Trends in Characteristics of Patients Listed for Liver Transplantation Will Lead to Higher Rates of Waitlist Removal Due to Clinical Deterioration

Abstract

Background Changes in the epidemiology of end stage liver disease may lead to increased risk of dropout from the liver transplant waitlist. Anticipating the future of liver transplant waitlist characteristics is vital when considering organ allocation policy. Methods We performed a discrete event simulation to forecast patient characteristics and rate of waitlist dropout. Estimates were simulated from 2015–2025. The model was informed by data from the Organ Procurement and Transplant Network, 2003–2014. National data are estimated along with forecasts for 2 regions. Results NASH will increase from 18% of waitlist additions to 22% by 2025. Hepatitis C will fall from 30% to 21%. Listings over age 60 will increase from 36% to 48%. The hazard of dropout will increase from 41% to 46% nationally. Wait times for transplant for patients listed with a MELD between 22 and 27 will double. Region 5, which transplants at relatively higher MELD scores, will experience an increase from 53% to 64% waitlist dropout. Region 11, which transplants at lower MELD scores, will have an increase in waitlist dropout from 30% to 44%. Conclusions The liver transplant waitlist size will remain static over the next decade due to patient dropout. Liver transplant candidates will be older, more likely to have NASH and will wait for transplantation longer even when listed at a competitive MELD score. There will continue to be significant heterogeneity among transplant regions where some patients will be more likely to drop out of the waitlist than receive a transplant.

The impact of post‐transplant diabetes mellitus on liver transplant outcomes

“…Our finding that PTDM onset occurs early in the first year post‐LT suggests the need to implement strategies to target PTDM immediately post‐LT. Moreover, given increasing rates of NAFLD on the transplant wait‐list, metabolic syndrome risk factors among donors, and more frequent LT for older individuals, special attention needs to be paid to the risk of developing PTDM, in particular among older LT recipients.…”

Perioperative glucose management and outcomes in liver transplant recipients: A qualitative systematic review

“…More patients with insulin resistance will come to transplant in the coming years. NAFLD is the fastest growing indication for transplant and will become the leading indication over the next decade[ 30 , 31 ]. The change in disease etiology may also be accompanied by donor grafts from older patients with DM and obesity that may be more susceptible to poor outcomes from hyperglycemic stressors[ 32 ].…”

Patients With Persistently Low MELD-Na Scores Continue to Be at Risk of Liver-related Death

“…2,3 This population is notable as patients with low MELD-Na scores comprise the vast majority of patients with cirrhosis in large national samples of waitlisted patients. 4,5 One single-center study of listed patients with MELD score less than 22 suggests that these patients succumb to liver related complications and have a mortality rate upwards of 30% over 2 years. 6 Unfortunately the above studies are limited by the inherent selection bias related to the transplant listing process.…”