Overview of the MELD score and the UNOS adult liver allocation system. Transplant Proc. 2007;39:3169-3174. [PMID: 18089345 DOI: 10.1016/j.transproceed.2007.04.025]

Development and Validation of a Novel Tool to Predict Model for End-Stage Liver Disease (MELD) Scores in Cirrhosis, Using Administrative Datasets

Background

The Model for End-Stage Liver Disease (MELD) score predicts disease severity and mortality in cirrhosis. To improve cirrhosis phenotyping in administrative databases lacking laboratory data, we aimed to develop and externally validate claims-based MELD prediction models, using claims data linked to electronic health records (EHR).

Methods

We included adults with established cirrhosis in two Medicare-linked EHR networks (training and internal validation; 2007-2017), and a Medicaid-linked EHR network (external validation; 2000-2014). Using least absolute shrinkage and selection operator (LASSO) with 5-fold cross-validation, we selected among 146 investigator-specified variables to develop models for predicting continuous MELD and relevant MELD categories (MELD<10, MELD≥15 and MELD≥20), with observed MELD calculated from laboratory data. Regression coefficients for each model were applied to the validation sets to predict patient-level MELD and assess model performance.

Results

We identified 4501 patients in the Medicare training set (mean age 75.1 years, 18.5% female, mean MELD=13.0), and 2435 patients in the Medicare validation set (mean age: 74.3 years, 31.7% female, mean MELD=12.3). Our final model for predicting continuous MELD included 112 variables, explaining 58% of observed MELD variability; in the Medicare validation set, the area-under-the-receiver operating characteristic curves (AUC) for MELD<10 and MELD≥15 were 0.84 and 0.90, respectively; the AUC for the model predicting MELD≥20 (using 27 variables) was 0.93. Overall, these models correctly classified 77% of patients with MELD<10 (95% CI=0.75-0.78), 85% of patients with MELD≥15 (95% CI=0.84-0.87), and 87% of patients with MELD≥20 (95% CI=0.86-0.88). Results were consistent in the external validation set (n=2240).

Conclusion

Our MELD prediction tools can be used to improve cirrhosis phenotyping in administrative datasets lacking laboratory data.

Expert Insights on Current Treatments for Hepatocellular Carcinoma: Clinical and Molecular Approaches and Bottlenecks to Progress

Hepatocellular carcinoma (HCC) is a primary liver tumor that typically occurs in the setting of chronic liver disease/cirrhosis. Treatment modalities for HCC have evolved and given the variety of treatment options, a multi-disciplinary approach requiring input from surgical, medical, and radiation oncology, hepatology, and interventional radiology is necessary. Multiple advances have been made over the last decade regarding treatment of HCC, especially advanced disease. Resection and transplantation remain as cornerstone curative-intent treatment options. For patients who are not candidates for curative-intent therapy, exciting progress has been made in molecular and cellular approaches to systemic therapy for HCC including immunotherapies and tyrosine kinase inhibitors. Although the prognosis for advanced HCC remains poor, the armamentarium of therapies has increased, and valuable years of life can be gained with these therapies. While the main therapeutic modality for early-stage disease remains resection, multimodal immunotherapy has emerged as first-line treatment for advanced disease. We herein review different clinical and molecular treatment modalities related to the treatment of HCC, as well as provide insights into future directions for HCC treatment. We highlight how research and progress are needed to move into a new era of molecular and cellular treatments.

Predictive potential of the MELD and Child-Turcotte-Pugh II scores for SBP in patients with cirrhosis and ascites

It is very important for patients with spontaneous bacterial peritonitis (SBP) to assess the length of survival and the risk of death, primarily because of the wide range of potential complications that can lead to multisystem organ failure and fatal outcome. The aim of this study was to determine the predictive potential of MELD and Child-Turcotte-Pugh II score for SBP in patients with cirrhosis and ascites. Material and methods: The study was designed as a prospective-analytical-observational and was conducted at the University Clinic for Gastroenterohepatology in Skopje for a period of one year. The study population included 70 hospitalized patients with established liver cirrhosis, regardless of etiology, divided into two groups, 35 patients with SBP and 35 non-SBP. Prognostic scores in patients with liver cirrhosis and ascites: MELD score, according to the formula: MELD = [(0.957 x Ln Creatinin) + (0.378 x Ln Bilirubin) + (1.12 x Ln INR) + (0.643) x 10]. The Child-Turcotte-Pugh II score includes 6 parameters: serum albumin and bilirubin, amount of ascites, degree of encephalopathy ( HE), prothrombin time (PT) and serum creatinine, and assessment of the degree of hepatic encephalopathy according to the West Haven criteria. Results: The average value of the MELD score in patients with SBP was 22.6 ± 8.27 and in non-SBP the average value was lower - 17.83±5.87. According to the Mann-Whitney U test, the difference between the mean values ​​was statistically significant for p <0.05 (z = 2.41; p = 0.015). A score of 30 to 39 was registered in 25.7% of patients with SBP, and only in 2.9% in non-SBP; the percentage difference was statistically significant for p <0.05 (Difference test, p = 0.0064 ). Patients with SBP had an average Child-Pugh score of 13.09 ± 2.48 or 100.0% C-class points. In patients with non-SBP, an average child-Pugh score of 9.63 ± 1.62 was recorded, or class B in 65.7% and class C in 34.3%. The percentage difference was statistically significant for p <0.05 (Difference test, p = 0.000000). According to the Mann-Whitney U test, the difference between the mean values ​​was statistically significant for p <0.05 (z = -5.44; p = 0.00001). ROC analysis indicated that the Child-Turcotte-Pugh II score contributed to the diagnosis of SBP - 90.7% (p = 0.000) (excellent predictor), closer to the ideal value of 1.0 and above the worst value of 0.5. ROC analysis indicated that the MELD score did not contribute to the diagnosis of SBP - 66.7% (p = 0.017) (weak predictor), closer to the worst value of 0.5. Conclusion:Our research confirmed that SBP occurs in patients with severe hepatic dysfunction calculated according to the CTP II score and MELD score. Mean value of the MELD score in patients with SBP was higher then in patients with non-SBP. On the other hand all patients with SBP had an average CTP II score, C-class points,  while the largest percentage of patients with non-SBP were class B-class points. MELD score is a weak predictor of SBP.  The best predictor for predicting SBP is the CTP II score (rank C).

Systemic Immune-Inflammatory Marker of High Meld Patients Is Associated With Early Mortality After Liver Transplantation

The scarcity of deceased donor livers has led to allocation of grafts to only the most seriously ill patients with a high Model for End-Stage Liver Disease (MELD) score, which has resulted in a high mortality rate after deceased donor liver transplantation (DDLT). The aim of this study is to identify risk factors for posttransplant mortality and thereby reduce futile outcomes in DDLT. Between 2013 and 2019, 57 recipients with MELD scores ≥30 underwent DDLT in our center. We retrieved data and identified the risk factors for 90-day posttransplant mortality. The perioperative clinical and laboratory parameters of patients who did or did not survive for 90 days were subjected to logistic regression analysis. Twelve patients died within 90 days. Results of univariate analysis indicated that the differences in patient survival were determined by the amount of intraoperative platelets transfused, the presence of posttransplant septicemia, and systemic immune-inflammation index (SII) at the time of listing with MELD scores ≥30. Multivariate analysis revealed that an SII ≥870 (× 10⁹/L) and posttransplant septicemia were independent risk factors for 90-day mortality. Twenty-two patients had SIIs ≥870, and 13 of these patients had posttransplant septicemia. Of the 13 patients, 90-day mortality occurred in 10 cases. However, in 35 patients with SIIs <870, 90-day mortality due to posttransplant septicemia was recorded only in 1 patient. In conclusion, a preoperative SII ≥870 in a patient with a high MELD score may be a significant risk factor for early posttransplant mortality. Because posttransplant septicemia in patients with high SIIs can lead to fatality, a more intensive effort to prevent infection is needed for patients undergoing DDLT carrying such risk factors to avoid futile liver transplantation.

TRI-SCORE: a new risk score for in-hospital mortality prediction after isolated tricuspid valve surgery

Aims 

Isolated tricuspid valve surgery (ITVS) is considered to be a high-risk procedure, but in-hospital mortality is markedly variable. This study sought to develop a dedicated risk score model to predict the outcome of patients after ITVS for severe tricuspid regurgitation (TR).

Methods and results 

All consecutive adult patients who underwent ITVS for severe non-congenital TR at 12 French centres between 2007 and 2017 were included. We identified 466 patients (60 ± 16 years, 49% female, functional TR in 49%). In-hospital mortality rate was 10%. We derived and internally validated a scoring system to predict in-hospital mortality using multivariable logistic regression and bootstrapping with 1000 re-samples. The final risk score ranged from 0 to 12 points and included eight parameters: age ≥70 years, New York Heart Association Class III–IV, right-sided heart failure signs, daily dose of furosemide ≥125 mg, glomerular filtration rate <30 mL/min, elevated bilirubin, left ventricular ejection fraction <60%, and moderate/severe right ventricular dysfunction. Tricuspid regurgitation mechanism was not an independent predictor of outcome. Observed and predicted in-hospital mortality rates increased from 0% to 60% and from 1% to 65%, respectively, as the score increased from 0 up to ≥9 points. Apparent and bias-corrected areas under the receiver operating characteristic curves were 0.81 and 0.75, respectively, much higher than the logistic EuroSCORE (0.67) or EuroSCORE II (0.63).

Conclusion 

We propose TRI-SCORE as a dedicated risk score model based on eight easy to ascertain parameters to inform patients and physicians regarding the risk of ITVS and guide the clinical decision-making process of patients with severe TR, especially as transcatheter therapies are emerging (www.tri-score.com).

Hepatobiliary Cancers, Version 2.2021, NCCN Clinical Practice Guidelines in Oncology

The NCCN Guidelines for Hepatobiliary Cancers focus on the screening, diagnosis, staging, treatment, and management of hepatocellular carcinoma (HCC), gallbladder cancer, and cancer of the bile ducts (intrahepatic and extrahepatic cholangiocarcinoma). Due to the multiple modalities that can be used to treat the disease and the complications that can arise from comorbid liver dysfunction, a multidisciplinary evaluation is essential for determining an optimal treatment strategy. A multidisciplinary team should include hepatologists, diagnostic radiologists, interventional radiologists, surgeons, medical oncologists, and pathologists with hepatobiliary cancer expertise. In addition to surgery, transplant, and intra-arterial therapies, there have been great advances in the systemic treatment of HCC. Until recently, sorafenib was the only systemic therapy option for patients with advanced HCC. In 2020, the combination of atezolizumab and bevacizumab became the first regimen to show superior survival to sorafenib, gaining it FDA approval as a new frontline standard regimen for unresectable or metastatic HCC. This article discusses the NCCN Guidelines recommendations for HCC.

MELD and MELD XI Scores as Predictors of Mortality After Pericardiectomy for Constrictive Pericarditis

OBJECTIVE

To assess the association between the preoperative model for end-stage liver disease (MELD) and MELD-XI (exclude international normalized ratio) score and outcomes in patients undergoing pericardiectomy for constrictive pericarditis.

PATIENTS AND METHODS

Patients >18 years of age undergoing pericardiectomy for constrictive pericarditis between January 1, 2007, and October 12, 2017, were analyzed with data for MELD and MELD-XI score calculation within 30 days preoperatively. The association between the MELD and MELD-XI scoring systems and risk of postoperative outcomes was assessed in regression models adjusting for relevant covariates. The primary outcome was operative mortality (death within 90 days or in hospital). Secondary outcomes included various measures of postoperative morbidity.

RESULTS

A total of 175 and 226 patients had data for MELD/MELD-XI, respectively. Ninety-day mortality was 8.7%. When stratified into tertiles of MELD-XI, the unadjusted risk of 90-day mortality was 2.7%, 8.2%, and 16.0%, respectively. In Cox regression models fitted for MELD-XI and MELD, higher scores associated with increased risk of mortality (P<.001 for both). In secondary multivariable analyses, both MELD-XI and MELD were associated with increased incidence of renal failure and greater levels of chest-tube output and transfusion, whereas MELD-XI was additionally associated with prolonged intubation and extended intensive care unit and hospital stays.

CONCLUSION

Among patients undergoing pericardiectomy for constrictive pericarditis, MELD-XI and MELD were associated with increased postoperative morbidity and mortality. Although the simpler MELD-XI score generally performed as well or better than MELD as a correlate of various outcomes, both scores can serve as a simple yet robust risk stratification tool for patients undergoing pericardiectomy for constrictive pericarditis.

Systemic therapy of liver cancer

Hepatocellular carcinoma (HCC) is a lethal malignancy with poor prognosis. More than 80% of patients are diagnosed at an advanced stage, and most patients with HCC also have liver cirrhosis that complicates cancer management. No targeted treatment options currently exist outside genomics-based clinical trials. Multiple tyrosine kinase inhibitors (mTKIs) such as sorafenib, lenvatinib, cabozantinib, and regorafenib have been used to treat advanced hepatocellular carcinoma (aHCC). Immune checkpoint inhibitors including nivolumab and pembrolizumab have shown survival benefit. More recently, atezolizumab in combination with bevacizumab resulted in improved overall survival and progression-free survival, compared with sorafenib in patients with aHCC in the first-line setting. The combination of nivolumab with ipilimumab as an alternative in the treatment of patients treated with sorafenib has inspired various combination studies of immune checkpoint inhibitors. Currently, ongoing studies of systemic therapy consist of various immune-based combination therapies. Finally, there is no established adjuvant and neoadjuvant therapy although a few early phase studies show promising results. In this chapter, we summarize current approaches of systemic treatment in patients with liver cancer.

[Current Status of Deceased Donor Liver Transplantation for Alcoholic Liver Disease in Korea in MELD Era]

The organ allocation system should be fair and efficient to predict the prognosis of patients with end-stage organ failure. The liver allocation system in Korea was changed to the model for end-stage liver disease (MELD) score system from Child-Turcotte-Pugh score-based status system in 2016. Since then, there have been some changes in matching liver graft to recipients in deceased liver transplantation. The severity of sickness of the end-stage liver failure patients has been increased in the MELD era than before. Since 2013, liver transplantation for alcoholic liver disease has been gradually increasing in Korea. We should take proper evaluation into consideration when we decide early liver transplantation particularly for patients with severe alcoholic hepatitis, who have a high MELD score. Above all, overcoming organ shortage, it is necessary for us to try to increase the number of deceased donors to meet the need for liver transplantation for end-stage liver disease patients.

Validation of a new prognostic model to predict short and medium-term survival in patients with liver cirrhosis

Background

MELD score and MELD score derivates are used to objectify and grade the risk of liver-related death in patients with liver cirrhosis. We recently proposed a new predictive model that combines serum creatinine levels and maximum liver function capacity (LiMAx®), namely the CreLiMAx risk score. In this validation study we have aimed to reproduce its diagnostic accuracy in patients with end-stage liver disease.

Methods

Liver function of 113 patients with liver cirrhosis was prospectively investigated. Primary end-point of the study was liver-related death within 12 months of follow-up.

Results

Alcoholic liver disease was the main cause of liver disease (n = 51; 45%). Within 12 months of follow-up 11 patients (9.7%) underwent liver transplantation and 17 (15.1%) died (13 deaths were related to liver disease, two not). Measures of diagnostic accuracy were comparable for MELD, MELD-Na and the CreLiMAx risk score as to power in predicting short and medium-term mortality risk in the overall cohort: AUROCS for liver related risk of death were for MELD [6 months 0.89 (95% CI 0.80–0.98) p < 0.001; 12 months 0.89 (95% CI 0.81–0.96) p < 0.001]; MELD-Na [6 months 0.93 (95% CI 0.85–1.00) p < 0.001 and 12 months 0.89 (95% CI 0.80–0.98) p < 0.001]; CPS 6 months 0.91 (95% CI 0.85–0.97) p < 0.01 and 12 months 0.88 (95% CI 0.80–0.96) p < 0.001] and CreLiMAx score [6 months 0.80 (95% CI 0.67–0.96) p < 0.01 and 12 months 0.79 (95% CI 0.64–0.94) p = 0.001]. In a subgroup analysis of patients with Child-Pugh Class B cirrhosis, the CreLiMAx risk score remained the only parameter significantly differing in non-survivors and survivors. Furthermore, in these patients the proposed score had a good predictive performance.

Conclusion

The CreLiMAx risk score appears to be a competitive and valid tool for estimating not only short- but also medium-term survival of patients with end-stage liver disease. Particularly in patients with Child-Pugh Class B cirrhosis the new score showed a good ability to identify patients not at risk of death.

Outcomes after multiple courses of granulocyte colony-stimulating factor and growth hormone in decompensated cirrhosis: A randomized trial

Decompensated cirrhosis (DC) carries a high mortality. Liver transplantation (LT) is the treatment of choice; however, the limited availability of donor organs has resulted in high waitlist mortality. The present study investigated the impact of multiple courses of granulocyte-colony stimulating factor (G-CSF) with or without growth hormone (GH) in these patients. Sixty-five patients with DC were randomized to standard medical therapy (SMT) plus G-CSF 3 monthly plus GH daily (group A; n = 23) or SMT plus G-CSF (group B; n = 21) or SMT alone (group C; n = 21). The primary outcome was transplant-free survival (TFS) at 12 months. Secondary outcomes were mobilization of CD34⁺ cells at day 6 and improvement in clinical scores, liver stiffness, nutrition, episodes of infection, and quality of life (QOL) at 12 months. There was significantly better 12-month TFS in groups A and B than in group C (P = 0.001). At day 6 of therapy, CD34⁺ cells increased in groups A and B compared to baseline (P < 0.001). There was a significant decrease in clinical scores, improvement in nutrition, better control of ascites, reduction in liver stiffness, lesser infection episodes, and improvement in QOL scores in groups A and B at 12 months as compared to baseline (P < 0.05). The therapies were well tolerated.

CONCLUSION

Multiple courses of G-CSF improved 12-month TFS, mobilized hematopoietic stem cells, improved disease severity scores, nutrition, fibrosis, QOL scores, ascites control, reduced infections, and the need for LT in patients with DC. However, the use of GH was not found to have any additional benefit. (Hepatology 2017).

Risk factors of acute kidney injury after orthotopic liver transplantation in China

In this study, we determined the risk factors for acute kidney injury (AKI) following orthotopic liver transplantation (OLT) in China. We collected 5074 donation after cardiac death (DCD) OLT recipients who underwent surgery between January 1, 2010, and December 31, 2015, in 86 academic hospitals or transplant centers in China. Univariate and multivariate analyses were used to investigate the criticality of donor, graft, or recipient variables in the development of post-OLT AKI. In all, 4482 patients were included (median age, 49.31 years). Post-OLT AKI occurred in 3.97% patients, and 73.6% of all OLT patients were male. The 1- and 5-year cumulative survival rates (CSRs) of the AKI group were 33.95% and 25.24%, respectively, compared with 86.34% and 70.05%, respectively, of the non-AKI group (P < 0.001). The independent risk factors for post-OLT AKI were blood loss, cold ischemia time, warm ischemia time, preoperative serum creatinine, the treatment period with dopamine, overexposure to calcineurin inhibitor, and combined mycophenolate mofetil use (P < 0.05). These had a high prediction accuracy for post-OLT AKI (area under the curve [AUC] = 0.740).

D-MELD, the Product of Donor Age and Preoperative MELD, Predicts Surgical Outcomes After Living Donor Liver Transplantation, Especially in the Recipients With HCV-positive and Smaller Grafts

BACKGROUND

Appropriate donor-recipient match has not been explored well in living-donor liver transplantation (LDLT) unlike deceased-donor liver transplantation. In this study, we evaluate the donor-recipient match using D-MELD (donor age × recipient Modified for End-stage Liver Disease [MELD] score) as a predictor of surgical outcomes in LDLT, paying attention to graft size and hepatitis C virus (HCV) status.

PATIENT AND METHODS

The 120 consecutive recipients who received adult-to-adult LDLT from March 2002 to December 2014 were divided into the two groups according to D-MELD score: D-MELD <1000 (low-D-MELD: n = 101) and D-MELD ≥1000 (high-D-MELD: n = 19).

RESULTS

The 90-day mortality rate was significantly higher in the high-DM group than in low-DM group: 36.8% versus 14.9% (P = .046). In the HCV-positive recipients, the 90-day mortality rate was significantly higher in high-DM group (n = 6) than in low-DM group (n = 37): 66.7% versus 13.5% (P = .012), and the 3-year survival rate was significantly lower in high-DM group than in the low-DM group: 33.3% versus 56.8% (P = .01). In the recipients with left graft, the 90-day mortality rate was significantly higher in the high-DM group (n = 8) than in the low-DM group (n = 41): 50% versus 14.6% (P = .044), and total bilirubin level on postoperative day 14 was significantly higher in the high-DM group than in the low-DM group: 17.4 mg/dL versus 9.2 mg/dL (P = .018).

CONCLUSIONS

It was clarified that D-MELD could predict early and long-term surgical outcomes in the recipients who were HCV-positive and who had smaller grafts.

Living donor liver transplantation for high model for end-stage liver disease score: What have we learned?

AIM: To assess the impact of model for end-stage liver disease (MELD) score on patient survival and morbidity post living donor liver transplantation (LDLT).

METHODS: A retrospective study was performed on 80 adult patients who had LDLT from 2011-2013. Nine patients were excluded and 71 patients were divided into two groups; Group 1 included 38 patients with a MELD score < 20, and Group 2 included 33 patients with a MELD score > 20. Comparison between both groups was done regarding operative time, intra-operative blood requirement, intensive care unit (ICU) and hospital stay, infection, and patient survival.

RESULTS: Eleven patients died (15.5%); 3/38 (7.9%) patients in Group 1 and 8/33 (24.2%) in Group 2 with significant difference (P = 0.02). Mean operative time, duration of hospital stay, and ICU stay were similar in both groups. Mean volume of blood transfusion and cell saver re-transfusion were 8 ± 4 units and 1668 ± 202 mL, respectively, in Group 1 in comparison to 10 ± 6 units and 1910 ± 679 mL, respectively, in Group 2 with no significant difference (P = 0.09 and 0.167, respectively). The rates of infection and systemic complications (renal, respiratory, cardiovascular and neurological complications) were similar in both groups.

CONCLUSION: A MELD score > 20 may predict mortality after LDLT.

WITHDRAWN: Risk factors of acute kidney injury after orthotopic liver transplantation in China

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Early warning and clinical outcome prediction of acute-on-chronic hepatitis B liver failure

Hepatitis B virus (HBV) associated acute-on-chronic liver failure (ACLF) is an increasingly recognized fatal liver disease encompassing a severe acute exacerbation of liver function in patients with chronic hepatitis B (CHB). Despite the introduction of an artificial liver support system and antiviral therapy, the short-term prognosis of HBV-ACLF is still extremely poor unless emergency liver transplantation is performed. In such a situation, stopping or slowing the progression of CHB to ACLF at an early stage is the most effective way of reducing the morbidity and mortality of HBV-ACLF. It is well-known that the occurrence and progression of HBV-ACLF is associated with many factors, and the outcomes of HBV-ACLF patients can be significantly improved if timely and appropriate interventions are provided. In this review, we highlight recent developments in early warning and clinical outcome prediction in patients with HBV-ACLF and provide an outlook for future research in this field.

Model for End-Stage Liver Disease (MELD) score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical entity and liver transplantation is the only definitive therapy to salvage these patients. However, the timing of liver transplant for these patients remains unclear.

METHODS

Seventy-eight patients undergoing liver transplantation because of hepatitis B ACLF were retrospectively analyzed from June 2004 to December 2010. The areas under the receiver operating characteristic curve (AUC) of Model for End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) score for the post-transplantation outcomes were calculated.

RESULTS

The median age was 44 years (range, 25-64 years), serum bilirubin 418.53 μmol/L (range, 112.90-971.40 μmol/L), INR 3.177 (range, 1.470-9.850), and creatinine 70.84 μmol/L (range, 12.39-844.1 μmol/L); the median MELD score was 32 (range, 21-53) and CTP score 12 (8-15). The AUCs of MELD and CTP scores for 3-month mortality were 0.581 (95% confidence interval [CI], 0.421-0.742; sensitivity, 87.5%; specificity, 32.8%) and 0.547 (95% CI, 0.401-0.693; sensitivity, 75%; specificity, 41%), respectively. Meanwhile, there were no significant differences in hospital mortality (P = .252) or morbidity (P = .338) between the patients with MELD score ≥30 and those <30.

CONCLUSIONS

MELD score had no predictive ability for the outcomes of patients with hepatitis B ACLF after orthotopic liver transplantation.

Retrospective evaluation of discrepancies between radiological and pathological size of hepatocellular carcinoma masses

BACKGROUND

The size of a hepatic neoplasm is critical for staging, prognosis and selection of appropriate treatment. Our study aimed to compare the radiological size of solid hepatocellular carcinoma (HCC) masses on magnetic resonance imaging (MRI) with the pathological size in a Chinese population, and to elucidate discrepancies.

MATERIALS AND METHODS

A total of 178 consecutive patients diagnosed with HCC who underwent curative hepatic resection after enhanced MRI between July 2010 and October 2013 were retrospectively identified and analyzed. Pathological data of the whole removed tumors were assessed and differences between radiological and pathological tumor size were identified. All patients were restaged using a modified Tumor-Node-Metastasis (TNM) staging system postoperatively according to the maximum diameter alteration. The lesions were classified as hypo-staged, iso-staged or hyper-staged for qualitative assessment. In the quantitative analysis, the relative pre and postoperative tumor size contrast ratio (%Δsize) was also computed according to size intervals. In addition, the relationship between radiological and pathological tumor diameter variation and histologic grade was analyzed.

RESULTS

Pathological examination showed 85 (47.8%) patients were overestimated, 82 (46.1%) patients underestimated, while accurate measurement by MRI was found in 11 (6.2%) patients. Among the total subjects, 14 (7.9%) patients were hypo-staged and 15 (8.4%) were hyper-staged post-operatively. Accuracy of MRI for calculation and characterized staging was related to the lesion size, ranging from 83.1% to 87.4% (<2cm to ≥5cm, p=0.328) and from 62.5% to 89.1% (cT1 to cT4, p=0.006), respectively. Overall, MRI misjudged pathological size by 6.0 mm (p=0.588 ), and the greatest difference was observed in tumors <2cm (3.6 mm, %Δsize=16.9%, p=0.028). No statistically significant difference was observed for moderately differentiated HCC (5.5mm, p=0.781). However, for well differentiated and poorly differentiated cases, radiographic tumor maximum diameter was significantly larger than the pathological maximum diameter by 3.15 mm and underestimated by 4.51 mm, respectively (p=0.034 and 0.020).

CONCLUSIONS

A preoperative HCC tumor size measurement using MRI can provide relatively acceptable accuracy but may give rise to discrepancy in tumors in a certain size range or histologic grade. In pathological well differentiated subjects, the pathological tumor size was significantly overestimated, but underestimated in poorly differentiated HCC. The difference between radiological and pathological tumor size was greatest for tumors <2 cm. For some HCC patients, the size difference may have implications for the decision of resection, transplantation, ablation, or arterially directed therapy, and should be considered in staging or selecting the appropriate treatment tactics.

Liver transplantation in the Nordic countries - An intention to treat and post-transplant analysis from The Nordic Liver Transplant Registry 1982-2013

AIM AND BACKGROUND

The Nordic Liver Transplant Registry (NLTR) accounts for all liver transplants performed in the Nordic countries since the start of the transplant program in 1982. Due to short waiting times, donor liver allocation has been made without considerations of the model of end-stage liver disease (MELD) score. We aimed to summarize key outcome measures and developments for the activity up to December 2013.

MATERIALS AND METHODS

The registry is integrated with the operational waiting-list and liver allocation system of Scandiatransplant (www.scandiatransplant.org) and accounted at the end of 2013 for 6019 patients out of whom 5198 were transplanted. Data for recipient and donor characteristics and relevant end-points retransplantation and death are manually curated on an annual basis to allow for statistical analysis and the annual report.

RESULTS

Primary sclerosing cholangitis, acute hepatic failure, alcoholic liver disease, primary biliary cirrhosis and hepatocellular carcinoma are the five most frequent diagnoses (accounting for 15.3%, 10.8%, 10.6%, 9.3% and 9.0% of all transplants, respectively). Median waiting time for non-urgent liver transplantation during the last 10-year period was 39 days. Outcome has improved over time, and for patients transplanted during 2004-2013, overall one-, five- and 10-year survival rates were 91%, 80% and 71%, respectively. In an intention-to-treat analysis, corresponding numbers during the same time period were 87%, 75% and 66%, respectively.

CONCLUSION

The liver transplant program in the Nordic countries provides comparable outcomes to programs with a MELD-based donor liver allocation system. Unique features comprise the diagnostic spectrum, waiting times and the availability of an integrated waiting list and transplant registry (NLTR).

Phase I trial of active specific immunotherapy with autologous dendritic cells pulsed with autologous irradiated tumor stem cells in hepatitis B-positive patients with hepatocellular carcinoma

Background and Objectives

Hepatocellular carcinoma (HCC) is often associated with chronic hepatitis due to hepatitis‐B or ‐C viruses. Active specific immunotherapy (ASI) with autologous dendritic cells (DC) presenting antigens from autologous tumor stem cell (TC) lines is associated with promising long‐term survival in metastatic cancer, but hepatitis patients were excluded. ASI might benefit high‐risk primary HCC patients following surgical resection, but first it is important to show that ASI does not exacerbate hepatitis.

Methods

Previously untreated HCC patients with a solitary lesion > 5 cm, or three lesions with at least one > 3 cm, or more than three lesions, underwent surgical resection from which autologous TC lines were established. Irradiated TC were incubated with autologous DC to create DC‐TC. After one course of trans‐arterial chemoembolization therapy (TACE), three weekly subcutaneous injections of DC‐TC suspended in granulocyte‐macrophage colony stimulating factor were administered. Patients were monitored for eight weeks.

Results

HCC cell lines were established within five weeks for 15/15 patients. Eight patients, all with chronic hepatitis B, were treated. There was no increase in hepatic transaminases, hepatitis B antigens, or viral DNA.

Conclusion

Autologous DC‐TC did not exacerbate HBV in these HCC patients. A phase II efficacy trial is being planned. J. Surg. Oncol. 2015 111:862–867. © 2014 Wiley Periodicals, Inc.

Current management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and leading cause of death among patients with cirrhosis. Treatment guidelines are based according to the Barcelona Clinic Liver Cancer staging system. The choice among therapeutic options that include liver resection, liver transplantation, locoregional, and systemic treatments must be individualized for each patient. The aim of this paper is to review the outcomes that can be achieved in the treatment of HCC with the heterogeneous therapeutic options currently available in clinical practice.

Hangzhou criteria for liver transplantation in hepatocellular carcinoma: a single-center experience

BACKGROUND AND AIM

The inclusion criteria for liver transplantation (LT) in hepatocellular carcinoma (HCC) are being expanded, and the Hangzhou criteria are the most accepted criteria in China. The aim of our study was to evaluate the Hangzhou criteria for LT in HCC with respect to the Milan criteria.

METHODS

We retrospectively collected data of 298 cases of LT in HCC in our center from August 2000 to December 2010, and then divided these patients into three groups according to the tumor characteristics: the Milan criteria group (n=97), the Hangzhou criteria group (n=172), and the out of Hangzhou criteria group (n=126). We compared the baseline characteristics and outcome of these three groups of patients.

RESULTS

Baseline patient characteristics showed no significant difference among the three groups, except for younger age in the out of Hangzhou group (P<0.05). Overall the 1-, 3-, and 5-year survival rates were 91.8, 88.7, and 86.6%, respectively, for the Milan criteria group; 86.6, 76.7, and 73.8% for the Hangzhou criteria group; and 76.2, 57.1, and 56.3% for the out of Hangzhou criteria group (P<0.05). The 1-, 3-, and 5-year tumor-free survival rates were 88.7, 86.6, and 86.6%, respectively, for the Milan criteria group; 83.7, 73.8, and 73.3% for the Hangzhou criteria group (P=0.014); and 63.5, 48.4, and 48.4% for the out of Hangzhou group, which was significantly lower than the rates in the other two groups (P=0.000).

CONCLUSION

Although the Hangzhou criteria lead to lower overall survival and tumor-free survival rates compared with the Milan criteria, the Hangzhou criteria indicate more HCC patients for LT and are associated with a considerable long-term outcome. The Hangzhou criteria should be accepted as the inclusion criteria for LT in HCC.

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.

Non-adherence and graft failure in adult liver transplant recipients

BACKGROUND

Non-adherence to medical therapy after liver transplantation is confounded by different methods of measurement.

AIMS

(1) To compare the performance of three different methods of measuring non-adherence: (a) biochemical (standard deviation [SD] tacrolimus levels), (b) clinician report, (c) self-report. (2) To identify pre-transplant predictors of post-transplant non-adherence. (3) To evaluate whether SD tacrolimus is an accurate predictor of graft outcomes.

METHODS

In this retrospective cohort study, charts of adult recipients of a liver transplant 2003-2009 (sample A, n = 444) were reviewed to determine pre-transplant predictors of non-adherence and clinician report of non-adherence. SD tacrolimus levels were measured between 6 and 18 months post-transplant. A subset of sample A (n = 122) completed a survey on non-adherence. The three methods were compared using linear and logistic regression. Multivariable analysis was used to investigate pre-transplant predictors of non-adherence. In sample B (transplant recipients 1995-2003, n = 544) Cox regression was used to determine the relationship between SD immunosuppressant level and graft failure.

RESULTS

Non-adherence was found in 22-62 % of subjects, with the highest rates indicated by self-report. Clinician report of non-adherence was associated with both self-report and SD tacrolimus. On multivariable analysis, unemployment at time of listing and chart evidence of pre-transplant non-adherence were significant predictors of higher SD of tacrolimus. History of substance abuse and pre-transplant chart evidence of non-adherence were also significant independent predictors of post-transplant chart evidence of non-adherence. Drug variability in the immediate post-transplant setting was independently associated with graft failure over time (hazard ratio 1.005 per unit increase in standard deviation, p = 0.04).

CONCLUSIONS

Non-adherence among liver transplant recipients is a common problem associated with increased risk of graft failure. SD tacrolimus can be used to measure non-adherent behavior and perhaps target patients for behavioral interventions.

The relationship between preoperative creatinine clearance and outcomes for patients undergoing liver transplantation: a retrospective observational study

Background

Renal failure with following continuous renal replacement therapy is a major clinical problem in liver transplant recipients, with reported incidences of 3% to 20%. Little is known about the significance of postoperative acute renal failure or acute-on-chronic renal failure to postoperative outcome in liver transplant recipients.

Methods

In this post hoc analysis we compared the mortality rates of 135 consecutive liver transplant recipients over 6 years in our center subject to their renal baseline conditions and postoperative RRT. We classified the patients into 4 groups, according to their preoperative calculated Cockcroft formula and the incidence of postoperative renal replacement therapy. Data then were analyzed in regard to mortality rates and in addition to pre- and peritransplant risk factors.

Results

There was a significant difference in ICU mortality (p=.008), hospital mortality (p=.002) and cumulative survival (p<.0001) between the groups. The highest mortality rate occurred in the group with RRT and normal baseline kidney function (20% ICU mortality, 26.6% hospital mortality and 50% cumulative 1-year mortality, respectively). The hazard ratio in this group was 9.6 (CI 3.2-28.6, p=.0001).

Conclusion

This study shows that in liver transplant recipient’s acute renal failure with postoperative RRT is associated with mortality and the mortality rate is higher than in patients with acute-on-chronic renal failure and postoperative renal replacement therapy.

Organ allocation for liver transplantation according to the public opinion

BACKGROUND

Although liver transplantation is the last resort for treating end stage liver diseases, this medical procedure is not available for all needful patients because of inadequate organ supply. Therefore, guidelines have been developed by medical experts to regulate the process. Some professionals believe that medical criteria are inadequate for organ allocation in all situations and may not secure fairness of organ allocation.

OBJECTIVES

The current study has been designed to identify decision criteria about allocation of donated liver to potential recipients from public points of view.

PATIENTS AND METHODS

This is a qualitative study that was conducted through individual interviews and Focus Group Discussions. Individual interviews were conducted among patients' companions and nurses in one of the two liver transplant centers in Iran. Group discussions were conducted among groups of ordinary people who had not dealt previously with the subject. Data was analyzed by Thematic Analysis method.

RESULTS

Most of the participants in this study believe that in equal medical conditions, some individual and societal criteria could be used to prioritize patients for receiving donated livers. The criteria include psychological acceptance, ability to pay post-operative care costs, being breadwinner of the family, family support, being socially valued, ability to be instructed, lack of mental disorders, young age of the recipient, being on waiting list for a long time, lack of patient's role in causing the illness, first time transplant recipient, critical medical condition, high success rate of transplantation, lack of concurrent medical illnesses, not being an inmate at the time of receiving transplant, and bearing Iranian nationality.

CONCLUSIONS

Taking public opinion into consideration may smooth the process of organ allocation to needful patients with equal medical conditions. It seems that considering these viewpoints in drafting organ allocation guidelines may increase confidence of the society to the equity of organ allocation in the country. This strategy may also persuade people to donate organs particularly after death.

Hepatocellular carcinoma: natural history, current management, and emerging tools

Hepatocellular carcinoma (HCC) is the most common primary liver tumor and represents the third-leading cause of cancer-related death in the world. The incidence of HCC continues to increase worldwide, with a unique geographic, age, and sex distribution. The most important risk factor associated with HCC is liver cirrhosis, with the majority of cases caused by chronic infection with hepatitis B (HBV) and C (HCV) viruses and alcohol abuse, although nonalcoholic fatty liver disease is emerging as an increasingly important cause. Primary prevention in the form of HBV vaccination has led to a significant decrease in HBV-related HCC, and initiation of antiviral therapy appears to reduce the incidence of HCC in patients with chronic HBV or HCV infection. Additionally, the use of ultrasonography enables the early detection of small liver tumors and forms the backbone of recommended surveillance programs for patients at high risk for the development of HCC. Cross-sectional imaging studies, including computed tomography and magnetic resonance imaging, represent further noninvasive techniques that are increasingly employed to diagnose HCC in patients with cirrhosis. The mainstay of potentially curative therapy includes surgery – either resection or liver transplantation. However, most patients are ineligible for surgery, because of either advanced disease or underlying liver dysfunction, and are managed with locoregional and/or systemic therapies. Randomized controlled trials have demonstrated a survival benefit with both local therapies, either ablation or embolization, and systemic therapy in the form of the multikinase inhibitor sorafenib. Despite this, median survival remains poor and recurrence rates significant. Further advances in our understanding of the molecular pathogenesis of HCC hold promise in improving the diagnosis and treatment of this highly lethal cancer.

Is the patient a candidate for liver transplantation?

Identifying whether someone is a good candidate for liver transplantation is a complex process that requires a team approach. There are several medical and psychosocial considerations involved, each of which is thoroughly explored during the evaluation process. Both the indications and contraindications to transplantation can change over time, reflecting advances in understanding of, and ability to treat, certain disease processes. Ultimately, the goal of liver transplantation remains to provide a survival benefit to those with acute or chronic liver diseases.

Influence of selected factors on survival after liver retransplantation

OBJECTIVE

The aim of this study was to examine the survival of adult liver retransplant recipients depending on selected factors: time from the primary transplantation, cold ischemia time, indications for retransplantation, patient age and United Network for Organ Sharing (UNOS) status.

PATIENTS AND METHODS

Between December 1989 and March 2011, we performed 43 orthotopic liver retransplantations (re-OLTs) among patients aged 20-62 years including 24 women and 19 men. The cold ischemia time was 250-820 minutes. UNOS status before re-OLT: UNOS 1 (n=19; 44%) UNOS 2A (n=15; 35%), and UNOS 2B (n=4; 9%). The time from OLT to re-OLT was 1-2, 146 days. The indications for re-OLT were arterial thrombosis (n=14; 33%), anastomotic biliary complication (n=3; 7%), recurrence of the original disease (n=9; 21%), hepatic vein thrombosis (n=1; 2%), primary nonfunction (PNF) dysfunction (n=2; [5%] /6 [14%]), de novo hepatitis C cirrhosis (n=2; 5%) and other etiologies (n=6; 14%).

RESULTS

The 6-year survival among the primary OLT group was 80% compared with 58% among the re-OLT group (P=.0001). One-year survivals in the re-OLT group according to UNOS status 1, 2A, and 2B were 47%, 60%, and 75%, respectively (P=.475). There was a low negative correlation between survival time and time between OLT and re-OLT. There was a low positive correlation between survival time and cold ischemia time. There was a low negative correlation between survival time and patient age.

CONCLUSIONS

There was a significant difference in survival between OLT and re-OLT. There was a correlation between survival time and time to re-OLTx; a shorter time corresponded to longer survival. There was a poor correlation between survival time and patient age. UNOS status before re-OLT and indication for re-OLTx influenced survival.

Milan Criteria and UCSF Criteria: A Preliminary Comparative Study of Liver Transplantation Outcomes in the United States

The application of orthotopic liver transplantation (OLT) for patients with hepatocellular cancer (HCC) necessitates highly selective criteria to maximize survival and to optimize allocation of a scarce resource. The objective of this study was to compare the outcomes of OLT for HCC in patients transplanted under Milan and UCSF criteria. The United Network of Organ Sharing (UNOS) database was queried for patients who had undergone OLT for HCC from 2002 to 2007, and 1,972 patients (Milan criteria, n = 1, 913; UCSF criteria, n = 59) were identified. Patients were stratified by pretransplant criteria (Milan versus UCSF), and clinical and pathologic factors and overall survival were compared. There were no differences in age, gender, diabetes mellitus, body mass index, and hepatitis B, or C status between the two groups. Overall survival was similar between the Milan and UCSF cohorts (1-, 2-, 3-, and 4-year survival rates: 88%, 81%, 76%, and 72% versus 91%, 80%, 68% and 51%, respectively, P = 0.21). Although the number of patients within UCSF criteria was small, our results nevertheless suggest that patients with HCC may have equivalent survival when transplanted under Milan and UCSF criteria. Long-term followup may better determine whether UCSF criteria should be widely adopted.

Occurrence of hepatopulmonary syndrome in patients with cirrhosis who are candidates for liver transplantation

OBJECTIVE

To determine the occurrence of hepatopulmonary syndrome (HPS) in patients with cirrhosis who are candidates for liver transplantation; to compare demographic, clinical, laboratory, and spirometric characteristics, as well as echocardiography results, arterial blood gas analysis, and severity of liver disease between the groups of patients with and without HPS; and to describe the occurrence of HPS in the subgroup of patients with cirrhosis and schistosomiasis mansoni (mixed liver disease).

METHODS

Between January and November of 2007, we evaluated 44 patients under treatment at the Liver Transplant Outpatient Clinic of the Federal University of Pernambuco Hospital das Clínicas, in the city of Recife, Brazil. The diagnostic criteria for HPS were intrapulmonary vascular dilatation, identified by transthoracic echocardiography, and an alveolar-arterial oxygen tension difference >or= 15 mmHg or a PaO2 < 80 mmHg.

RESULTS

The mean age of the patients was 52 years, and 31 patients (70%) were male. The most common cause of cirrhosis was alcohol use. Schistosomiasis was present in 28 patients (64%). Of the 44 patients, 20 (45.5%) were diagnosed with HPS. No significant differences were found between those patients and the patients without HPS in terms of any of the characteristics studied. Of the 28 patients with cirrhosis and schistosomiasis, 10 (35.7%) were diagnosed with HPS.

CONCLUSIONS

In the population studied, HPS was highly prevalent and did not correlate with any of the variables analyzed.

Prioritization for liver transplantation

There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit. The first is based on the severity of cirrhosis, using Child-Turcotte-Pugh score and, more recently, the Model for End-stage Liver Disease (MELD) score, or variants of MELD, for allocation. Although prospectively developed and validated, the MELD score has several limitations, including interlaboratory variations for measurement of serum creatinine and international normalized ratio of prothrombin time, and a systematic adverse female gender bias. Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy. The MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors incorporated into the scoring system. Several utility models are based on donor and recipient characteristics. Combined poor recipient and donor characteristics lead to very poor outcomes, which in a utility system would be considered unacceptable. Finally, transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation. However, complex statistical models are required, and unmeasured characteristics may unduly affect the models. Well-designed prospective studies and simulation models are necessary to establish the optimal allocation system in liver transplantation.

Model for end-stage liver disease combined with serum prealbumin to predict the prognosis of patients with decompensated liver cirrhosis

OBJECTIVE

To evaluate the prognostic value of model for end-stage liver disease (MELD) combined with serum prealbumin (PA) in patients with decompensated liver cirrhosis.

METHODS

A total of 252 patients were enrolled in the study and followed 1 year. PA was measured and MELD score was calculated on the first day of admission. Analysis of variance (anova) was used to assess correlation between PA level and MELD score. Multivariable Cox proportional hazards model was used to screen the prognosis related factors. Kaplan-Meier survival curves were drawn.

RESULTS

Of the 252 patients, 28 died within 3 months, 58 within 6 months and 91 within 1 year. Serum PA level in dead patients was significantly lower than that in survival patients (P < 0.005) and decreasing with increasing of MELD score. Cox analysis showed that MELD score > 18 (RR = 2.749) and PA < 70 mg/L (RR = 2.412) were independent prognosis risk factors. The risk ratio of MELD score combined with PA level (1.854, P < 0.01) was higher than that of MELD score alone (1.054, P < 0.05). Kaplan-Meier survival curve analysis showed that MELD score ≤ 18 combined with PA ≥ 70 mg/L could clearly discriminate patients who would survive or die within 6 month and 1 year follow up.

CONCLUSION

MELD score ≤ 18 combined with PA ≥ 70 mg/L could predict the 6-month and 1-year prognosis of patients with decompensated liver cirrhosis, and was superior to that of MELD score alone.

An increase in deceased donor incidence alleviated the need for urgent adult living donor liver transplantation in a Korean high-volume center

PURPOSE

This study analyzed the effects of a recent increase in deceased donors on the pattern of adult liver transplantation (OLT) in a high-volume center in Korea.

METHODS

OLT patterns relative to pretransplant recipient status were analyzed for 112 deceased donor LTs (DDLT) and 743 living donor OLT (LDLT) in a single center as compared to nationwide Korean data over 3 years from 2006 to 2008.

RESULTS

During the study period, the annual proportion of institutional urgent OLT was relatively invariable (20% to 25.2%), but the annual proportion of DDLTs to all OLT increased from 8.9% to 19.9%, as did the annual rate of DDLTs among those undergoing urgent OLT, from 18.6% to 65.8%, with a reciprocal decrease in the proportion of urgent LDLTs. Korean nationwide data also showed a noticeable increase in deceased liver graft allocation for urgency from 39.8% to 62.2% over the same time period.

CONCLUSION

An increase in deceased donors up to 5 per million enabled an increase in urgent adult DDLTs, alleviating the need for urgent adult LDLTs in Korea.

The beneficial impact of temporary porto-caval shunt in orthotopic liver transplantation: a single center analysis

The use of temporary porto-caval shunt (TPCS) has been shown to improve hemodynamic stability and renal function in patients undergoing orthotopic liver transplantation (OLT). We evaluated the impact of TPCS in OLT and analyzed the differences according to model for end-stage liver disease (MELD), donor risk index (DRI) and D-MELD. This is a retrospective single-center analysis of 148 consecutive OLT. Fifty-eight OLT were performed using TPCS and 90 without TPCS. Donor and recipient data with pre-OLT, intraoperative and postoperative variables were reviewed. Overall graft survival was 89.9% at 3 months and 81.7% at 1 year. Graft survival at 3 months and 1 year was 93.1% and 79.2%, respectively, in TPCS group versus 85.6% and 82.2%, respectively, in non-TPCS group (P = NS). Intraoperative packed red blood cells requirement was lower in TPCS group (7.5 ± 5.8 vs. 12.2 ± 14.2, P = 0.006) and non-TPCS group required higher intraoperative total dose of phenylephrine (16% vs. 28%, P = 0.04). TPCS group had lower 30-day postoperative mortality (1.7% vs. 10%, P = 0.04), no difference was observed at 90 days. Graft survival was lower in patients with high DRI; in this group graft loss was higher at 1 month (25% vs. 4.3%, P = 0.005) and 3 months (25% vs. 4.3%, P = 0.005) when TPCS was not used. TPCS improves perioperative outcome, this being more evident when high-risk grafts are placed into high-risk patients.

Liver transplant considerations for evaluation, CTP, and MELD

The detailed evaluation of a patient for liver transplant candidacy involves health care professionals from various disciplines to ensure that liver transplantation is optimal for patient morbidity and mortality from the medical and psychosocial perspective. The national liver allocation policy is complex and should be updated periodically based on continual assessment of outcomes that result from current policies. Streamlining of policies and procedures and implementing appropriate documentation across all transplant centers is required and regulated by National agencies such as OPTN/UNOS and CMS. This ensures safe and appropriate organ allocation and the delivery of high-quality transplant services.

Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients

Introduction

The impact of model of end stage liver disease (MELD) score on postoperative morbidity and mortality is still elusive, especially for high MELD. There are reports of poorer patient outcome in transplant candidates with high MELD score, others though report no influence of MELD score on outcome and survival.

Methods

We retrospectively analyzed data of 144 consecutive liver transplant recipients over a 72-month period in our transplant unit, from January 2003 until December 2008 and performed uni- and multivariate analysis for morbidity and mortality, in particular to define the influence of MELD to these parameters.

Results

This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by intensive care unit (ICU) stay longer than 10 days (odds ratio 7.0) but in contrast had no negative impact on mortality. Furthermore, we identified transfusion of more than 7 units of red blood cells as independent risk factor for mortality (hazard ratio 7.6) and for prolonged ICU stay (odds ratio [OR] 7.8) together with transfusion of more than 10 units of fresh frozen plasma (OR 11.6). Postoperative renal failure is a strong predictor of morbidity (OR 7.9) and postoperative renal replacement therapy was highly associated with increased mortality (hazard ratio 6.8), as was hepato renal syndrome prior to transplantation (hazard ratio 13.2).

Conclusions

This study identified MELD score greater than 23 as an independent risk factor of morbidity represented by ICU stay longer than 10 days but in contrast had no negative impact on mortality. This finding supports the transplantation of patients with high MELD score but only with knowledge of increased morbidity.

Disparities in organ allocation and access to liver transplantation in the USA

Liver transplantation has become the standard of care for the treatment of chronic liver disease. In 1986, the United Network for Organ Sharing (UNOS) was formed to ensure the just and equitable allocation of donor livers. At the time, UNOS decided to use the Childs-Turcotte-Pugh scoring system to determine the degree of liver disease in potential transplant patients. Unfortunately, it was shown that the Childs-Turcotte-Pugh system was easily manipulated and did not provide equal access to donor organs. Owing to this fact, the Model of End Stage Liver Disease (MELD) score was instituted by UNOS in February 2002. While the institution of MELD has shown an improvement in organ allocation and outcomes, disparities still exist. This article discusses UNOS and the MELD allocation system as well as the racial, geographic and gender disparities that occur despite the institution of the MELD system.

Risk factor analysis in patients with liver cirrhosis undergoing cardiovascular operations

BACKGROUND

Variable outcomes of cardiac operations have been reported in cirrhotic patients, but no definitive predictive prognostic factors have been established. This retrospective study assessed operative results to identify risk factors associated with morbidity after cardiovascular operations in cirrhotic patients.

METHODS

The study comprised 42 cirrhotic patients who underwent cardiovascular operations from January 1991 to January 2009. Thirty patients were Child-Turcotte-Pugh class A, and 12 were class B. Hospital morbidity occurred in 13 patients (31.0%; M group), including 4 who died in-hospital. Patients without severe complications (N group) were compared with the M group patients. The Model for End-Stage Liver Disease (MELD) score was evaluated in 25 patients.

RESULTS

Significant differences in hospital morbidity between the M vs N groups were identified for platelet count (8.7 +/- 3.8 vs 12.1 +/- 4.2 x 10(4)/microL), MELD score (17.8 +/- 5.3 vs 9.8 +/- 4.9), operation time (370 +/- 88 vs 313 +/- 94 minutes), and cardiopulmonary bypass time (174 +/- 46 vs 149 +/- 53 minutes) in univariate analyses (p < 0.005). Platelet count, operation time, and age were significantly associated with hospital morbidity in multivariate analyses (p < 0.005). Platelet count of 9.6 x 10(4)/microL and MELD score of 13 were cutoff values for hospital morbidity.

CONCLUSIONS

Careful consideration of operative indications and methods are necessary in cirrhotic patients with low platelet counts or high MELD scores. A high incidence of hospital morbidity is predicted in patients with platelet counts of less than 9.6 x 10(4)/microL or MELD scores exceeding 13.

Model for end-stage liver disease predicts mortality for tricuspid valve surgery

BACKGROUND

Patients undergoing tricuspid valve surgery have a mortality of 9.8%, which is higher than expected given the complexity of the procedure. Despite liver dysfunction seen in many patients with tricuspid disease, no existing risk model accounts for this. The Model for End-Stage Liver Disease (MELD) score accurately predicts mortality for abdominal surgery. The objective of this study was to determine if MELD could accurately predict mortality after tricuspid valve surgery and compare it to existing risk models.

METHODS

From 1994 to 2008, 168 patients (mean age, 61 +/- 14 years; male = 72, female = 96) underwent tricuspid repair (n = 156) or replacement (n = 12). Concomitant operations were performed in 87% (146 of 168). Patients with history of cirrhosis or MELD score 15 or greater (MELD = 3.8*LN [total bilirubin] + 11.2*log normal [international normalized ratio] + 9.6*log normal [creatinine] + 6.4) were compared with patients without liver disease or MELD score less than 15. Preoperative risk, intraoperative findings, and complications including operative mortality were evaluated. Statistical analyses were performed using chi(2), Fisher's exact test, and area under the curve (AUC) analyses.

RESULTS

Patients with a history of liver disease or MELD score of 15 or greater had significantly higher mortality (18.9% [7 of 37] versus 6.1% [8 of 131], p = 0.024). To further characterize the effect of MELD, patients were stratified by MELD alone. No major differences in demographics or operation were identified between groups. Mortality increased as MELD score increased, especially when MELD score of 15 or greater (p = 0.0015). A MELD score less than 10, 10 to 14.9, 15 to 19.9, and more than 20 was associated with operative mortality of 1.9%, 6.8%, 27.3%, and 30.8%, respectively. By multivariate analysis, MELD score of 15 or greater remained strongly associated with mortality (p = 0.0021). The MELD score predicted mortality (AUC = 0.78) as well as the European System for Cardiac Operative Risk Evaluation logistic risk calculator (AUC = 0.78, p = 0.96).

CONCLUSIONS

The MELD score predicts mortality in patients undergoing tricuspid valve surgery and offers a simple and effective method of risk stratification in these patients.