Model for End-Stage Liver Disease (MELD) score and organ allocation from cadaveric donors for 198 liver transplantation procedures performed in a single center

Factors Associated with Mortality and Graft Failure in Liver Transplants: A Hierarchical Approach

BACKGROUND

Liver transplantation has received increased attention in the medical field since the 1980s following the introduction of new immunosuppressants and improved surgical techniques. Currently, transplantation is the treatment of choice for patients with end-stage liver disease, and it has been expanded for other indications. Liver transplantation outcomes depend on donor factors, operating conditions, and the disease stage of the recipient. A retrospective cohort was studied to identify mortality and graft failure rates and their associated factors. All adult liver transplants performed in the state of São Paulo, Brazil, between 2006 and 2012 were studied.

METHODS AND FINDINGS

A hierarchical Poisson multiple regression model was used to analyze factors related to mortality and graft failure in liver transplants. A total of 2,666 patients, 18 years or older, (1,482 males; 1,184 females) were investigated. Outcome variables included mortality and graft failure rates, which were grouped into a single binary variable called negative outcome rate. Additionally, donor clinical, laboratory, intensive care, and organ characteristics and recipient clinical data were analyzed. The mortality rate was 16.2 per 100 person-years (py) (95% CI: 15.1-17.3), and the graft failure rate was 1.8 per 100 py (95% CI: 1.5-2.2). Thus, the negative outcome rate was 18.0 per 100 py (95% CI: 16.9-19.2). The best risk model demonstrated that recipient creatinine ≥ 2.11 mg/dl [RR = 1.80 (95% CI: 1.56-2.08)], total bilirubin ≥ 2.11 mg/dl [RR = 1.48 (95% CI: 1.27-1.72)], Na+ ≥ 141.01 mg/dl [RR = 1.70 (95% CI: 1.47-1.97)], RNI ≥ 2.71 [RR = 1.64 (95% CI: 1.41-1.90)], body surface ≥ 1.98 [RR = 0.81 (95% CI: 0.68-0.97)] and donor age ≥ 54 years [RR = 1.28 (95% CI: 1.11-1.48)], male gender [RR = 1.19(95% CI: 1.03-1.37)], dobutamine use [RR = 0.54 (95% CI: 0.36-0.82)] and intubation ≥ 6 days [RR = 1.16 (95% CI: 1.10-1.34)] affected the negative outcome rate.

CONCLUSIONS

The current study confirms that both donor and recipient characteristics must be considered in post-transplant outcomes and prognostic scores. Our data demonstrated that recipient characteristics have a greater impact on post-transplant outcomes than donor characteristics. This new concept makes liver transplant teams to rethink about the limits in a MELD allocation system, with many teams competing with each other. The results suggest that although we have some concerns about the donors features, the recipient factors were heaviest predictors for bad outcomes.

Survival benefit of liver transplantation and the effect of underlying liver disease

BACKGROUND

The benefit of liver transplantation relative to initial degree of underlying liver disease and time on the waiting list remains poorly defined. We sought to examine the survival benefit attributable to liver transplantation across a wide range of Model for End-Stage Liver Disease (MELD) scores.

METHODS

The study population included patients with end-stage liver disease enlisted in Rio Grande do Sul, Brazil, between 2001 and 2005. Survival and hazard function for enlisted and transplanted patients were estimated using parametric and nonparametric methods. MELD score was utilized to account for underlying liver disease.

RESULTS

Of 1,130 eligible patients, 520 (46.0%) were transplanted, 266 (23.5%) died on the waiting list, 141 (12.5%) were excluded from the waiting list, and 203 (18.0%) remained enlisted and were awaiting transplantation at the time of last observation. At 1 year after transplantation, a MELD score of 15 represented a transition point in terms of overall survival benefit (MELD 10, 90% vs 83%; MELD 15, 81% vs 80%; MELD 20, 63% vs 78%; MELD 25, 42% vs 74%; MELD 30, 21% vs71%; enlisted vs transplant patients, respectively). MELD scores at which transplantation seemed to be beneficial relative to the amount of follow-up time was MELD 23, 17, 15, and 12 at 6 months, and 1, 2, and 5 years, respectively, from time of transplantation/enlistment.

CONCLUSION

Although patients with greater MELD scores enjoy a pronounced and early benefit from transplantation, patients with lesser MELD scores do gain from transplantation, although a greater period of time is needed to realize the survival benefit.

Values of end-stage liver disease model in assessment of prognosis in patients with decompensated liver cirrhosis

AIM: To compare the prognostic values of for end-stage liver disease (MELD) model and Child-Turcotte-Pugh (CTP) for patients with decompensated liver cirrhosis.

METHODS: From a previously collected database, 203 patients with decompensated liver cirrhosis admitted to our hospital were studied and followed up at least for one year. MELD and CTP score and classification were calculated on entry. Receiver operating characteristics curves (ROC) and the area under ROC were used to determine the ability of the scores for predicting three, six and twelve month mortality. Kaplan-Meier survival analysis (K-M) was performed using the cut-offs to establish the predictive power of each score.

RESULTS: There were 23, 39 and 85 dead cases within 3, 6 and 12 mo respectively. There was a significant correlation between the MELD and CTP score in 3, 6 and 12 mo (r = 0.76, 0.69, 0.71, P < 0.01). The areas under the receiver operating characteristics curves of MELD and CTP for the occurrence of death in 3 mo were 0.886 and 0.775. There was a significant difference in the 3 mo between two scores (P < 0.01). The areas under the receiver operating characteristics curves for MELD was 0.892 compared with 0.876 for CTP at 6 mo (P > 0.05); the area was 0.873 and 0.886 respectively at 12 mo (P > 0.05). Both MELD and CTP scores predicted the death rate and survival rate within 3, 6 and 12 mo by survival analysis (P < 0.01).

CONCLUSION: MELD is a strong prognosis predictor for the decompensated liver cirrhosis. MELD was significantly better than CTP score for predicting in-hospital mortality in 3 mo. However, these are not superior to CTP score and CTP classification in 6 and 12 mo.