher rate of hospitalizations, a higher prevalence of hepatocellular carcinoma, and an increased risk of mortality. Malnutrition is another frequent complication of cirrhosis, the prevalence of which increases with the degree of liver dysfunction, worsening the prognosis. This article describes the results of the expert consensus and the responses of the panelists on the nutritional management in routine clinical practice of patients with diabetes/hyperglycemia hospitalized (non-critically ill) with liver cirrhosis.

Neutrophil-to-Lymphocyte Ratio Can Distinguish Patients with Liver Cirrhosis from Healthy People but Cannot Distinguish Patients with Cirrhotic Hepatocellular Carcinoma from Patients with Liver Cirrhosis

PURPOSE

Identifying cirrhotic hepatocellular carcinoma (HCC) during liver cirrhosis (LC) stage is pivotal for improving the clinical outcomes of cirrhotic HCC patients. Inflammation-driven markers play a crucial role in tumorigenesis and tumor progression. Neutrophil-to-lymphocyte ratio (NLR) is an inflammatory response marker. This study aimed to evaluate the ability of NLR to distinguish cirrhotic HCC from LC.

METHODS

Data of healthy control (HC) people, LC patients, cirrhotic HCC patients, and non-cirrhotic HCC patients were retrospectively analyzed. Mann-Whitney U test and Chi-squared test were used to compare demographic and clinical parameters in different groups. Spearman correlation analysis was used to assess correlations. Receiver operating characteristic (ROC) curves were performed to determine diagnostic accuracy.

RESULTS

A total of 419 participants were enrolled in this study, including 152 HC people, 131 LC patients, 96 cirrhotic HCC patients, and 40 non-cirrhotic HCC patients. Level of NLR was elevated significantly in LC compared with HC (P < 0.001). No significant differences were found for NLR between LC and cirrhotic HCC (P = 0.083), as well as between cirrhotic HCC and non-cirrhotic HCC (P = 0.729). NLR was positively correlated with platelet-to-lymphocyte ratio (r = 0.33, P < 0.001). The area under the ROC curve (AUC) value for NLR to distinguish LC from HC was 0.759 (P < 0.001), and AUC value to distinguish cirrhotic HCC from LC was 0.567 (P = 0.083), and AUC value to distinguish non-cirrhotic HCC from cirrhotic HCC was 0.519 (0.415-0.623) (P = 0.729).

CONCLUSION

NLR can distinguish LC from HC but cannot not distinguish cirrhotic HCC from LC.

Prognostic value of decline in model for end-stage liver disease score and hepatic encephalopathy in hepatitis B-related acute-on-chronic liver failure patients treated with plasma exchange

OBJECTIVE

To investigate the prognostic value of Model for End-Stage Liver Disease (MELD) score and Hepatic Encephalopathy (HE) for short-term prognosis of Hepatitis B virus-related Acute-on-Chronic Liver Failure (HBV-ACLF) patients treated with plasma exchange (PE).

METHODS

A total of 108 patients with HBV-ACLF treated with PE were retrospectively enrolled between January 2014 to December 2020. Based on survival at 28 days, patients were divided into survival (N = 87) and death groups (N = 21). Clinical data and laboratory indicators were analyzed.

RESULTS

Compared with the survival group, the death group was associated with higher ACLF grade and incidence of HE. The levels of total bilirubin, prothrombin time, creatinine, blood urea nitrogen, MELD score, and Chinese Group on the Study of Severe Hepatitis B-ACLF II (COSSH II) score were significantly higher in the death group than in the survival group (p < .05). Grade 1 ACLF and the MELD score after PE treatment at one week were independent risk factors for 28-day liver transplantation-free mortality (OR = 0.062, 95%CI: 0.005-0.768; OR = 1.328, 95%CI: 1.153-1.531). A MELD score at one week of at least 25.5 was associated with a poor short-term prognosis. Of note, HE was a strong independent risk factor for a decline in MELD score at one week. (OR = 11.815, 95%CI: 3.187-43.796, p < 0.001).

CONCLUSION

We found patients with HE at admission and MELD score of at least 25.5 at one week after PE treatment had a poor short-term prognosis and should prompt preparation for liver transplantation. Trial Registration: The trial is registered at ClinicalTrials.gov (CT.gov identifier: NCT04231565). Registered 13 May 2020.

Models to predict the short-term survival of acute-on-chronic liver failure patients following liver transplantation

Background

Acute-on-chronic liver failure (ACLF) is featured with rapid deterioration of chronic liver disease and poor short-term prognosis. Liver transplantation (LT) is recognized as the curative option for ACLF. However, there is no standard in the prediction of the short-term survival among ACLF patients following LT.

Method

Preoperative data of 132 ACLF patients receiving LT at our center were investigated retrospectively. Cox regression was performed to determine the risk factors for short-term survival among ACLF patients following LT. Five conventional score systems (the MELD score, ABIC, CLIF-C OFs, CLIF-SOFAs and CLIF-C ACLFs) in forecasting short-term survival were estimated through the receiver operating characteristic (ROC). Four machine-learning (ML) models, including support vector machine (SVM), logistic regression (LR), multi-layer perceptron (MLP) and random forest (RF), were also established for short-term survival prediction.

Results

Cox regression analysis demonstrated that creatinine (Cr) and international normalized ratio (INR) were the two independent predictors for short-term survival among ACLF patients following LT. The ROC curves showed that the area under the curve (AUC) ML models was much larger than that of conventional models in predicting short-term survival. Among conventional models the model for end stage liver disease (MELD) score had the highest AUC (0.704), while among ML models the RF model yielded the largest AUC (0.940).

Conclusion

Compared with the traditional methods, the ML models showed good performance in the prediction of short-term prognosis among ACLF patients following LT and the RF model perform the best. It is promising to optimize organ allocation and promote transplant survival based on the prediction of ML models.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02164-6.

Technical and Medium-Term Clinical Outcomes of Transjugular Intrahepatic Portosystemic Shunt with Fluoroscopy and Additional Trans-abdominal Ultrasound Guidance

Background and Objective The aim of the study is to evaluate the technical and clinical outcomes of transjugular intrahepatic portosystemic shunt (TIPS) performed with additional transabdominal ultrasound guidance.

Material and Methods Patients who underwent TIPS between January 2004 to January 2020 in our center were studied. Technical, hemodynamic, angiographic, and clinical outcome were recorded up to 1 year of follow-up.

Results TIPS was attempted in 162 patients (median [range] age 37[3–69] years; 105 were males and 57 were females; Etiology: Budd-Chiari syndrome [BCS] 91, cirrhosis 65, symptomatic acute portal venous thrombosis [PVT] 3, veno-occlusive disease [VOD] 2, congenital portosystemic shunt [CPSS] 1) during the study period. Indication for TIPS was refractory ascites in 135 patients (BCS 86, cirrhosis 49) and variceal bleed in 21 patients (BCS 5, cirrhosis 16). Technical success was seen in 161 of the 162 (99.4%) patients. The tract was created from hepatic vein in 55 patients and inferior vena cava (IVC) in 106 patients. Complications within 1 week post TIPS were seen in 29 of the 162 (18%) patients, of whom one developed unexplained arrhythmia and hypotension and died. Of the patients with available follow-up, clinical success was noted in 120 (81%), while 14 (9%) patients had partial nonresponse and six (4%) had complete nonresponse. Eight (5%) patients died during the follow-up period.

Conclusion The technical success of TIPS creation with additional transabdominal ultrasound guidance is very high with low peri-procedural complication rate. It has enabled the inclusion of a wider spectrum of cases like acute PVT and obliterated hepatic veins which were otherwise considered contraindications.

Liver transplantation: survival and indexes of donor-recipient matching

OBJECTIVE

The aim of this study was to determine the prospective capacity and impact of donor risk index, preallocation survival outcomes following liver transplant, donor model for end-stage liver disease, and balance of risk on patients' 30-day survival after liver transplantation.

METHODS

We prospectively analyzed patient survival in a multicentric observational cohort of adult liver transplantation through the year of 2019 at the state of Paraná, Brazil. The receiver operating characteristic curve, the area under the curve, and the best cutoff point (i.e., the Youden's index) were estimated to analyze the prognostic value of each index.

RESULTS

In total, 252 liver transplants were included with an average model for end-stage liver disease score of 21.17 and a 30-day survival of 79.76%. The donor risk index was the only prognostic variable with no relation to patients' 30-day mortality model for end-stage liver disease and donor model for end-stage liver disease have no prognostic value on receiver operating characteristic curve, but preallocation survival outcomes following liver transplant, survival outcomes following liver transplant, and balance of risk presented good relationship with this observation. The cutoff value was estimated in 11-12 points for balance of risk and 9-12 for preallocation survival outcomes following liver transplant and survival outcomes following liver transplant. The 30-day survival for the group of transplants with scores up to 12 points (n=172) in all the three indexes was 87.79%, and for those transplants with scores higher than 12 it was 36.36%.

CONCLUSIONS

The 30-day survival is 79.76%, and balance of risk, survival outcomes following liver transplant, and preallocation survival outcomes following liver transplant are the good prognostic indexes. The cutoff value of 12 points has clinical usefulness to predict the post-liver transplantation results.

Experiences from six years of quality assured Model of End Stage Liver Disease (MELD) diagnostics

BACKGROUND

The model of end-stage liver disease (MELD) score was established for the allocation of liver transplants. The score is based on the medical laboratory parameters: bilirubin, creatinine and the international normalized ratio (INR). A verification algorithm for the laboratory MELD diagnostic was established, and the results from the first six years were analyzed.

METHODS

We systematically investigated the validity of 7,270 MELD scores during a six-year period. The MELD score was electronically requested by the clinical physician using the laboratory system and calculated and specifically validated by the laboratory physician in the context of previous and additional diagnostics.

RESULTS

In 2.7% (193 of 7,270) of the cases, MELD diagnostics did not fulfill the specified quality criteria. After consultation with the sender, 2.0% (145) of the MELD scores remained invalid for different reasons and could not be reported to the transplant organization. No cases of deliberate misreporting were identified. In 34 cases the dialysis status had to be corrected and there were 24 cases of oral anticoagulation with impact on MELD diagnostics.

CONCLUSION

Our verification algorithm for MELD diagnostics effectively prevented invalid MELD results and could be adopted by transplant centers to prevent diagnostic errors with possible adverse effects on organ allocation.

New OPTN Simultaneous Liver-Kidney Transplant (SLKT) Policy Improves Racial and Ethnic Disparities

(1) Background: On 10 August 2017, the Organ Procurement and Transplantation Network (OPTN) adopted standardized eligibility criteria to properly determine which transplant candidates should undergo Simultaneous Liver-Kidney Transplant (SLKT). Racial and ethnic disparities have not been examined after 2017. Therefore, using the United Network for Organ Sharing (UNOS), we aim to evaluate post-graft survival outcomes among Caucasians, African Americans, and Hispanics. (2) Methods: Kaplan-Meier curves and Cox regression models are used to compare post-transplant graft survival for Caucasians, African Americans (AAs), and Hispanics. Competing risk analysis is used to evaluate the cumulative incidence of death or re-transplantation with re-transplantation and death as competing risks. (3) Results: On multivariate Cox regression analysis, no differences in graft survival are found in AA (hazard ratio (HR): 1.30; 95% CI: 0.74-2.29 p = 0.354) or Hispanics (HR: 1.18; 95% CI: 0.70-2 p = 0.520) compared to Caucasians after 2017. On competing risk analysis of the risk of death with re-transplantation as a competing risk, no difference is found between ethnic minorities after 2017. There is a similar finding from competing risk analysis of the risk of re-transplantation with death as a competing risk. (4) Conclusion: After introducing standardized eligibility criteria for SLKT allocation, the post-graft survival outcomes remain similar between the different racial and ethnic groups, displaying the benefits of adopting such policy in 2017.

Hepatic Encephalopathy and Spontaneous Bacterial Peritonitis Improve Cirrhosis Outcome Prediction: A Modified Seven-Stage Model as a Clinical Alternative to MELD

Classification of cirrhosis based on clinical stages is rapid and based on five stages at present. Two other relevant events, hepatic encephalopathy (HE) and spontaneous bacterial peritonitis (SBP), can be considered in a clinical perspective but no study has implemented a seven-stage classification and confirmed its value before. In addition, long-term validation of the Model for End-Stage Liver Disease (MELD) in large cohorts of patients with cirrhosis and comparison with clinical findings are insufficient. Therefore, we performed a study to address these items. From the Chang-Gung Research Database (CGRD), 20,782 patients with cirrhosis were enrolled for an historical survival study. The MELD score, the five-stage clinical score (i.e., occurrence of esophageal varices (EV), EV bleeding, ascites, sepsis) and a novel seven-stage clinical score (i.e., occurrence of EV, EV bleeding, ascites, sepsis, HE, SBP) were compared with their Cox models by receiver operating characteristic (ROC) analysis. The addition of HE and SBP to the seven-stage model had a 5% better prediction result than the five-stage model did in the survival ROC analysis. The result showed that the seven clinical stages are associated with an increased risk for mortality. However, the predicted performances of the seven-stage model and MELD system are likely equivalent. In conclusion, the study (i) proved that clinical staging of cirrhosis based on seven items/stages had higher prognostic value than the five-stage model and (ii) confirmed the validity of the MELD criteria vs. clinical assessment.

Perioperative antiviral therapy improves the prognosis of HBV DNA-negative patients with HBV-related hepatocellular carcinoma

OBJECTIVE

To investigate the effect of perioperative antiviral therapy on the prognosis of hepatitis B virus (HBV) DNA-negative patients with HBV-related hepatocellular carcinoma (HCC).

METHODS

The clinical data of 140 patients who were positive for hepatitis B surface antigen (HBsAg) but negative for HBV DNA before partial hepatectomy were retrospectively analyzed. Propensity score matching (PSM) was used to eliminate the influence of confounding factors on prognosis. Postoperative liver function, HBV reactivation rate, recurrence-free survival (RFS) and overall survival (OS) were compared between antiviral and non-antiviral therapy groups.

RESULTS

Compared with the non-antiviral therapy group, the antiviral therapy group had a lower rate of HBV reactivation and better postoperative liver function (P < 0.05). The 1-year, 2-year and 3-year survival rates of the antiviral therapy group were better than those of the non-antiviral therapy group before or after PSM (P < 0.05). Prognostic analysis excluding 11 patients with HBV reactivation showed that perioperative antiviral therapy could significantly improve OS (P = 0.004), but had no significant effect on RFS (P = 0.056). Multivariate analyzes showed that antiviral therapy was associated with better OS.

CONCLUSION

Perioperative antiviral therapy can significantly reduce the risk of HBV reactivation and improve postoperative liver function, RFS and OS.

Impact of Model for End-stage Liver Disease Score-based Allocation System in Korea: A Nationwide Study

BACKGROUND

In June 2016, the Korean Network for Organ Sharing implemented a Model for End-stage Liver Disease (MELD) score-based allocation system to better prioritize deceased-donor liver transplant (DDLT) candidates. The aim of this study was to assess the impact of this allocation system.

METHODS

We compared waiting list and posttransplant outcomes during the first year of operation of the MELD allocation system (from June 2016 to May 2017) with an equivalent period before its implementation (from June 2015 to May 2016).

RESULTS

A total of 3041 candidates were listed for DDLT (1464 pre-MELD, 1577 post-MELD era) and 892 patients received DDLT during the study period. A decrease in waiting list mortality and an increase in DDLT rate were observed after MELD implementation. However, the number of living donor liver transplants did not differ significantly pre- to post-MELD. As was expected, introduction of the MELD allocation system increased mean MELD scores at DDLT (24.1 ± 8.3 pre-MELD, 34.5 ± 7.0 post-MELD era, P < 0.001). Posttransplant patient survival rates at 1-year were 79.9% in pre-MELD era and 76.2% in post-MELD era (P = 0.184). The proportion of interregional organ transfer increased from 25.1% to 40.5%. Furthermore, transplant benefits increased with MELD scores.

CONCLUSIONS

The MELD system was found to address the goal of fairness well. Implementation of the MELD system improved equity in terms of access to DDLT regardless of regions. Although a greater proportion of more severely ill patients received DDLT after MELD implementation, posttransplant survivals remained unchanged.

Racial/Ethnic Disparities in Access and Outcomes of Simultaneous Liver-Kidney Transplant Among Liver Transplant Candidates With Renal Dysfunction in the United States

BACKGROUND

Since the Model for End-stage Liver Disease (MELD) allocation system was implemented, the proportion of simultaneous liver-kidney transplantation (SLKT) has increased significantly. However, whether racial/ethnic disparities exist in access to SLKT and post-SLKT survival remains understudied.

METHODS

A retrospective cohort of patients aged ≥18 years with renal dysfunction on the liver transplant (LT) waiting list was obtained from Organ Procurement and Transplantation Network. Renal dysfunction was defined as estimated glomerular filtration rate <60 mL/min/1.73 m at listing for LT. Multilevel time-to-competing-events regression adjusting for center effect was used to examine the likelihood of receiving SLKT. Inverse probability of treatment weighted survival analyses were used to analyze posttransplant mortality outcomes.

RESULTS

For patients with renal dysfunction at listing for LT, not listed for simultaneous kidney transplant, non-Hispanic black (NHB) and Hispanic patients were more likely to receive SLKT than non-Hispanic white (NHW) patients (NHB: multivariable-adjusted hazard ratio [aHR] 2.57; 95% confidence interval [CI], 1.42-4.65; Hispanic: aHR, 2.03; 95% CI, 1.14-3.60). For post-SLKT outcomes, compared to NHW patients, NHB patients had a lower mortality risk before 24 months (aHR, 0.80; 95% CI, 0.65-0.97) but had a higher mortality risk (aHR, 2.00; 95% CI, 1.59-2.55) afterward; in contrast, Hispanic patients had a lower overall mortality risk than NHW patients (aHR, 0.61; 95% CI, 0.51-0.74).

CONCLUSIONS

In the MELD era, racial/ethnic differences exist in access and survival of SLKT for patients with renal dysfunction at listing for LT. Future studies are warranted to examine whether these differences remain in the post-SLK allocation policy era.

Heart Transplant and Hepato-Renal Dysfunction: The Model of End-Stage Liver Disease Excluding International Normalized Ratio as a Predictor of Postoperative Outcomes

INTRODUCTION

Preoperative liver and renal dysfunction remain surgical risk factors for both postoperative morbidity and mortality. The Model of End-Stage Liver Disease Excluding INR (international normalized ratio), or MELD-XI, score calculation may help as a predictor in patients with advanced heart failure. We analyzed the impact of progressive elevated MELD-XI values among recipients of heart transplant at our institution.

METHODS

The data of a total of 425 consecutive adult patients who underwent heart transplantation, between January 2000 and August 2018, have been reviewed and divided into 3 cohorts according to preoperative MELD-XI calculations (MELD-XI < 11; MELD-XI 11-18; and MELD-XI > 18). Early and late outcomes have been analyzed.

RESULTS

Patients with a MELD-XI score > 18 had a more critical clinical condition preoperatively and had a higher risk of early mortality (hazard ratio [HR] 1.45 [1.11-1.67], P < .001). They showed high risk for postoperative dialysis (HR 2.8 [1.5-5.3], P < .001), rethoracothomy for bleeding (HR 2.1 [1.2-4.1], P = .001), prolonged time of mechanical ventilation, time of intensive care unit stay (HR 2.2 [1.3-3.8], P = .005), and graft failure requiring mechanical circulatory support (HR 1.9 [1.1-3.3], P = .003). After risk adjustment per MELD-XI cohort, ischemic dilated cardiomyopathy, redo operation, and cold ischemic time > 240 minutes resulted in being the strongest predictors of early mortality (P < .001). The 5-year and 10-year survival for MELD-XI > 18 cohort was 63% and 47% vs 72% and 59% in the control group (MELD-XI < 18) (log-rank, P < .001).

CONCLUSIONS

Patients with an elevated preoperative MELD-XI profile presented more comorbidities and significantly lower survival. This suggests the MELD-XI score may provide further insight into appropriate recipient and eventual donor selection. Renal insufficiency and congestive hepatopathy should be properly optimized before heart transplantation.

Treatment of AECHB and Severe Hepatitis (Liver Failure)

This chapter describes the general treatment and immune principles and internal management for AECHB and HBV ACLF, including ICU monitoring, general supportive medications/nutrition/nursing, immune therapy, artificial liver supportive systems, hepatocyte/stem cell, and liver transplant, management for special populations, frequently clinical complications and the utilization of Chinese traditional medicines.

Early clinical indicators of severe hepatitis B include acratia, gastrointestinal symptoms, a daily increase in serum bilirubin >1 mg/dL, toxic intestinal paralysis, bleeding tendency and mild mind anomaly or character change, and the presence of other diseases inducing severe hepatitis. Laboratory indicators include T-Bil, PTA, cholinesterase, pre-albumin and albumin. The roles of immune indicators (such as IL-6, TNF-α, and fgl2), gene polymorphisms, HBV genotypes, and gene mutations as early clinical indicators.

Intensive Care Unit monitor patients with severe hepatitis include intracranial pressure, infection, blood dynamics, respiratory function, renal function, blood coagulation function, nutritional status and blood purification process. Nursing care should not only include routine care, but psychological and special care (complications).

Nutrition support and nursing care should be maintained throughout treatment for severe hepatitis. Common methods of evaluating nutritional status include direct human body measurement, creatinine height index (CHI) and subject global assessment of nutrition (SGA). Malnourished patients should receive enteral or parenteral nutrition support.

Immune therapies for severe hepatitis include promoting hepatocyte regeneration (e.g. with glucagon, hepatocyte growth factor and prostaglandin E1), glucocorticoid suppressive therapy, and targeting molecular blocking. Corticosteroid treatment should be early and sufficient, and adverse drug reactions monitored. Treatments currently being investigated are those targeting Toll-like receptors, NK cell/NK cell receptors, macrophage/immune coagulation system, CTLA-4/PD-1 and stem cell transplantation.

In addition to conventional drugs and radioiodine, corticosteroids and artificial liver treatment can also be considered for severe hepatitis patients with hyperthyreosis. Patients with gestational severe hepatitis require preventive therapy for fetal growth restriction, and it is necessary to choose the timing and method of fetal delivery. For patients with both diabetes and severe hepatitis, insulin is preferred to oral antidiabetic agents to control blood glucose concentration. Liver toxicity of corticosteroids and immune suppressors should be monitored during treatment for severe hepatitis in patients with connective tissue diseases including SLE, RA and sicca syndrome. Patient with connective tissue diseases should preferably be started after the antiviral treatment with nucleos(t)ide analogues.

An artificial liver can improve patients’ liver function; remove endotoxins, blood ammonia and other toxins; correct amino acid metabolism and coagulation disorders; and reverse internal environment imbalances. Non-bioartificial livers are suitable for patients with early and middle stage severe hepatitis; for late-stage patients waiting for liver transplantation; and for transplanted patients with rejection reaction or transplant failure. The type of artificial liver should be determined by each patient’s condition and previous treatment purpose, and patients should be closely monitored for adverse reactions and complications. Bio- and hybrid artificial livers are still under development.

MELD score is the international standard for choosing liver transplantation. Surgical methods mainly include the in situ classic type and the piggyback type; transplantation includes no liver prophase, no liver phase or new liver phase. Preoperative preparation, management of intraoperative and postoperative complications and postoperative long-term treatment are keys to success.

Severe hepatitis belongs to the categories of “acute jaundice”, “scourge jaundice”, and “hot liver” in traditional Chinese medicine. Treatment methods include Chinese traditional medicines, acupuncture and acupoint injection, external application of drugs, umbilical compress therapy, drip, blow nose therapy, earpins, and clysis. Dietary care is also an important part of traditional Chinese medicine treatment.

Prevalence and Prognosis of Portopulmonary Hypertension in 223 Liver Transplant Recipients

Objective

To investigate the prevalence and prognosis of portopulmonary hypertension (PoPH) in liver transplant recipients.

Methods

Patients with advanced liver disease who underwent orthotopic liver transplantation (OLT) were included in this retrospective study from January 2012 to June 2015. According to the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines for the diagnosis of pulmonary hypertension (PH), patients with tricuspid regurgitation velocity (TRV) >3.4 m/s or 2.9 m/s ≤ TRV ≤ 3.4 m/s coexisting with other echocardiographic PH signs were judged as PH. PH patients with portal hypertension and without other known causes of PH were diagnosed as PoPH.

Results

A total of 223 (170 males and 53 females) middle-aged (50.9 ± 9 years old) liver transplant recipients were included in this study. Fourteen patients (6.3%) were diagnosed with PoPH, and none of the patients were treated with vasodilators before or after OLT. After OLT, patients were followed up for 26 ± 13.5 months. In total, 8 of 14 (57%) PoPH patients died, and the main cause of death was pulmonary infection. Kaplan–Meier survival curves revealed a significant difference in survival between PoPH and non-PoPH patients (p < 0.001), and the median survival time after OLT of PoPH was 11.4 months.

Conclusions

The prevalence of PoPH was 6.3% in OLT recipients. The survival of untreated PoPH patients was dismal after OLT.

D-dimer level in liver transplant recipients on the first day after surgery is correlated with postoperative thrombosis recurrence

OBJECTIVE

This study aimed to investigate the relationship between plasma D-dimer level, preoperative complications, and thrombosis in liver transplant recipients.

METHODS

The clinical data of 525 liver transplant recipients with end-stage liver disease (ESLD) in the First Affiliated Hospital of Zhejiang University from October 2012 to December 2015 were retrospectively analyzed. The patients were grouped based on thrombosis before and after surgery to determine the risk factors for postoperative thrombosis recurrence.

RESULTS

Of the preoperative complications assessed, esophageal varices and thrombosis were significantly correlated (P = 0.000); ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy were significantly correlated with preoperative D-dimer level (P < 0.001, P < 0.001, and P = 0.002, respectively); during the first week after surgery, the D-dimer level was significantly and consecutively higher than that before surgery and was significantly higher in the group with both preoperative and postoperative thrombosis than in the other groups on the first day after surgery (P < 0.001); the area under the curve (AUC) for diagnosis of postoperative thrombosis recurrence in the preoperative thrombosis group using plasma D-dimer level on the first day after surgery was 0.698 (P = 0.001); Cox regression analysis showed that D-dimer was an independent risk factor for postoperative thrombosis recurrence (HR = 3.062, P = 0.029).

CONCLUSION

D-dimer level on the first day after liver transplant is related to thrombosis recurrence and is an independent risk factor for postoperative thrombosis recurrence.

Increased Level of Interleukin 6 Associates With Increased 90-Day and 1-Year Mortality in Patients With End-Stage Liver Disease

BACKGROUND & AIMS

Organ allocation for liver transplantation is based on prognosis, using the model for end-stage liver disease (MELD) or MELD including serum sodium (MELD-Na) score. These scores do not consider systemic inflammation and septic complications. Blood level of C-reactive protein (CRP), in addition to the MELD score, associates with mortality in patients with end-stage liver disease, whereas levels of interleukin 6 (IL6) have not been systematically studied.

METHODS

We performed a retrospective observational cohort study of 474 patients with end-stage liver disease (63.5% male; median age, 56.9 years), evaluated for liver transplantation in Germany, with at least 1 year of follow up. Data were collected on blood levels of CRP, IL6, and white blood cell count (WBC). Findings were analyzed in relation to mortality and compared with patients' MELD scores and MELD-Na scores. For survival analysis, the cohort was divided into quartiles of IL6, CRP, and WBC levels, as well as MELD scores. Log-rank test and the Cox proportional hazards regression model were used to compare the groups, and area under the receiver operating characteristic (AUROC) values were calculated.

RESULTS

Blood levels of IL6 and MELD scores associated with mortality: none of the patients with levels of IL6 below the first quartile (below 5.3 pg/mL) died within 1 year. In contrast, 67.7% of the patients in the highest quartile of IL6 level (37.0 pg/mL or more) died within 1 year. MELD score also correlated with mortality: among patients with MELD scores below 8.7, 0.9% died within 1 year, whereas in patients with MELD scores of 18.0 or more, 67.4% died within 1 year. The predictive value of level of IL6 (AUROC, 0.940) was higher than level of CRP (AUROC, 0.866) (P = .009) or WBC (AUROC, 0.773) (P < .001) for 90-day mortality. MELD scores associated with 90-day mortality (AUROC, 0.933) (P = .756) as did MELD-Na score (AUROC, 0.946) (P = .771). Level of IL6 associated with 1-year mortality (AUROC, 0.916) to a greater extent than liver synthesis or detoxification markers international normalized ratio (AUROC, 0.839) (P = .007) or bilirubin (AUROC 0.846) (P = .007). Level of IL6 was an independent, significant risk factor for mortality after adjustment for MELD score, MELD-Na score, level of CRP, or WBC.

CONCLUSIONS

In a retrospective analysis, we found high blood levels of IL6 to associate with 90-day and 1-year mortality in patients with end-stage liver disease; its predictive value was comparable to that of MELD or MELD-Na score, and was higher than that of level of CRP or WBC. Further studies should be performed to confirm the results in different cohorts.

Successful introduction of Model for End-stage Liver Disease scoring in deceased donor liver transplantation in Korea: analysis of first 1 year experience at a high-volume transplantation center

Backgrounds/Aims

Model for End-stage Liver Disease (MELD) score was adopted in June 2016 in Korea.

Methods

We analyzed changes in volumes and outcomes of deceased donor liver transplantation (DDLT) for 1 year before and after introduction of MELD scoring at Asan Medical Center.

Results

There were 64 cases of DDLT in 1 year before MELD introduction and 106 in 1 year after MELD introduction, an increase of 65%. The volume of DDLTs abruptly increased during first 3 months, but then returned to its usual level before MELD introduction, which indicated 3-month depletion of accumulated recipient pool with high MELD scores. The number of pediatric DDLT cases increased from 3 before MELD introduction to 11 after it, making up 21.4% and 47.8% of all cases of pediatric liver transplantation, respectively. The number of cases of retransplanted DDLTs increased from 4 to 27, representing 6.3% and 25.5% of all DDLT cases, respectively. The number of status 1 DDLT cases increased from 5 to 12, being 7.8% and 11.3% of all cases. Patient survival outcomes were similar before and after MELD introduction.

Conclusions

The number of DDLTs temporarily increased after adoption of MELD scoring due to accumulated recipient pool with high MELD scores. The numbers of retransplanted and pediatric DDLT cases significantly increased. Patient survival in adult and pediatric DDLT was comparable before and after adoption of MELD scoring. These results imply that Korean MELD score-based allocation system was successfully established within its first year.

The postoperative Model for End stage Liver Disease score as a predictor of short-term outcome after transplantation of extended criteria donor livers

BACKGROUND

Recently, the postoperative Model for End stage Liver Disease score (POPMELD) was suggested as a definition of postoperative graft dysfunction and a predictor of outcome after liver transplantation (LT).

AIM

The aim of the present study was to validate this concept in the context of extended criteria donor (ECD) organs.

PATIENTS AND METHODS

Single-center prospectively collected data (OPAL study/01/11-12/13) of 116 ECD LTs were utilized. For each recipient, the Model for End stage Liver Disease (MELD) score was calculated for 7 postoperative days (PODs). The ability of international normalized ratio, bilirubin, aspartate aminotransferase, Donor Risk Index, a recent definition of early allograft dysfunction, and the POPMELD was compared to predict 90-day graft loss. Predictive abilities were compared by receiver operating characteristic curves, sensitivity and specificity, and positive and negative predictive values.

RESULTS

The median Donor Risk Index was 1.8. In all, 60.3% of recipients were men [median age of 54 (23-68) years]. The median POD1-7 peak-aspartate aminotransferase value was 1052 (194-17 577) U/l. The rate of early allograft dysfunction was 22.4%. The 90-day graft survival was 89.7%. Out of possible predictors of the 90-day graft loss MELD on POD5 was the best predictor of outcome (area under the curve=0.84). A MELD score of 16 or more on POD5 predicted the 90-day graft loss with a specificity of 80.8%, a sensitivity of 81.8%, and a positive and negative predictive value of 31 and 97.7%.

CONCLUSION

A MELD score of 16 or more on POD5 is an excellent predictor of outcome in ECD donor LT. Routine evaluation of POPMELD scores might support clinical decision-making and should be reported routinely in clinical trials.

Thromboelastographic reference ranges for a cirrhotic patient population undergoing liver transplantation

AIM

To describe the thromboelastography (TEG) “reference” values within a population of liver transplant (LT) candidates that underline the differences from healthy patients.

METHODS

Between 2000 and 2013, 261 liver transplant patients with a model for end-stage liver disease (MELD) score between 15 and 40 were studied. In particular the adult patients (aged 18-70 years) underwent to a first LT with a MELD score between 15 and 40 were included, while all patients with acute liver failure, congenital bleeding disorders, and anticoagulant and/or antiplatelet drug use were excluded. In this population of cirrhotic patients, preoperative haematological and coagulation laboratory tests were collected, and the pretransplant thromboelastographic parameters were studied and compared with the parameters measured in a previously studied population of 40 healthy subjects. The basal TEG parameters analysed in the cirrhotic population of liver candidates were as follows: Reaction time (r), coagulation time (k), Angle-Rate of polymerization of clot (αAngle), Maximum strenght of clot (MA), Amplitudes of the TEG tracing at 30 min and 60 min after MA is measured (A30 and A60), and Fibrinolysis at 30 and 60 min after MA (Ly30 and Ly60). The possible correlation between the distribution of the reference range and the gender, age, MELD score (higher or lower than 20) and indications for transplantation (liver pathology) were also investigated. In particular, a MELD cut-off value of 20 was chosen to verify the possible correlation between the thromboelastographic reference range and MELD score.

RESULTS

Most of the TEG reference values from patients with end-stage liver disease were significantly different from those measured in the healthy population and were outside the suggested normal ranges in up to 79.3% of subjects. Wide differences were found among all TEG variables, including r (41.5% of the values), k (48.6%), α (43.7%), MA (79.3%), A30 (74.4%) and A60 (80.9%), indicating a prevailing trend to hypocoagulability. The differences between the mean TEG values obtained from healthy subjects and the cirrhotic population were statistically significant for r (P = 0.039), k (P < 0.001), MA (P < 0.001), A30 (P < 0.001), A60 (P < 0.001) and Ly60 (P = 0.038), indicating slower and less stable clot formation in the cirrhotic patients. In the cirrhotic population, 9.5% of patients had an r value shorter than normal, indicating a tendency for faster clot formation. Within the cirrhotic patient population, gender, age and the presence of hepatocellular carcinoma or alcoholic cirrhosis were not significantly associated with greater clot firmness or enhanced whole blood clot formation, whereas greater clot strength was associated with a MELD score < 20, hepatitis C virus and cholestatic-related cirrhosis (P < 0.001; P = 0.013; P < 0.001).

CONCLUSION

The range and distribution of TEG values in cirrhotic patients differ from those of healthy subjects, suggesting that a specific thromboelastographic reference range is required for liver transplant candidates.

Plasma Amino Acid Concentrations Predict Mortality in Patients with End-Stage Liver Disease

BACKGROUND

The liver plays a key role in amino acid metabolism. In former studies, a ratio between branched-chain and aromatic amino acids (Fischer's ratio) revealed associations with hepatic encephalopathy. Furthermore, low concentrations of branched-chain amino acids were linked to sarcopenia in literature. Encephalopathy and sarcopenia are known to dramatically worsen the prognosis. Aim of this study was to investigate a complex panel of plasma amino acids in the context of mortality in patients with end-stage liver disease.

METHODS

166 patients evaluated for orthotopic liver transplantation were included. 19 amino acids were measured from citrated plasma samples using mass spectrometry. We performed survival analysis for plasma amino acid constellations and examined the relationship to established mortality predictors.

RESULTS

33/166 (19.9%) patients died during follow-up. Lower values of valine (p<0.001), Fischer's ratio (p<0.001) and valine to phenylalanine ratio (p<0.001) and higher values of phenylalanine (p<0.05) and tyrosine (p<0.05) were significantly associated with mortality. When divided in three groups, the tertiles discriminated cumulative survival for valine (p = 0.016), phenylalanine (p = 0.024) and in particular for valine to phenylalanine ratio (p = 0.003) and Fischer's ratio (p = 0.005). Parameters were also significantly correlated with MELD and MELD-Na score.

CONCLUSIONS

Amino acids in plasma are valuable biomarkers to determine increased risk of mortality in patients with end-stage liver disease. In particular, valine concentrations and constellations composed of branched-chain and aromatic amino acids were strongly associated with prognosis. Due to their pathophysiological importance, the identified amino acids could be used to examine individual dietary recommendations to serve as potential therapeutic targets.

Recalibrating the Child-Turcotte-Pugh Score to Improve Prediction of Transplant-Free Survival in Patients with Cirrhosis

BACKGROUND

The Child-Turcotte-Pugh (CTP) score is a widely used and validated predictor of long-term survival in cirrhosis. However, the cutpoints for stratifying laboratory variables in CTP have never been validated.

OBJECTIVE

The objective of this study was to identify evidence-based cutpoints for the CTP laboratory subscores to improve its predictive capacity for transplant-free survival.

DESIGN

Retrospective observational study.

DATA SOURCE

Using a cohort of 30,897 cirrhotic US Veteran patients with at least 5 years of follow-up, we performed Cox proportional hazard survival model iterations varying the upper and lower cutpoints for INR, total bilirubin and albumin CTP subscores. Cutpoints yielding the highest Harrell's C-statistics for concordance with transplant-free survival were incorporated into a modified CTP (mCTP) score. Validation of the mCTP was performed at multiple time frames within the follow-up period of the cohort and within subsets defined by disease etiology.

RESULTS

Modification of CTP cutpoints increased the Harrell's C-statistic for age- and gender-adjusted Cox proportional hazard models from 0.701 ± 0.002 to 0.709 ± 0.002 and the risk ratio per unit change from 1.49 (1.48-1.50) to 1.53 (1.52-1.54). The modified cutpoints showed superiority in predicting 5-year transplant-free survival in various disease etiology subgroups. A mCTP substituting serum creatinine for INR performed superiorly for predicting 5-year transplant-free survival.

CONCLUSION

We propose an evidence-based recalibration of CTP score cutpoints that optimizes this model's capacity to predict transplant-free survival in patients with cirrhosis. The CTP score remains the best predictor of 5-year overall and transplant-free survival in patients with cirrhosis.

Higher Mortality in registrants with sudden model for end-stage liver disease increase: Disadvantaged by the current allocation policy

Liver allocation is based on current Model for End-Stage Liver Disease (MELD) scores, with priority in the case of a tie being given to those waiting the longest with a given MELD score. We hypothesized that this priority might not reflect risk: registrants whose MELD score has recently increased receive lower priority but might have higher wait-list mortality. We studied wait-list and posttransplant mortality in 69,643 adult registrants from 2002 to 2013. By likelihood maximization, we empirically defined a MELD spike as a MELD increase ≥ 30% over the previous 7 days. At any given time, only 0.6% of wait-list patients experienced a spike; however, these patients accounted for 25% of all wait-list deaths. Registrants who reached a given MELD score after a spike had higher wait-list mortality in the ensuing 7 days than those with the same resulting MELD score who did not spike, but they had no difference in posttransplant mortality. The spike-associated wait-list mortality increase was highest for registrants with medium MELD scores: specifically, 2.3-fold higher (spike versus no spike) for a MELD score of 10, 4.0-fold higher for a MELD score of 20, and 2.5-fold higher for a MELD score of 30. A model incorporating the MELD score and spikes predicted wait-list mortality risk much better than a model incorporating only the MELD score. Registrants with a sudden MELD increase have a higher risk of short-term wait-list mortality than is indicated by their current MELD score but have no increased risk of posttransplant mortality; allocation policy should be adjusted accordingly.

Muscle wasting: a nutritional criterion to prioritize patients for liver transplantation

PURPOSE OF REVIEW

Cirrhosis is the result of the progression of necroinflammatory liver diseases leading to fibrosis, portal hypertension, and a catabolic state, which might cause muscle wasting or sarcopenia. In this review, we analyze the methods for muscularity assessment, the incidence and clinical impact of muscle wasting, and potential novel therapeutic strategies in cirrhosis. Finally, we evaluate the value of muscle wasting inclusion to conventional systems for liver transplant prioritization.

RECENT FINDINGS

Muscle wasting is present in up to 45% of patients with cirrhosis and is associated with higher risk of sepsis-related death rather than liver failure mortality. Despite the fact that muscle wasting is not included in the scores for prognosis in cirrhotic patients, as in the case of Model for End-Stage Liver Disease (MELD) or Child-Pugh, its presence should alert clinicians to the same extent as other complications do, such as ascites, hepatic encephalopathy, or variceal bleeding. Two studies have shown increased mortality risk after liver transplantation in patients with muscle wasting, whereas one study did not. Modification of MELD to include muscle wasting is associated with a modest improvement in the prediction of mortality in patients with cirrhosis.

SUMMARY

Muscle wasting is a frequent complication in cirrhosis and contributes to increased risk of sepsis-related mortality. The impact on mortality of muscle wasting after liver transplantation is controversial and needs further study. The MELD-sarcopenia score is associated with improvement in mortality prediction; however, prior to the widespread use of this composite score, validation in larger cohorts of patients with cirrhosis is necessary.

Impact of different creatinine measurement methods on liver transplant allocation

Introduction

The model for end-stage liver disease (MELD) score is used in many countries to prioritize organ allocation for the majority of patients who require orthotopic liver transplantation. This score is calculated based on the following laboratory parameters: creatinine, bilirubin and the international normalized ratio (INR). Consequently, high measurement accuracy is essential for equitable and fair organ allocation. For serum creatinine measurements, the Jaffé method and enzymatic detection are well-established routine diagnostic tests.

Methods

A total of 1,013 samples from 445 patients on the waiting list or in evaluation for liver transplantation were measured using both creatinine methods from November 2012 to September 2013 at the university hospital Leipzig, Germany. The measurements were performed in parallel according to the manufacturer’s instructions after the samples arrived at the institute of laboratory medicine. Patients who had required renal replacement therapy twice in the previous week were excluded from analyses.

Results

Despite the good correlation between the results of both creatinine quantification methods, relevant differences were observed, which led to different MELD scores. The Jaffé measurement led to greater MELD score in 163/1,013 (16.1%) samples with differences of up to 4 points in one patient, whereas differences of up to 2 points were identified in 15/1,013 (1.5%) samples using the enzymatic assay. Overall, 50/152 (32.9%) patients with MELD scores >20 had higher scores when the Jaffé method was used.

Discussion

Using the Jaffé method to measure creatinine levels in samples from patients who require liver transplantation may lead to a systematic preference in organ allocation. In this study, the differences were particularly pronounced in samples with MELD scores >20, which has clinical relevance in the context of urgency of transplantation. These data suggest that official recommendations are needed to determine which laboratory diagnostic methods should be used when calculating MELD scores.

When to consider liver transplant during the management of chronic liver disease

The decision to perform liver transplantation for a particular patient is never the decision of one single individual, although a single individual could preclude transplant as an option if the opportunity for referral is missed. Every physician treating patients with cirrhosis, including primary care physicians and primary gastroenterologists, should watch for the essential turning points at which a patient may become eligible for a transplant referral. Timing of referral could be assessed according to either the type of liver disease or non–disease-specific measures of disease severity. Although the MELD score is an easily accessible and convenient tool it is not as well known as CTP classification, and many cirrhotic patients under long-term management may not be being allocated a MELD score regularly calculated by their primary physicians. Because a slow progression in MELD score may occur without a change in symptoms, reaching the MELD score acceptable for transplant referral may go unrecognized. As generalists face the rising prevalence of NAFLD and the rising prevalence of cirrhosis and HCC from HCV, there will be an increasing need for education in the management of liver disease. It will be necessary for specialists and health care systems to better inform primary care physicians about the recommendations on criteria for transplant referral and the critical windows of opportunity within which they can act. Although there is a recognized knowledge gap that needs to be addressed, once a patient is in medical care, inadequate physician knowledge should never be the cause for late timing or missing the opportunity for referral.

Addressing geographic disparities in liver transplantation through redistricting

Severe geographic disparities exist in liver transplantation; for patients with comparable disease severity, 90-day transplant rates range from 18% to 86% and death rates range from 14% to 82% across donation service areas (DSAs). Broader sharing has been proposed to resolve geographic inequity; however, we hypothesized that the efficacy of broader sharing depends on the geographic partitions used. To determine the potential impact of redistricting on geographic disparity in disease severity at transplantation, we combined existing DSAs into novel regions using mathematical redistricting optimization. Optimized maps and current maps were evaluated using the Liver Simulated Allocation Model. Primary analysis was based on 6700 deceased donors, 28 063 liver transplant candidates, and 242 727 Model of End-Stage Liver Disease (MELD) changes in 2010. Fully regional sharing within the current regional map would paradoxically worsen geographic disparity (variance in MELD at transplantation increases from 11.2 to 13.5, p = 0.021), although it would decrease waitlist deaths (from 1368 to 1329, p = 0.002). In contrast, regional sharing within an optimized map would significantly reduce geographic disparity (to 7.0, p = 0.002) while achieving a larger decrease in waitlist deaths (to 1307, p = 0.002). Redistricting optimization, but not broader sharing alone, would reduce geographic disparity in allocation of livers for transplant across the United States.

Predictive value of Refit Model for End-Stage Liver Disease, Refit Model for End-Stage Liver Disease-Na, and pre-existing scoring system for 3-month mortality in Korean patients with cirrhosis

BACKGROUND AND AIM

The Model for End-Stage Liver Disease (MELD) has been widely used for predicting short-term mortality in patients with cirrhosis in the U.S. A modification of the MELD score was published in 2011. This was validated for Korean patients with cirrhosis.

METHODS

The medical records of patients with cirrhosis who were admitted to Konkuk University Hospital from 2006 to 2010 were retrospectively reviewed. The predictive value for 3-month mortality was compared between the Refit MELD, Refit MELD-Na, MELD, MELD-Na, and Child-Pugh score. The comparison was performed by calculating the area under the receiver operating curve (AUROC).

RESULTS

A total of 882 patients were enrolled and 77 (8.7%) died within 3 months. The most common etiology was alcohol (45.4%) followed by hepatitis B (34.2%). The AUROCs of the Refit MELD, Refit MELD-Na, MELD, MELD-Na, and Child-Pugh score were 0.842, 0.817, 0.844, 0.848, and 0.831, respectively. The Refit MELD-Na showed a lower value than MELD-Na (P = 0.0005), MELD (P = 0.0190), and the Refit MELD (P = 0.0174). When the patients with hepatitis B, C, and alcoholic cirrhosis were analyzed, the AUROCs were 0.960, 0.920, 0.953, 0.951, 0.896, 0.959, 0.956, 0.947, 0.956, 0.943, and 0.746, 0.707, 0.752, 0.747, 0.755.

CONCLUSIONS

The improvement in predictive value for 3-month mortality was not definite. The Refit MELD-Na especially showed the lowest value. This result may have been due to differences in underlying etiology of cirrhosis between Korea and the U.S. Thus, a larger prospective study is warranted.

An acute change in lung allocation score and survival after lung transplantation: a cohort study

BACKGROUND

Lung transplantation is an effective treatment for patients with advanced lung disease. In the United States, lungs are allocated on the basis of the lung allocation score (LAS), a composite measure of transplantation urgency and utility. Clinical deteriorations result in increases to the LAS; however, whether the trajectory of the LAS has prognostic significance is uncertain.

OBJECTIVE

To determine whether an acute increase in the LAS before lung transplantation is associated with reduced posttransplant survival.

DESIGN

Retrospective cohort study of adult lung transplant recipients listed for at least 30 days between 4 May 2005 (LAS implementation) and 31 December 2010 in the United Network for Organ Sharing registry. An acute increase in the LAS was defined as an LAS change (LASΔ) greater than 5 units between the 30 days before and the time of transplantation. Multivariable Cox proportional hazard models were used to examine the relationship between an LASΔ >5 and posttransplant graft survival.

SETTING

All U.S. lung transplantation centers.

PATIENTS

5749 lung transplant recipients.

MEASUREMENTS

Survival time after lung transplantation.

RESULTS

702 (12.2%) patients experienced an LASΔ >5. These patients had significantly worse posttransplant survival (hazard ratio, 1.31 [95% CI, 1.11 to 1.54]; P = 0.001]) after adjustment for the LAS at transplantation (LAS-T) and other clinical covariates. The effect of an LASΔ >5 was independent of the LAS-T, underlying diagnosis, center volume, or donor characteristics.

LIMITATION

Analysis was based on center-reported data.

CONCLUSION

An acute increase in LAS before transplantation is associated with posttransplant survival after adjustment for LAS-T. Further emphasis on serial assessment of the LAS could improve the ability to offer accurate prediction of survival after transplantation.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Predicting early allograft failure and mortality after liver transplantation: the role of the postoperative model for end-stage liver disease score

Early allograft dysfunction (EAD) is a serious complication after liver transplantation (LT). There is no uniform definition of EAD, and most definitions are based on arbitrary laboratory values. The aim of this study was to devise a definition of EAD that maximizes the predictive power for early death and graft failure. In this single-center, retrospective study, the ability of the international normalized ratio (INR), total bilirubin, aspartate aminotransferase (AST), physiological Model for End-Stage Liver Disease (MELD) score, and serum albumin levels within 7 days after LT to predict 90-day mortality or graft loss was compared with 2 previously used definitions of EAD: (1) peak total bilirubin level >10 mg/dL on days 2 to 7 and (2) either a total bilirubin level >10 mg/dL or an INR >1.6 on day 7 or an AST or alanine aminotransferase level >2000 IU/L within the first 7 days. Of 572 enrolled LT patients 38 died or required retransplantation within 90 days. Peak INR, total bilirubin level, AST levels, and MELD scores were predictors of 90-day graft failure. MELD score on postoperative day 5 was the best predictor with an area under the curve of the receiver operating characteristic curve of 0.812 (95% CI: 0.739-0.886, P < 0.001). The best cutoff of MELD score on day 5 for predicting 90-day mortality or graft loss was 18.9. A MELD score >18.9 on postoperative day 5 was a better predictor than any other laboratory value or definition of EAD. This study has demonstrated that the MELD score can be a useful tool not only for pretransplant graft allocation but also for postoperative risk stratification.

Donor-recipient matching: myths and realities

Liver transplant outcomes keep improving, with refinements of surgical technique, immunosuppression and post-transplant care. However, these excellent results and the limited number of organs available have led to an increasing number of potential recipients with end-stage liver disease worldwide. Deaths on waiting lists have led liver transplant teams maximize every organ offered and used in terms of pre and post-transplant benefit. Donor-recipient (D-R) matching could be defined as the technique to check D-R pairs adequately associated by the presence of the constituents of some patterns from donor and patient variables. D-R matching has been strongly analysed and policies in donor allocation have tried to maximize organ utilization whilst still protecting individual interests. However, D-R matching has been written through trial and error and the development of each new score has been followed by strong discrepancies and controversies. Current allocation systems are based on isolated or combined donor or recipient characteristics. This review intends to analyze current knowledge about D-R matching methods, focusing on three main categories: patient-based policies, donor-based policies and combined donor-recipient systems. All of them lay on three mainstays that support three different concepts of D-R matching: prioritarianism (favouring the worst-off), utilitarianism (maximising total benefit) and social benefit (cost-effectiveness). All of them, with their pros and cons, offer an exciting controversial topic to be discussed. All of them together define D-R matching today, turning into myth what we considered a reality in the past.

Is liver transplantation using organs donated after cardiac death cost-effective or does it decrease waitlist death by increasing recipient death?

OBJECTIVES

The aim of this study was to evaluate the cost-effectiveness in liver transplantation (LT) of utilizing organs donated after cardiac death (DCD) compared with organs donated after brain death (DBD).

METHODS

A Markov-based decision analytic model was created to compare two LT waitlist strategies distinguished by organ type: (i) DBD organs only, and (ii) DBD and DCD organs. The model simulated outcomes for patients over 10 years with annual cycles through one of four health states: survival; ischaemic cholangiopathy; retransplantation, and death. Baseline values and ranges were determined from an extensive literature review. Sensitivity analyses tested model strength and parameter variability.

RESULTS

Overall survival is decreased, and biliary complications and retransplantation are increased in recipients of DCD livers. Recipients of DBD livers gained 5.6 quality-adjusted life years (QALYs) at a cost of US$69 000/QALY, whereas recipients on the DBD + DCD LT waitlist gained 6.0 QALYs at a cost of US$61 000/QALY. The DBD + DCD organ strategy was superior to the DBD organ-only strategy.

CONCLUSIONS

The extension of life and quality of life provided by DCD LT to patients on the waiting list who might otherwise not receive a liver transplant makes the continued use of DCD livers cost-effective.

Model for End-stage Liver Disease

Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15-20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score.

Hepatic disease biomarkers and liver transplantation: what is the potential utility of microRNAs?

Liver transplantation represents the treatment of choice for acute hepatic failure or chronically induced end stage of liver disease. Molecular characterization of hepatic injury and recovery processes encloses the key for biomarker discovery in the liver transplantation field. Several pathological hepatic processes were demonstrated to be associated with deregulated miRNA profiles. Moreover, abnormal concentration levels of circulating cell-free miRNAs correlate with specific hepatic injury. The high molecular stability and emerging rapid assessment techniques invite further consideration of miRNAs as feasible monitoring and outcome predictive biomarkers for liver disease and liver transplantation. The present review aims to provide an overview of recent achievements in research on the potential applicability of miRNAs as biomarkers in liver disease and liver transplantation.