Survival outcomes in liver transplant recipients with Model for End‐stage Liver Disease scores of 40 or higher: a decade‐long experience

Panchal, Hemang B.; Durinka, Joel B.; Patterson, Jeromy; Karipineni, Farah; Ashburn, Sarah; Siskind, E. J.; Ortíz, Jorge

doi:10.1111/hpb.12485

Cited by 37 publications

(29 citation statements)

References 12 publications

(42 reference statements)

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“…In recent years, the notion of "futility" of LT has been used if post-transplant mortality was higher than waiting list mortality 81,82 or in case of 3month or in-hospital mortality after LT. 76,83 However, authors of a recent review preferred to correct "futile" LT to "potentially inappropriate" LT, thus reducing the value judgment inherent to the term "futile". 80 This semantic change follows the adoption of these new terms by a multisociety statement that provided guidance for clinicians to prevent and manage disputes regarding patients with advanced critical illnesses.…”

Section: Therapiesmentioning

confidence: 99%

Approaches for patients with very high MELD scores

Artru

Samuel

2019

JHEP Reports

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In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.

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Section: Therapiesmentioning

confidence: 99%

Approaches for patients with very high MELD scores

Artru

Samuel

2019

JHEP Reports

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“…These conflicting results, compared to the results of the present study, could be explained by differences in pretransplant patient selection and clinical management, especially for patients with high MELD scores and complex morbidity. Another retrospective longitudinal analysis of United Network for Organ Sharing (UNOS) data on all liver transplantations performed between February 2002 and June 2011, including 33 398 transplant recipients, showed that overall post‐transplant patient survival was inversely correlated with increasing MELD score, but LT in recipients with MELD scores ≥40 achieved acceptable long‐term survival outcomes . Moreover, another recent analysis of UNOS data from 2002 to 2013, based on 50 838 transplant recipients, showed a significant interaction between MELD score and hospitalization status on post‐LT survival.…”

Section: Discussionmentioning

confidence: 99%

“…The following algorithm was used to calculate the MELD score: MIN (40,ROUND(10*(0.957*LOG(MIN(MAX (0.0113*CREAT,1),4)) + 0.378*LOG(MAX (0.06*BILI,1)) + 1.12*LOG(MAX(INR,1)) + 0.643))). The MELD score was categorized into 6 different groups of severity: <15, [15][16][17][18][19][20], [20][21][22][23][24][25]…”

Section: Data Collection and Variables Recordedmentioning

confidence: 99%

Impact of the new MELD‐based allocation system on waiting list and post‐transplant survival—a cohort analysis using the French national CRISTAL database

et al. 2019

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Liver transplant advisory group, clinical centers, and transplant unit surgical and medical supervisors (see the list of participants attached in Acknowledgements). SUMMARYConcerns related to equity and efficacy of our previous center-based allocation system have led us to introduce a patient-based allocation system called the "Liver Score" that incorporates the model for end-stage liver disease (MELD) score. The main objective of this study was to compare waitlist and post-transplant survivals before and after implementation of the "Liver Score" using the French transplant registry (period before: 2004-2006 and period after: 2007-2012). Patients transplanted during the second period were sicker and had a higher MELD. One-year waitlist survival (74% vs. 76%; P = 0.8) and 1-year post-transplant survival (86.3% vs. 85.7%; P = 0.5) were similar between the 2 periods. Cirrhotic recipients with MELD >35 had lower 1-year post-transplant survival compared to those with MELD <35 (74.8% vs. 86.3%; P < 0.01), mainly explained by their higher intubation and renal failure rates. The MELD showed a poor discriminative capacity. In cirrhotic recipients with MELD >35, patients presenting 2 or 3 risk factors (dialysis, intubation, or infection) had a lower 1-year survival compared to those with none of these risk factors (61.2% vs. 92%; P < 0.01). The implementation of the MELD-based allocation system has led to transplant sicker patients with no impact on waitlist and post-transplant survivals. Nevertheless, selection of patients with MELD >35 should be completed to allow safe transplantation.

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“…In the era of high‐acuity liver transplantation, there is a need to evaluate those factors that negatively contribute to overall graft and patient survival because patient selection remains a critical determinant of OLT outcomes. Although previous studies have evaluated age, sepsis, cardiac risk, and extreme MELD as potential predictors of poor outcomes, a similar assessment has never been undertaken to assess acute pancreatitis, which occurs in 1.5%‐3.0% of liver transplant patients . Previous studies of pancreatitis among liver transplant patients have demonstrated its association with acute liver failure and hepatitis B virus in the preoperative setting, and with interventional procedures (such as ERCP) in the postoperative setting .…”

Section: Discussionmentioning

confidence: 99%

Peritransplant pancreatitis: A marker of high mortality and graft failure in liver transplant patients

Russell¹,

Park²,

Agopian³

et al. 2017

Liver Transpl

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Perioperative pancreatitis is a significant comorbid condition in surgical patients. However, the degree to which pancreatitis affects graft and overall survival in liver transplant recipients has not been evaluated. This study assesses the impact of pancreatitis on graft and patient survival in adult orthotopic liver transplantation (OLT). All patients undergoing OLT at a single academic institution from 2007 to 2015 were reviewed. Pancreatitis was classified by method of diagnosis (intraoperative/radiographic [IO/R] versus isolated serologic diagnosis) and timing (preoperative versus postoperative diagnosis). Twenty-three patients were identified with peritransplant pancreatitis (within 30 days preoperatively or postoperatively). A control group of patients without pancreatitis undergoing OLT was composed of 775 patients. Graft failure/death rates for patients with versus without pancreatitis were 7.4% versus 7.4% at 30 days, 33.3% versus 12.6% at 90 days, and 44.4% versus 26.9% at 12 months. Four patients with pancreatitis (17.4%) required emergent retransplantation and subsequently died within 90 days of their second transplant. Overall, 6 patients with pancreatitis (26.1%) died within 90 days of transplantation. Patients with pancreatitis had a hazard ratio (HR) for death or graft failure of 2.28 as compared with controls (P < 0.01). The effect of pancreatitis is most pronounced among those diagnosed by IO/R findings, with an adjusted HR of 2.53 (P < 0.01) and those diagnosed in the postoperative period, adjusted HR of 2.57 (P = 0.01). In conclusion, perioperative pancreatitis is associated with early graft failure and patient mortality, regardless of the method or timing of the diagnosis. Given these results, IO/R findings of pancreatitis should induce caution and potentially preclude OLT until resolved. Liver Transplantation 23 925-932 2017 AASLD.

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Survival outcomes in liver transplant recipients with Model for End‐stage Liver Disease scores of 40 or higher: a decade‐long experience

Abstract: Liver transplantation in recipients with MELD scores of ≥40 offers acceptable longterm survival outcomes. Futility predictors indicate the need for prospective follow-up studies to define the population to gain the highest benefit from this precious resource.

Cited by 37 publications

References 12 publications

Approaches for patients with very high MELD scores

Approaches for patients with very high MELD scores

Impact of the new MELD‐based allocation system on waiting list and post‐transplant survival—a cohort analysis using the French national CRISTAL database

Peritransplant pancreatitis: A marker of high mortality and graft failure in liver transplant patients

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