Pretransplant MELD score as a predictor of outcome after liver transplantation for chronic hepatitis C

Analysis of Short-Term and Long-Term Outcomes of Living Donor Liver Transplantation for Patients with a High Model for End-Stage Liver Disease Score

BACKGROUND

The Model of End-Stage Liver Disease (MELD) scoring system can predict short-term survival among patients awaiting liver transplantation and is used to allocate organs prioritizing liver transplantation. Patients with high MELD scores have been reported to have worse early graft dysfunction and survival. However, recent studies have shown that patients with high MELD scores had satisfactory graft survival, although they showed more postoperative complications. In this study, we examined the effect of the MELD score on the short-term and long-term prognosis of living donor liver transplantation (LDLT).

METHODS

This study included 102 patients who underwent LDLT in our institution between 2005 and 2020. The patients were divided into 3 groups according to MELD score (low MELD group: ≤20, moderate MELD group: 21-30, and high MELD group: ≥31). Perioperative factors were compared among the 3 groups, and cumulative overall survival rates were calculated using the Kaplan-Meier method.

RESULTS

The patients' characteristics were comparable, and the median age was 54 years. Hepatitis C virus cirrhosis was the most common primary disease (n = 40), followed by hepatitis B virus (n = 11). The low MELD group consisted of 68 patients (median score: 16, 10-20); the moderate MELD group, 24 patients (median score: 24, 21-30); and the high MELD group, 10 patients (median score: 35, 31-40). The mean operative time (1241 min versus 1278 min versus 1158 min, P = .19) and mean blood loss (7517 mL vs 11162 mL vs 8808 mL, P = .71) were not significantly different among the 3 groups. The vascular and biliary complication rates were similar. The periods of intensive care unit and hospital stay tended to be longer in the high MELD group, but the difference was insignificant. The 1-year postoperative survival rate (85.3 % vs 87.5 % vs 90.0 %, P = .90) and overall survival rate were also not significantly different among the 3 groups.

CONCLUSIONS

Our study showed that LDLT patients with high MELD scores do not have a worse prognosis than those with low scores.

Impact of Integrating Insulin-Like Growth Factor 1 Levels into Model for End-Stage Liver Disease Score for Survival Prediction in Hepatocellular Carcinoma Patients

BACKGROUND

Liver reserve affects survival in hepatocellular carcinoma (HCC). Model for End-Stage Liver Disease (MELD) score is used to predict overall survival (OS) and to prioritize HCC patients on the transplantation waiting list, but more accurate models are needed. We hypothesized that integrating insulin-like growth factor 1 (IGF-1) levels into MELD score (MELD-IGF-1) improves OS prediction as compared to MELD.

METHODS

We measured plasma IGF-1 levels in training (n = 310) and validation (n = 155) HCC cohorts and created MELD-IGF-1 score. Cox models were used to determine the association of MELD and MELD-IGF-1 with OS. Harrell's c-index was used to compare the predictive capacity.

RESULTS

IGF-1 was significantly associated with OS in both cohorts. Patients with an IGF-1 level of ≤26 ng/mL in the training cohort and in the validation cohorts had significantly higher hazard ratios than patients with the same MELD but IGF-1 >26 ng/mL. In both cohorts, MELD-IGF-1 scores had higher c-indices (0.60 and 0.66) than MELD scores (0.58 and 0.60) (p < 0.001 in both cohorts). Overall, 26% of training and 52.9% of validation cohort patients were reclassified into different risk groups by MELD-IGF-1 (p < 0.001).

CONCLUSIONS

After independent validation, the MELD-IGF-1 could be used to risk-stratify patients in clinical trials and for priority assignment for patients on liver transplantation waiting list.

Pre-transplant ALBI Grade 3 Is Associated with Increased Mortality After Liver Transplantation

BACKGROUND

Although MELD score is a reliable tool for estimating mortality in the waiting list, criteria for preoperative prediction of survival after liver transplantation (LT) are lacking. ALBI score was validated as a prognostic marker for hepatocellular carcinoma patients undergoing transarterial chemoembolization, hepatic resection, and sorafenib treatment but not for LT outcomes yet. This study aimed to evaluate ALBI score as a prognostic factor in LT.

METHODS

This is a single-center analysis of patients undergoing LT between October 2001 and June 2017. Primary endpoint was overall post-LT mortality. Secondary endpoint was 90-day mortality.

RESULTS

Of all 301 patients included in this study, 185 (61.5%) were males. The median age was 54.1 ± 11.3 years. Univariate and multivariate analysis revealed that ALBI grade 3 (HR 1.836, 95% CI 1.154-2.921, p = 0.010), low serum albumin (HR 0.628, 95% CI 0.441-0.893, p = 0.010), black race (HR 2.431, 95% CI 1.160-5.092, p = 0.019), and elevated body mass index (HR 1.061, 95% CI 1.022-1.102, p = 0.002) all were associated with decreased overall survival following LT. Patients with both ALBI grade 3 (n = 25) and calculated MELD score ≥ 25 had the lowest overall survival (p < 0.001).

DISCUSSION

ALBI grade 3 was related to lower post-LT survival and can be utilized as a tool for risk stratification in LT.

Model for End-Stage Liver Disease Score Before Hepatic Transplantation and Root Mean Square of the Diaphragmatic Domes Affect Postoperative Extubation Time

INTRODUCTION

The liver transplantation procedure, in addition to its prolonged surgical time, also predisposes to complications such as changes in respiratory mechanics, lung volumes, and gas exchange.

OBJECTIVE

This study aims to verify if clinical factors related to the recipient, namely immediate pretransplant Model for End-Stage Liver Disease (MELD) score, surgical time, and root square metric (RMS) of the diaphragmatic domes, affect the extubation time after liver transplantation.

METHOD

A prospective study, with a sample collected for convenience, gathered age (years), sex (male or female), MELD score immediately prior to transplantation (without the addition of special situation scores), and surgical time and time for extubation (in minutes). The latter were obtained from the physiotherapy team records, and surface electromyography was performed within 30 minutes after elective extubation, by a single researcher, with supplemental oxygen support, maintaining SpO₂ ≥ 95% and following protocol of positioning and acquisition of electromyographic signals based on the study of Oliveira et al (2012).

RESULTS

For the 21 patients studied, the RMS of the left dome showed a moderate-intensity correlation (-0.56) with the time of extubation, and linear multiple regression model the left dome (P = .013) and preoperative MELD score (P = .048) showed significant correlation with extubation time.

CONCLUSION

The preoperative MELD score and the RMS values of the left dome significantly correlate with the time for patient extubation after liver transplantation, showing the effect of previously acquired muscle weakness and preoperative MELD score on postoperative outcome.

COMPARATIVE STUDY ON LIVER TRANSPLANTATION WITH AND WITHOUT HEPATOCELLULAR CARCINOMA WITH CIRRHOSIS: ANALYSIS OF MELD, WAITING TIME AND SURVIVAL

Background :

Liver transplantation is the usual treatment for hepatocellular carcinoma.

Aim:

To analyze the MELD score, waiting time and three month and one year survival for liver transplantation in cirrhotic patients affected by hepatocellular carcinoma or not.

Methods :

This was a retrospective, observational and analytical study of 93 patients submitted to liver transplantation.

Results :

There were 28 hepatocellular carcinoma and 65 non-hepatocellular carcinoma patients with no differences related to age and sex distribution. The main causes of cirrhosis on hepatocellular carcinoma were hepatitis C virus (57.1%) and hepatitis B virus (28.5%), more frequent than non-hepatocellular carcinoma patients, which presented 27.7% and 4.6% respectively. The physiological and exception MELD score on hepatocellular carcinoma were 11.9 and 22.3 points. On non-hepatocellular carcinoma, it was 19.4 points, higher than the physiological MELD and lower than the exception MELD on hepatocellular carcinoma. The waiting time for transplantation was 96.2 days for neoplasia, shorter than the waiting time for non-neoplasia patients, which was 165.6 days. Three month and one year survival were 85.7% and 78.6% for neoplasia patients, similar to non-neoplasia, which were 77% and 75.4%.

Conclusion:

Hepatocellular carcinoma patients presented lower physiological MELD score, higher exception MELD score and shorter waiting time for transplantation when compared to non-hepatocellular carcinoma patients. Three month and one year survival were the same between the groups.

Impact of dynamic changes in MELD score on survival after liver transplantation - a Eurotransplant registry analysis

BACKGROUND & AIMS

With restricted numbers of available organs, futility in liver transplantation has to be avoided. The concept of dynamic changes in MELD score (DeltaMELD) has previously been shown to be a simple tool to identify patients with the greatest risk of death after transplantation. Aim was to validate this concept with the Eurotransplant (ET) database.

METHODS

A retrospective registry analysis was performed on all patients listed for liver transplantation within ET between 2006 and 2011. Patients <18 years of age, acute liver failure, malignancy and patients listed for retransplantation were excluded. Influence of MELD at listing (MELDon), MELD at transplantation (MELDoff), DeltaMELD, age, sex, underlying disease and time on the waiting list on overall survival after liver transplantation were evaluated.

RESULTS

A total of 16 821 patients were listed for liver transplantation, 8096 met the inclusion criteria. Age, MELD on and DeltaMELD showed significant influence on survival on the waiting list. Age and DeltaMELD showed influence on survival after liver transplantation, with DeltaMELD>10 showing a 1.6-fold increased risk of death.

CONCLUSION

The concept of DeltaMELD was validated in a large, prospective data set. It provides a simple tool to identify patients with increased risk of death after liver transplantation and might help improve long-term results.

Recipient Age and Mortality Risk after Liver Transplantation: A Population-Based Cohort Study

The aim of the present large population-based cohort study is to explore the risk factors of age-related mortality in liver transplant recipients in Taiwan. Basic information and data on medical comorbidities for 2938 patients who received liver transplants between July 1, 1998, and December 31, 2012, were extracted from the National Health Insurance Research Database on the basis of ICD-9-codes. Mortality risks were analyzed after adjusting for preoperative comorbidities and compared among age cohorts. All patients were followed up until the study endpoint or death. This study finally included 2588 adults and 350 children [2068 (70.4%) male and 870 (29.6%) female patients]. The median age at transplantation was 52 (interquartile range, 43–58) years. Recipients were categorized into the following age cohorts: <20 (n = 350, 11.9%), 20–39 (n = 254, 8.6%), 40–59 (n = 1860, 63.3%), and ≥60 (n = 474, 16.1%) years. In the total population, 428 deaths occurred after liver transplantation, and the median follow-up period was 2.85 years (interquartile range, 1.2–5.5 years). Dialysis patients showed the highest risk of mortality irrespective of age. Further, the risk of death increased with an increase in the age at transplantation. Older liver transplant recipients (≥60 years), especially dialysis patients, have a higher mortality rate, possibly because they have more medical comorbidities. Our findings should make clinicians aware of the need for better risk stratification among elderly liver transplantation candidates.

Pretransplant model for end-stage liver disease score as a predictor of postoperative complications after liver transplantation

The model for end-stage liver disease (MELD) is used to determine organ allocation priorities for orthotopic liver transplantation (OLT), although its value to predict posttransplantation mortality and morbility is controversial. The aim of this study was to analyze postoperative courses and (to evaluate the relationships between MELD score and postoperative) complications. We retrospectively examined the courses of 242 patients including 186 males and 56 females of overall mean age of 53 +/- 10 years who underwent primary liver transplantation. The classification of Dindo-characterized 5 grades of severity to evaluate postoperative events. The data showed that 171 patients (70.7%) experienced complications, while 71 (29.3%) had none. We observed that MELD score and complications were related (P < .05). Patients with complicated courses post-OLT displayed a 22.80 mean value of the MELD score, while those without complications showed a 17.64 mean value. The MELD score was also significantly associated with the time of intensive care unit stay and in hospital. Finally, we noted that MELD score and mortality were significantly correlated (P < .05). In conclusion, MELD score can be considered to be an objective system to predict the prevalence and severity of postoperative complications after liver transplantation.

A validated model for predicting outcome after liver transplantation: implications on transplanting the extremely sick

Given the organ shortage, there is a need to optimize outcome after liver transplantation (LT). We defined posttransplant hospital length of stay > 60 days (LOS > 60) as a surrogate of suboptimal outcome. In the first phase of the study, a 'Study cohort' (SC) of 643 patients was used to identify risk factors and construct a mathematical model to identify recipients with anticipated inferior results. In the second phase, a cohort of 417 patients was used for validation of the model ['Validation Cohort' (VC)]. In the SC, 65 patients (10.1%) had LOS > 60 days. One- and 3-year patient/graft survival rates were 81.9%/76.1% and 73.4%/67.4%, respectively. Patient and graft survival rates of those with LOS > 60 days were inferior (P < 0.0001), while transplant cost was greater [3.42 relative units (RU) vs. 1 RU, P < 0.0001]. In a multivariable analysis, pretransplant dialysis (P < 0.001), mechanical ventilation (P < 0.015), MELD (P < 0.003), and age (P < 0.009) were predictors of LOS > 60 days [ROC curve - 0.75 (95% CI 0.70, 0.81)]. In the VC, 53 patients (12.7%) were expected to have adverse outcome by the model. These patients had longer LOS (P < 0.0001), higher cost (<0.0001), and inferior patient and graft survival (P < 0.007).

How do transplant surgeons accomplish optimal portal venous flow during living-donor liver transplantation? Noninvasive measurement of indocyanine green elimination rate

BACKGROUND

Balancing donor safety and graft volume is difficult. We previously reported that intentional modulation of portal venous pressure (PVP) during living-donor liver transplantation (LDLT) is crucial to overcoming problems with small-for-size grafts; however, detailed studies of portal venous flow (PVF) and a reliable parameter are still required.

PATIENTS AND METHODS

The elimination rate (k) of indocyanine green (ICG) was measured in 49 adult LDLT recipients. PVP was controlled during LDLT, with a target of <20 mm Hg. ICG reflects hepatocyte volume and effective PVF. The kICG value is divided by the graft weight to calculate PVF. Recipients were divided into 2 groups: those with severe and/or fatal complications within 1 month after LDLT and those without.

RESULTS

Survival rates and postoperative profiles were significantly different between the 2 groups. Univariate analysis showed significant differences in ABO blood group, final PVP, final kICG, and the final kICG/graft weight value; however, multivariate analysis showed that only the kICG/graft weight value was significant. The cutoff level for the final kICG/graft weight value for predicting successful LDLT was 3.1175 × 10(-4)/g.

CONCLUSION

Accurate evaluation and monitoring of optimal PVF during LDLT should overcome the use of small-for-size grafts and improve donor safety and recipient outcomes.

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.

Short-term pretransplant renal replacement therapy and renal nonrecovery after liver transplantation alone

BACKGROUND AND OBJECTIVES

Candidates with AKI including hepatorenal syndrome often recover renal function after successful liver transplantation (LT). This study examined the incidence and risk factors associated with renal nonrecovery within 6 months of LT alone among those receiving acute renal replacement therapy (RRT) before LT.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Scientific Registry of Transplant Recipients data were linked with Centers for Medicare and Medicaid Services ESRD data for 2112 adult deceased-donor LT-alone recipients who received acute RRT for ≤90 days before LT (February 28, 2002 to August 31, 2010). Primary outcome was renal nonrecovery (post-LT ESRD), defined as transition to chronic dialysis or waitlisting or receipt of kidney transplant within 6 months of LT. Cumulative incidence of renal nonrecovery was calculated using competing risk analysis. Cox regression identified recipient and donor predictors of renal nonrecovery.

RESULTS

The cumulative incidence of renal nonrecovery after LT alone among those receiving the pre-LT acute RRT was 8.9%. Adjusted renal nonrecovery risk increased by 3.6% per day of pre-LT RRT (P<0.001). Age at LT per 5 years (P=0.02), previous-LT (P=0.01), and pre-LT diabetes (P<0.001) were significant risk factors of renal nonrecovery. Twenty-one percent of recipients died within 6 months of LT. Duration of pretransplant RRT did not predict 6-month post-transplant mortality.

CONCLUSIONS

Among recipients on acute RRT before LT who survived after LT alone, the majority recovered their renal function within 6 months of LT. Longer pre-LT RRT duration, advanced age, diabetes, and re-LT were significantly associated with increased risk of renal nonrecovery.

Is SAPS 3 better than APACHE II at predicting mortality in critically ill transplant patients?

OBJECTIVES

This study compared the accuracy of the Simplified Acute Physiology Score 3 with that of Acute Physiology and Chronic Health Evaluation II at predicting hospital mortality in patients from a transplant intensive care unit.

METHOD

A total of 501 patients were enrolled in the study (152 liver transplants, 271 kidney transplants, 54 lung transplants, 24 kidney-pancreas transplants) between May 2006 and January 2007. The Simplified Acute Physiology Score 3 was calculated using the global equation (customized for South America) and the Acute Physiology and Chronic Health Evaluation II score; the scores were calculated within 24 hours of admission. A receiver-operating characteristic curve was generated, and the area under the receiver-operating characteristic curve was calculated to identify the patients at the greatest risk of death according to Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores. The Hosmer-Lemeshow goodness-of-fit test was used for statistically significant results and indicated a difference in performance over deciles. The standardized mortality ratio was used to estimate the overall model performance.

RESULTS

The ability of both scores to predict hospital mortality was poor in the liver and renal transplant groups and average in the lung transplant group (area under the receiver-operating characteristic curve = 0.696 for Simplified Acute Physiology Score 3 and 0.670 for Acute Physiology and Chronic Health Evaluation II). The calibration of both scores was poor, even after customizing the Simplified Acute Physiology Score 3 score for South America.

CONCLUSIONS

The low predictive accuracy of the Simplified Acute Physiology Score 3 and Acute Physiology and Chronic Health Evaluation II scores does not warrant the use of these scores in critically ill transplant patients.

How transplant surgeons can overcome the inevitable insufficiency of allograft size during adult living-donor liver transplantation: strategy for donor safety with a smaller-size graft and excellent recipient results

Small-for-size grafts are an issue in liver transplantation. Portal venous pressure (PVP) was monitored and intentionally controlled during living-donor liver transplantation (LDLT) in 155 adult recipients. The indocyanine green elimination rate (kICG) was simultaneously measured in 16 recipients and divided by the graft weight (g) to reflect portal venous flow (PVF). The target PVP was <20 mmHg. Patients were divided by the final PVP (mmHg): Group A, PVP < 12; Group B, 12 ≤ PVP < 15; Group C, 15 ≤ PVP < 20; and Group D, PVP ≥ 20. With intentional PVP control, we performed splenectomy and collateral ligation in 80 cases, splenectomy in 39 cases, and splenectomy, collateral ligation, and additional creation in five cases. Thirty-one cases received no modulation. Groups A and B showed good LDLT results, while Groups C and D did not. Final PVP was the most important factor for the LDLT results, and the PVP cutoffs for good outcomes and clinical courses were both 15.5 mmHg. The respective kICG/graft weight cutoffs were 3.5580 × 10(-4) /g and 4.0015 × 10(-4) /g. Intentional PVP modulation at <15 mmHg is a sure surgical strategy for small-for-size grafts, to establish greater donor safety with good LDLT results. The kICG/graft weight value may have potential as a parameter for optimal PVF and a predictor for LDLT results.

Liver transplant outcome: a comparison between high and low MELD score recipients

OBJECTIVE

To compare low and high MELD scores and investigate whether existing renal dysfunction has an effect on transplant outcome.

METHODS

Data was prospectively collected among 237 liver transplants (216 patients) between March 2003 and March 2009. Patients with cirrhotic disease submitted to transplantation were divided into three groups: MELD > or = 30, MELD < 30, and hepatocellular carcinoma. Renal failure was defined as a +/- 25% decline in estimated glomerular filtration rate as observed 1 week after the transplant. Median MELD scores were 35, 21, and 13 for groups MELD > or = 30, MELD < 30, and hepatocellular carcinoma, respectively.

RESULTS

Recipients with MELD > or = 30 had more days in Intensive Care Unit, longer hospital stay, and received more blood product transfusions. Moreover, their renal function improved after liver transplant. All other groups presented with impairment of renal function. Mortality was similar in all groups, but renal function was the most important variable associated with morbidity and length of hospital stay.

CONCLUSION

High MELD score recipients had an improvement in the glomerular filtration rate after 1 week of liver transplantation.

Left-sided grafts for living-donor liver transplantation and split grafts for deceased-donor liver transplantation: their impact on long-term survival

BACKGROUND

A small-for-size graft is important in living-donor liver transplantation (LDLT) and deceased-donor liver transplantation (DDLT).

SUBJECTS AND METHODS

First, we confirmed the effect of initial graft volume on survival using a rat model of liver transplantation (LT). We then evaluated the actual long-term survival based on graft type in 1421 LTs (including 1364 LDLTs) at Kyoto University and 2000 DDLTs at the Mayo Clinic, to evaluate donor safety in LDLT and the possibility of shifting to split orthotopic liver transplantation (SOLT) in DDLT.

RESULTS

In the rat model, SOLTs with 40%- and 20%-grafts had a poor survival. A total of 697 pediatric LTs showed good long-term outcomes (survival rate was 0.764 at 21.2 years). The survival rate of 724 adult LTs was 0.664 at 17.8 years. The survival rates of auxiliary partial orthotopic liver transplantation with a left-sided graft (0.421 at 15.0 years) and SOLT with a left-sided graft (0.000 at 0.8 years) need to be improved. Although the survival rate of 1965 adult DDLTs with a whole-liver graft in the Mayo Clinic was 0.727 at 12.8 years, that of adult SOLT was 0.595 at 11.0 years.

CONCLUSION

From the viewpoint of greater donor safety and expanded donor candidates in LDLT, the choice of a left-sided graft still remains controversial. A shift to SOLT to achieve excellent results should be established to resolve a donor shortage in DDLT.

Serum ferritin concentration and transferrin saturation before liver transplantation predict decreased long-term recipient survival

Serum ferritin (SF) concentration is a widely available parameter used to assess iron homeostasis. It has been described as a marker to identify high-risk patients awaiting liver transplantation (LT) but is also elevated in systemic immune-mediated diseases, metabolic syndrome, and in hemodialysis where it is associated with an inferior prognosis. This study analyzed whether SF is not only a predictor of liver-related mortality prior to LT but also an independent marker of survival following LT. In a dual-center, retrospective study, a cohort of 328 consecutive first-LT patients from Hannover Medical School, Germany (2003-2008, follow-up 1260 days), and 82 consecutive LT patients from Regensburg University Hospital, Germany (2003-2007, follow-up 1355 days) as validation cohort were analyzed. In patients exhibiting SF ≥365 μg/L versus <365 μg/L prior to LT, 1-, 3-, and 5-year post-LT survival was 73.3% versus 81.1%, 64.4% versus 77.3%, and 61.1% versus 74.4%, respectively (overall survival P = 0.0097), which was confirmed in the validation cohort (overall survival of 55% versus 83.3%, P = 0.005). Multivariate analyses identified SF ≥365 μg/L combined with transferrin saturation (TFS) <55%, hepatocellular carcinoma, and the survival after LT (SALT) score as independent risk factors for death. In patients with SF concentrations ≥365 μg/L and TFS <55%, overall survival was 54% versus 74.8% in the remaining group (P = 0.003). In the validation cohort, it was 28.6% versus 72% (P = 0.017), respectively.

CONCLUSION

SF concentration ≥365 μg/L in combination with TFS <55% before LT is an independent risk factor for mortality following LT. Lower TFS combined with elevated SF concentrations indicate that acute phase mechanisms beyond iron overload may play a prognostic role. SF concentration therefore not only predicts pre-LT mortality but also death following LT.

Pre-transplant MELD and sodium MELD scores are poor predictors of graft failure and mortality after liver transplantation

BACKGROUND

Incorporating serum sodium concentrations into the model for end-stage liver disease (MELD) score may increase its sensitivity for identifying priority patients for orthotopic liver transplantation (OLT). We, therefore, evaluated and compared the ability of the sodium MELD and MELD scores to predict graft and patient survival after OLT.

METHODS

The United Network for Organ Sharing (UNOS) registry includes all US adult OLTs performed between January 2000 and August 2008. For 15,156 patients who met inclusion criteria, MELD score was calculated; for 6,193 patients whose serum sodium concentrations was between 120 and 135 mEq/dl, immediately before OLT, sodium MELD score was calculated. The corresponding hazard ratios (HR) for MELD and sodium MELD on graft and patient survival were assessed using the Cox proportional hazards regression models. The concordance probability estimate (CPE) was used to evaluate predictive ability of each time-to-event model.

RESULTS

MELD and sodium MELD scores were both significant predictors in univariable Cox regression models for graft failure [HR (95% CI) for every 10 units increase in the predictor: 1.10 (1.04, 1.17), P = 0.001, and 1.05 (1.00, 1.10), P = 0.03, respectively], and for mortality (1.14 (1.07, 1.21), P < 0.001, and 1.07 (1.02, 1.12), P = 0.01, respectively), with CPE of 0.52-0.53.

CONCLUSION

While MELD and sodium MELD were each significantly associated with survival after OLT, their predictive abilities were poor. The sodium MELD score does not improve prediction accuracy over the MELD score. Weak prediction may result from unaccounted variability in recipient and donor status, as well as surgical and postoperative factors.

Do chronic liver disease scoring systems predict outcomes in trauma patients with liver disease? A comparison of MELD and CTP

BACKGROUND

Although the Child-Turcotte-Pugh (CTP) score is an established outcome prediction tool for patients with liver disease, the Model for End-Stage Liver Disease (MELD) score has recently supplanted CTP for patients awaiting transplantation. Currently, data regarding the use of CTP in trauma is limited, whereas MELD remains unstudied. We compared MELD and CTP to determine which scoring system is a better clinical outcome predictor after trauma.

METHODS

A review of trauma admissions during 2003-2008 revealed 68 patients with chronic liver disease. Single and multiple variable analyses determined predictors of hepatic complications and survival. MELD and CTP were compared using odds ratios and area under the receiver operating curve (AUC) analyses. A p value ≤0.05 was significant.

RESULTS

The mean MELD and CTP scores of the population were 13.1 ± 6.0 and 8.3 ± 1.8, respectively (mean ± SD). Overall, 73.5% had one or more complications and 29.4% died. When survivors were compared with nonsurvivors, no difference in mean MELD scores was found, although mean CTP score (survivors, 7.7 ± 1.5; nonsurvivors, 9.4 ± 1.9; p = 0.001) and class ("C" survivors, 12.1%; "C" nonsurvivors, 56.3%; p = 0.002) were different, with survival relating to liver disease severity. Odds ratios and AUC determined that MELD was not predictive of hepatic complications or hospital survival (p > 0.05), although both CTP score and class were predictive (p < 0.05; AUC > 0.70).

CONCLUSION

Trauma patients suffering from cirrhosis can be expected to have poorer than predicted outcomes using traditional trauma scoring systems, regardless of injury severity. Scoring systems for chronic liver disease offer a more effective alternative. We compared two scoring systems, MELD and CTP, and determined that CTP was the better predictor of hepatic complications and survival in our study population.

Scoring short-term mortality after liver transplantation

Liver transplantation can prolong survival and improve the quality of life of patients with end-stage liver disease. This study retrospectively reviewed the medical records of 149 patients who had received liver transplants in a tertiary care university hospital from January 2000 to December 2007. Demographic, clinical, and laboratory variables were recorded. Each patient was assessed by 4 scoring systems before transplantation and on postoperative days 1, 3, 7, and 14. The overall 1-year survival rate was 77.9%. The Sequential Organ Failure Assessment (SOFA) score had better discriminatory power than the Child-Pugh points, Model for End-Stage Liver Disease score, and RIFLE (risk of renal dysfunction, injury to the kidney, failure of the kidney, loss of kidney function, and end-stage kidney disease) criteria. Moreover, the SOFA score on day 7 post-liver transplant had the best Youden index and highest overall correctness of prediction for 3-month (0.86, 93%) and 1-year mortality (0.62, 81%). Cumulative survival rates at the 1-year follow-up after liver transplantation differed significantly (P < 0.001) between patients who had SOFA scores < or = 7 on post-liver transplant day 7 and those who had SOFA scores > 7 on post-liver transplant day 7. In conclusion, of the 4 evaluated scoring systems, only the SOFA scores calculated before liver transplantation were statistically significant predictors of 3-month and 1-year posttransplant mortality. SOFA on post-liver transplant day 7 had the best discriminative power for predicting 3-month and 1-year mortality after liver transplantation.

Improved outcome of adult recipients with a high model for end-stage liver disease score and a small-for-size graft

Although adult-to-adult living donor liver transplantation (ALDLT) has shown comparable outcomes to deceased donor liver transplantation, the outcome of patients with a high MELD score (>25) and a small-for-size graft (SFSG<0.8% of graft-to-recipient weight ratio) is not known. For 7 years, 167 consecutive hepatitis B virus-infected recipients underwent ALDLT at our institution. Based on their MELD score without additional score for hepatocellular carcinoma (HCC), the recipients were divided into Group L (low MELD score, n = 105) or Group H (high MELD score, n = 62). To analyze the risk of the graft size, the patients were further stratified as follows: Group Hs (high MELD score and SFSG, n = 11), Hn (high MELD score and normal size graft, n = 51), Ls (low MELD score and SFSG, n = 18), and Ln (low MELD score and normal size graft, n = 87). The primary endpoint was one-year patient survival rate (1-YSR). The mean follow-up period was 32.6 months. The mean MELD scores were 17.1 in Group L and 32.6 in Group H. Group H had more patients with the complications of cirrhosis but less patients with HCC than Group L (p < 0.05). However, major morbidity rates and 1-YSR were similar in comparisons between Group L (46.7% and 86.7%) and H (59.7% and 83.8%) (p > 0.05). 1-YSR was similar among Group Hs (72.7%), Hn (86.3%), Ls (83.3%), and Ln (88.5%) groups (p = 0.278). The multivariate analysis revealed accompanying HCC and the year of transplant were risk factors for poor 1-YSR. However, 1-YSR without HCC patients was also similar in comparisons between group L (90.2%) and H (91.7%) (p = 0.847), and among Group Hs (80.0%), Hn (94.7%), Ls (72.7%), and Ln (96.7%) (p = 0.072). In conclusion, high MELD score (>25) didn't predict 1-YSR in ALDLT. Improvement of the 1-YSR might be affected by center's experience as well as the selection of patients with low risk of recurrence of HCC.

Calcineurin inhibitor minimization protocols in liver transplantation

Liver transplant recipients are at increasingly high risk for suffering from impaired renal function and probable need of renal replacement therapy. Extended criteria organs and transplantation of patients with higher model for end-stage liver disease scores further increase this problem. Acute and chronic nephrotoxicity are the trade-off in immunosuppression with potent calcineurin inhibitors (CNIs). As a good renal function is associated with better graft and patient survival, CNI minimization protocols have been developed. Current strategies to overcome CNI toxicity include reduction or withdrawal of CNIs concurrently with switching over to mammalian target of rapamycin inhibitor or mycophenolate mofetil (MMF)-based regimens. This strategy caused an improvement in renal function in a significant number of liver transplantation patients according to several studies. However, total CNI avoidance seems to result in higher rejection rates. To prevent chronic renal dysfunction in patients prone to or with acute renal failure, CNI delay - with induction therapy for bridging - followed by low-dose CNI in combination with MMF are proven strategies without risking higher rejection rates. An individualized, tailor-made immunosuppressive regime, with a special focus on renal function is recommended. This review gave an overview on CNI minimization protocols in liver transplantation also focusing on recently analyzed studies.

Should liver transplantation in patients with model for end-stage liver disease scores <or= 14 be avoided? A decision analysis approach

Studies have shown that liver transplantation offers no survival benefits to patients with Model for End-Stage Liver Disease (MELD) scores <or= 14 in comparison with remaining on the waitlist. The consensus of a 2003 transplant community national conference was that a minimum MELD score should be required for placement on the liver waitlist, but no minimum listing national policy was enacted at that time. We developed a Markov microsimulation model to compare results under the present US liver allocation policy with outcomes under a "Rule 14" policy of barring patients with a MELD score of <or=14 from the waitlist or transplantation. For probabilities in the microsimulation model, we used data on all adult patients (>or=18 years) listed for or undergoing primary liver transplantation in the United States for chronic liver disease from 1/1/2003 through 12/31/2007 with follow-up until 2/1/2008. The "Rule 14" policy gave a 3% improvement in overall patient survival over the present system at 1, 2, 3, and 4 years and predicted a 13% decrease in overall waitlist time for patients with MELD scores of 15 to 40. Patients with the greatest benefit from a "Rule 14" policy were those with MELD scores of 6 to 10, for whom a 17% survival advantage was predicted from waiting on the list versus undergoing transplantation. Our analysis supports changing the national liver allocation policy to not allow liver transplantation for patients with MELD <or= 14.

Hyponatremia and mortality among patients on the liver-transplant waiting list

BACKGROUND

Under the current liver-transplantation policy, donor organs are offered to patients with the highest risk of death.

METHODS

Using data derived from all adult candidates for primary liver transplantation who were registered with the Organ Procurement and Transplantation Network in 2005 and 2006, we developed and validated a multivariable survival model to predict mortality at 90 days after registration. The predictor variable was the Model for End-Stage Liver Disease (MELD) score with and without the addition of the serum sodium concentration. The MELD score (on a scale of 6 to 40, with higher values indicating more severe disease) is calculated on the basis of the serum bilirubin and creatinine concentrations and the international normalized ratio for the prothrombin time.

RESULTS

In 2005, there were 6769 registrants, including 1781 who underwent liver transplantation and 422 who died within 90 days after registration on the waiting list. Both the MELD score and the serum sodium concentration were significantly associated with mortality (hazard ratio for death, 1.21 per MELD point and 1.05 per 1-unit decrease in the serum sodium concentration for values between 125 and 140 mmol per liter; P<0.001 for both variables). Furthermore, a significant interaction was found between the MELD score and the serum sodium concentration, indicating that the effect of the serum sodium concentration was greater in patients with a low MELD score. When applied to the data from 2006, when 477 patients died within 3 months after registration on the waiting list, the combination of the MELD score and the serum sodium concentration was considerably higher than the MELD score alone in 32 patients who died (7%). Thus, assignment of priority according to the MELD score combined with the serum sodium concentration might have resulted in transplantation and prevented death.

CONCLUSIONS

This population-wide study shows that the MELD score and the serum sodium concentration are important predictors of survival among candidates for liver transplantation.

Hyponatremia and mortality among patients on the liver-transplant waiting list

BACKGROUND

Under the current liver-transplantation policy, donor organs are offered to patients with the highest risk of death.

METHODS

Using data derived from all adult candidates for primary liver transplantation who were registered with the Organ Procurement and Transplantation Network in 2005 and 2006, we developed and validated a multivariable survival model to predict mortality at 90 days after registration. The predictor variable was the Model for End-Stage Liver Disease (MELD) score with and without the addition of the serum sodium concentration. The MELD score (on a scale of 6 to 40, with higher values indicating more severe disease) is calculated on the basis of the serum bilirubin and creatinine concentrations and the international normalized ratio for the prothrombin time.

RESULTS

In 2005, there were 6769 registrants, including 1781 who underwent liver transplantation and 422 who died within 90 days after registration on the waiting list. Both the MELD score and the serum sodium concentration were significantly associated with mortality (hazard ratio for death, 1.21 per MELD point and 1.05 per 1-unit decrease in the serum sodium concentration for values between 125 and 140 mmol per liter; P<0.001 for both variables). Furthermore, a significant interaction was found between the MELD score and the serum sodium concentration, indicating that the effect of the serum sodium concentration was greater in patients with a low MELD score. When applied to the data from 2006, when 477 patients died within 3 months after registration on the waiting list, the combination of the MELD score and the serum sodium concentration was considerably higher than the MELD score alone in 32 patients who died (7%). Thus, assignment of priority according to the MELD score combined with the serum sodium concentration might have resulted in transplantation and prevented death.

CONCLUSIONS

This population-wide study shows that the MELD score and the serum sodium concentration are important predictors of survival among candidates for liver transplantation.

Six consecutive cases of successful adult ABO-incompatible living donor liver transplantation: a proposal for grading the severity of antibody-mediated rejection

BACKGROUND

The clinical symptoms, histological findings, and treatments for antibody-mediated rejection (AMR), which is the leading cause of graft loss in adult ABO-incompatible liver transplantation (ABO-I-LT), have rarely been discussed.

METHODS

We performed adult living donor ABO-I-LT on six patients. We used anti-CD20 monoclonal antibody combined with plasma exchange preoperatively and intraportal or hepatic-arterial infusion, consisting of prostaglandin E1, corticosteroids, and protease inhibitor postoperatively to prevent AMR. Splenectomy was performed in patients 1, 4, 5 and 6 but not in patients 2 and 3. Weekly liver biopsies were performed after ABO-I-LT. When severe AMR was diagnosed, we performed plasma exchange combined with gamma-globulin bolus infusion (PE+IVIG).

RESULTS

In patients 1-3, severe jaundice, rapid decreases in platelet counts, and severe coagulopathy were observed in the early postoperative period. Liver biopsies sampled after the onset of these clinical findings were characterized by severe periportal and lobular hemorrhagic and neutrophil infiltration, suggesting that severe AMR occurred. However, after the initiation of PE+IVIG, AMR was remedied in all three patients. In patients 4-6, severe AMR was not observed. Mild AMR characterized by mild portal hemorrhagic infiltration was observed in patient 4, and moderate AMR characterized by moderate periportal and lobular hemorrhagic infiltration was observed in patient 6. Patients 4-6 did not require PE+IVIG and their clinical course was uneventful.

CONCLUSION

Given the experience of these six patients, we consider that AMR may be graded based on liver biopsy findings including hemorrhagic infiltration and neutrophil infiltration, as well as clinical findings. All six patients are currently doing well.

Association between donor-recipient serum sodium differences and orthotopic liver transplant graft function

Previous studies have shown that donor hypernatremia and possibly recipient hyponatremia negatively impact graft function after orthotopic liver transplant (OLT). The purpose of this retrospective investigation was to determine whether measured differences in serum sodium values between cadaveric donors and OLT recipients (DeltaNa(+)) influence immediate postoperative allograft function and short-term patient outcomes. Two hundred and fifty patients that underwent OLT from January 2001 to December 2005 were included in this study. The DeltaNa(+) for each donor recipient pair was correlated with standard postoperative liver function tests as well as recipient length of intensive care unit stay (LOICUS), length of hospital stay (LOHS) and recipient survival. The relationship between donor hypernatremia (serum sodium >or= 155 mEq/mL), recipient hyponatremia (serum sodium level <or= 130 mEq/mL), and postoperative outcomes were analyzed as well. Adjustments were made for baseline potential confounders, including model for end-stage liver disease (MELD) score, preservation solution used (HTK vs. UW), recipient and donor demographics and cold ischemia time (CIT). DeltaNa(+) as well as donor hypernatremia and recipient hyponatremia were not found to be associated with immediate postoperative allograft function, intraoperative blood product usage, LOICUS, LOHS or short-term patient survival. However, both the preoperative MELD score and HTK preservation solution used were significantly associated with several patient outcomes. A higher MELD score was associated with both increased red blood cell (RBC) (P < 0.001) and fresh frozen plasma (FFP) usage (P = 0.002), elevated postoperative total bilirubin levels (P < 0.001), increased LOHS (P = 0.04), and a higher 30-day post transplant mortality (P = 0.02). The use of HTK preservation solution was associated with higher mean postoperative aspartate aminotransferase levels (P = 0.02) and decreased mean RBC (P < 0.001) and FFP usage (P = 0.009) compared to UW preservation solution use.

Prognostic Impact of Model for End-Stage Liver Disease Score in Patients Undergoing Liver Transplantation With Suboptimal Livers

BACKGROUND/AIMS

The aim of this retrospective study is to analyze the prognostic impact of Model for End-Stage Liver Disease (MELD) score in patients undergoing liver transplantation (OLT) with suboptimal livers.

METHODS

Between January 2002 and January 2006, 160 adult patients with liver cirrhosis received a whole liver for primary OLT at our institution including 81 with a suboptimal liver (SOL group) versus 79 with an optimal liver (group OL). The definition of suboptimal liver was: one major criterion (age >60 years, steatosis >20%) or at least two minor criteria: sodium >155 mEq/L, Intensive Care Unit stay >7 days, dopamine >10 microg/kg/min, abnormal liver tests, and relevant hemodynamic instability.

RESULTS

Baseline recipients characteristics were comparable in the two study groups. The SOL group had a significantly greater number of early graft deaths (<30 days) than the OL group, while the 3-year Kaplan-Meier patient survivals were similar. Using logistic regression, MELD score was significantly related to patient death only in the SOL group (P = .01), and the receiver operator characteristics curve method identified 17 as the best MELD cutoff with the 3-year survival of 93% versus 85% for MELD < or =7 versus >17, respectively (P > 05). In comparison, it was 94% and 72% in the SOL group (P < .05). Similarly, MELD >17 was significantly associated with early graft death rates only in the SOL group.

CONCLUSION

This study advised surgeons to not use suboptimal livers for patients with advanced MELD scores, thus supporting a donor-recipient matching policy.

The model for end-stage liver disease (MELD)

The Model for End-stage Liver Disease (MELD) was initially created to predict survival in patients with complications of portal hypertension undergoing elective placement of transjugular intrahepatic portosystemic shunts. The MELD which uses only objective variables was validated subsequently as an accurate predictor of survival among different populations of patients with advanced liver disease. The major use of the MELD score has been in allocation of organs for liver transplantation. However, the MELD score has also been shown to predict survival in patients with cirrhosis who have infections, variceal bleeding, as well as in patients with fulminant hepatic failure and alcoholic hepatitis. MELD may be used in selection of patients for surgery other than liver transplantation and in determining optimal treatment for patients with hepatocellular carcinoma who are not candidates for liver transplantation. Despite the many advantages of the MELD score, there are approximately 15%-20% of patients whose survival cannot be accurately predicted by the MELD score. It is possible that the addition of variables that are better determinants of liver and renal function may improve the predictive accuracy of the model. Efforts at further refinement and validation of the MELD score will continue.

Effect of nonviral factors on hepatitis C recurrence after liver transplantation

OBJECTIVE

Hepatitis C (HCV) is now the most common indication for orthotopic liver transplantation (OLT). While graft reinfection remains universal, progression to graft cirrhosis is highly variable. This study examined donor, recipient, and operative variables to identify factors that affect recurrence of HCV post-OLT to facilitate graft-recipient matching.

METHODS

Retrospective review of 307 patients who underwent OLT for HCV over a 10-year period at our center. Recurrence of HCV was identified by the presence of biochemical graft dysfunction and concurrent liver biopsy showing diagnostic pathologic features. Time to recurrence was the endpoint for statistical analysis. Five donor, 6 recipient, and 2 operative variables that may affect recurrence were analyzed by univariate comparison and Cox proportional hazard regression models.

RESULTS

Recurrence-free survival in the 307 study patients was 69% and 34% at 1 and 5 years, respectively. Four predictive variables related to either donor or recipient characteristics were identified. Advanced donor age, prolonged donor hospitalization, increasing recipient age, and elevated recipient MELD scores were found to increase the relative risk of HCV recurrence. Examination of HLA disparity between donors and recipients demonstrated no correlation between class I or class II mismatches and recurrence-free survival.

CONCLUSIONS

We have identified donor and recipient characteristics that significantly predict hepatitis C recurrence following liver transplantation. These factors are identifiable before transplant and, if considered when matching donors to HCV recipients, may decrease the incidence of HCV recurrence after OLT. A change in the current national liver allocation system would be needed to realize the full value of this benefit.

A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation

The Model for End-Stage Liver Disease (MELD) score is now used for allocation in liver transplantation (LT) waiting lists, replacing the Child-Turcotte-Pugh (CTP) score. However, there is debate as whether it is superior to CTP score to predict mortality in patients with cirrhosis on the LT waiting list and after LT. We reviewed studies comparing the accuracy of MELD vs. CTP score in transplantation settings. We found that in studies of the LT waiting list (12,532 patients with cirrhosis), only 4 of 11 showed MELD to be superior to CTP in predicting short-term (3-month) mortality. In addition, 2 of 3 studies (n = 1,679) evaluating the changes in MELD score (DeltaMELD) showed that DeltaMELD had better prediction for mortality than the baseline MELD score. The impact of MELD on post-LT mortality was assessed in 15 studies (20,456 patients); only 6 (9,522 patients) evaluated the discriminative ability of MELD score using the concordance (c) statistic (the MELD score had always a c-statistic < 0.70). In 11 studies (19,311 patients), high MELD score indicated poor post-LT mortality for cutoff values of 24-40 points. In re-LT patients, 2 of 4 studies evaluated the discriminative ability of MELD score on post-LT mortality. Finally, several studies have shown that the predictive ability of MELD score increases by adding clinical variables (hepatic encephalopathy, ascites) or laboratory (sodium) parameters. On the basis of the current literature, MELD score does not perform better than the CTP score for patients with cirrhosis on the waiting list and cannot predict post-LT mortality.

Liver transplantation with the Meld system: a prospective study from a single European center

The efficacy of the Meld system to allocate livers has never been investigated in European centers. The outcome of 339 patients with chronic liver disease listed according to their Meld score between 2003 and 2005 (Meld era) was compared to 224 patients listed during the previous 2 years according to their Child score (Child era). During the Meld era, hepatocellular carcinomas (HCCs) had a 'modified' Meld based on their real Meld, waiting time and tumor stage. The dropouts were deaths, tumor progressions and too sick patients. The rate of removals from the list due to deaths and tumor progressions was significantly lower in the Meld than in the Child era: 10% and 1.2% versus 16.1% and 4.9%, p < 0.05. The 1-year patient survival on the list was significantly higher in the Meld era (84% vs. 72%, p < 0.05). The prevalence of transplantation for HCC increased from 20.5% in the Child to 48.9% in the Meld era (p < 0.001), but between HCCs and non-HCCs of this latter era the dropouts were comparable (9.4% vs. 14.9%, p = n.s.) as was the 1-year patient survival on the list (83% vs. 84%, p = n.s.). The Meld allocation system improved the outcome of patients with or without HCC on the list.

Impact of model for end-stage liver disease (MELD) scoring system on pathological findings at and after liver transplantation

The Model for End-Stage Liver Disease (MELD) scoring system, a validated objective liver disease severity scale, was adopted in February 2002 to allocate cadaveric organs for liver transplantation (LT). To improve transplantability before succumbing to advanced disease, patients with low-stage hepatocellular carcinoma (HCC) are given extra points in this system commensurate with their predicted mortality. Our aims were to determine 1) any change in the pathological findings at LT following the implementation of this system and 2) the impact of scoring advantage given to early-stage HCC. Clinicopathologic findings were compared before (pre-MELD, n = 87) and after (MELD, n = 58) the introduction of the MELD system. The findings in the pre-MELD vs. MELD groups were as follows: HCC, 27.5% vs. 48.3% (P = 0.001); portal vein thrombosis (PVT), 13.7% vs. 25.9% (P = 0.08); cholestasis, 16.1% vs. 32.7% (P = 0.026); inflammation grade of 2 or more, 43.7% vs. 48.3% (P = not significant); hepatitis C (HCV), 45.9% vs. 51.7% (P = not significant); HCV with lymphoid aggregates, 25% vs. 60% (P = 0.003); HCV with hyperplastic hilar nodes, 15.0% vs. 36.6% (P = 0.001); and post-LT HCC recurrence, 4.1% vs. 3.4% (P = not significant). Non-HCC-related findings were further compared in the 2 subgroups of pre-MELD (n = 57) and MELD (n = 31) after exclusion of HCC and fulminant hepatic failure (FHF) cases, and only cholestasis was significantly increased in the subgroup MELD. In conclusion, increased incidence of native liver cholestasis in the MELD era may be the histologic correlate of clinically severe liver disease. The scoring advantage given to low-stage HCC did result in a significantly increased incidence of HCC in the MELD group, but it did not adversely affect the post-LT recurrence rate.

Preoperative characteristics and intraoperative transfusion and vasopressor requirements in patients with low vs. high MELD scores

Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation.

An outcome comparison between primary liver transplantation and retransplantation based on the pretransplant MELD score

Survival after liver retransplantation (RLTX) is worse than after primary liver transplantation (LTX). We studied retrospectively the 2-year outcome in 44 patients who received RLTX more than 30 days after the primary transplant and in 669 after LTX performed between December 1993 and October 1999, focusing on the relation between the model for end-stage liver disease (MELD) score immediately pretransplant and post-transplant survival. A 2-year survival for RLTX was inferior to LTX (65.9% vs. 82.9%, P < or = 0.01). This difference was greatest with MELD scores < 25; survival within 2 years remained 11.3-18.2% less for RLTX than for LTX (6 months, P = 0.002; 12 months, P = 0.029, 24 months, P = 0.123). Mortality was mainly related to early vascular complications and sepsis. Two-year survival after RLTX was 81.8% if RLTX occurred < 2 years after LTX and 50% if the interval between LTX and RLTX was > 2 years (P < 0.05). MELD scores were similar in 2-year survivors and nonsurvivors after late RLTX (P = 0.82). Late RLTX is marked by poor survival regardless of the pretransplant MELD score. The MELD-based allocation system may not benefit patients who undergo retransplantation.

MELD and prediction of post-liver transplantation survival

The model for end-stage liver disease (MELD) was developed to predict short-term mortality in patients with cirrhosis. It has since become the standard tool to prioritize patients for liver transplantation. We assessed the value of pretransplant MELD in the prediction of posttransplant survival. We identified adult patients who underwent liver transplantation at our institution during 1991-2002. Among 2,009 recipients, 1,472 met the inclusion criteria. Based on pretransplant MELD scores, recipients were stratified as low risk (< or = 15), medium risk (16-25), and high risk (>25). The primary endpoints were patient and graft survival. Mean posttransplant follow-up was 5.5 years. One-, 5- and 10-year patient survival was 83%, 72%, and 58%, respectively, and graft survival was 76%, 65%, and 53%, respectively. In univariable analysis, patient and donor age, patient sex, MELD score, disease etiology, and retransplantation were associated with posttransplantation patient and graft survival. In multivariable analysis adjusted for year of transplantation, patient age >65 years, donor age >50 years, male sex, and retransplantation and pretransplant MELD scores >25 were associated with poor patient and graft survival. The impact of MELD score >25 was maximal during the first year posttransplant. In conclusion, older patient and donor age, male sex of recipient, retransplantation, and high pretransplant MELD score are associated with poor posttransplant outcome. Pretransplant MELD scores correlate inversely with posttransplant survival. However, better prognostic models are needed that would provide an overall assessment of transplant benefit relative to the severity of hepatic dysfunction.

Different model for end-stage liver disease score block distributions may have a variable ability for outcome prediction

BACKGROUND

The model for end-stage liver disease (MELD) scoring system has become the prevailing criteria for organ allocation in liver transplantation. However, it is not clear if the predictive accuracy of MELD is equally homogeneous in different distribution of MELD score blocks.

METHODS

We investigated 472 cirrhotic patients (mean MELD, 14.3+/-5.5), and compared the predictive accuracy of MELD and the corresponding Child-Turcotte-Pugh (CTP) scores in patients with low (<16), intermediate (10-20) and high (>14) MELD score range by using c-statistic for area under the receiver operating characteristic curve (AUC) at different time frames.

RESULTS

The MELD scores well correlated with CTP scores at baseline (rho=0.492, P<0.001). Overall, MELD was significantly better than the CTP system to predict the risk of mortality. However, in stratified analysis there were no significant differences between MELD and CTP for the c-statistic in patients with low and intermediate range MELD scores at 3-, 6-, 9-, and 12-month (p values all > 0 1). Among patients with high MELD scores, MELD was consistently more accurate than the CTP system in predicting the mortality at 3- (AUC, 0.715 vs. 0.543, P=0.020), 6- (0.705 vs. 0.536, P=0.003), 9- (0.737 vs. 0.507, P<0.001) and 12-month (0.716 vs. 0.526, P<0.001), respectively.

CONCLUSIONS

MELD has a better performance only in a subset of patients with higher MELD scores. The outcome in patients with lower range MELD scores cannot be reliably predicted solely with their MELD scores, and alternative prognostic markers should be used in conjunction to enhance the predictive accuracy.

Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy

BACKGROUND

Acute renal failure (ARF) in the setting of end-stage liver disease has a dismal prognosis without liver transplantation. Renal replacement therapy (RRT) is a common bridge to liver transplant despite a paucity of supportive data. We investigated our single-center patient population to determine efficacy of RRT in liver transplant candidates with ARF.

METHODS

We identified 102 liver transplant candidates receiving RRT for ARF between April 30, 1999 and January 31, 2004. Patients that had initiated RRT intra- or postoperatively or received outpatient hemodialysis or peritoneal dialysis prior to admission were excluded. Survival to liver transplant, short-term mortality following liver transplant, and selected clinical characteristics were examined.

RESULTS

Of patients who received RRT, 35% survived to liver transplant or discharge. Mortality was 94% in patients not receiving a liver and was associated with a higher Acute Physiological and Chronic Health Evaluation (APACHE) II, lower mean arterial pressure, and the use of continuous renal replacement therapy (CRRT). Patients receiving CRRT had greater severity of illness than those on hemodialysis. The 1-year mortality of patients initiating RRT prior to liver transplant was 30% versus 9.7% for all other liver recipients (P < 0.0045).

CONCLUSION

RRT is justifiable for liver transplant candidates with ARF. Though mortality was high, a substantial percentage (31%) of patients survived to liver transplant. Postoperative mortality is increased compared with all other liver transplant recipients, but is acceptable considering the near-universal mortality without transplantation.