Nonstandard Exception Requests Impact Outcomes for Pediatric Liver Transplant Candidates

Abstract

Non-standard exceptions requests (NSERs), in which transplant centers appeal on a case-by-case basis for PELD/MELD points, have been highly utilized for pediatric liver transplant candidates. We evaluated whether NSE outcomes, are associated with waitlist and post-transplant mortality. UNOS Scientific Registry of Transplant Recipients data on pediatric liver transplant candidates listed 2009-2014 were analyzed after excluding those granted automatic UNOS exceptions. Of 2,581 pediatric waitlist candidates, 44% had an NSE request. Of the 1,134 children with NSERs, 93% were approved and 7% were denied. For children 2-18 years at listing, NSER denial increased the risk of waitlist mortality or removal for being too sick (SHR 2.99, 95% CI 1.26-7.07, p=0.01 in multivariate analysis). For children younger than 2, NSER denial did not impact waitlist mortality/removal. Children with NSER approved had reduced risk of graft loss 3 years post-transplant in univariate but not multivariable analysis (OR 0.73, 95% CI 0.53-1.01, p=06). Those with NSER denial had a higher risk of post-transplant death than those with no NSER (HR 2.43, 95% CI 0.99-5.95, p=0.05, multivariable analysis), but NSER approval did not impact post-transplant death. Further research on NSER utilization in pediatric liver transplant is needed to optimize organ allocation and outcomes for children.

Disparities in Waitlist and Posttransplantation Outcomes in Liver Transplant Registrants and Recipients Aged 18 to 24 Years

“…8 Additional studies have also found that children and adults who are granted nonstandard exception scores have decreased waitlist mortality and are more likely to be transplanted compared to registrants without nonstandard exception requests. 23,24 In support of these trends, we found that adults 18–24 year olds were significantly less likely to be granted an exception score at any time while on the waiting list, had lower MELD exception scores compared to 0–17 year olds and had poorer waitlist outcomes despite having the highest mean calculated MELD score at listing and transplantation. In our study, while the primary indications for liver transplantation were similar between 12–17 year olds and 18–24 year olds, the decline in the use of exception scores at the transition between adolescence and adulthood was dramatic.…”

Predicting ideal outcome after pediatric liver transplantation: An exploratory study using machine learning analyses to leverage Studies of Pediatric Liver Transplantation Data

“…The reasons for this are likely multifactorial and may reflect systemic bias (both societal and health system) experienced by minorities across the phases of care. Previous studies in pediatric LT have suggested a disparity in access to care, presentation to care, and waitlist priority for patients of non‐white race . Black adults who received kidney transplants were found to have increased prevalence of cardiac disease pretransplant, which could suggest that comorbidities may contribute to this racial gap .…”

Functional status at listing predicts waitlist and posttransplant mortality in pediatric liver transplant candidates

“…In analyses of the United Network for Organ Sharing (UNOS) database, KPS at listing predicts waitlist mortality in adult liver transplant candidates, even after adjusting for Model for End-Stage Liver Disease (MELD) score and other risk factors. 12 One option for improving the accuracy of risk prediction is to identify other variables or risk categories that predict outcomes but are not captured by current score or status categories. [1][2][3][4] The UNOS registry currently includes data on functional status in pediatric liver transplant candidates using the Lansky playperformance scale (LPPS), which parallels the KPS.…”