MELD 3.0: The Model for End-Stage Liver Disease Updated for the Modern Era

Disparities in liver transplantation for metabolic dysfunction-associated steatohepatitis-associated hepatocellular carcinoma

BACKGROUND

Metabolic dysfunction-associated steatohepatitis (MASH) is increasingly common, as is hepatocellular carcinoma (HCC) in the background of MASH. Liver transplantation (LT) provides superior long-term survival for patients with unresectable MASH-HCC, but not all patients have equal access to transplant. MASH-HCC disproportionately affects Hispanic patients, but minorities are less likely to undergo LT for HCC. Additionally, females also undergo LT at lower rates than males.

AIM

To investigate whether race/ethnicity and sex affect LT waitlist outcomes.

METHODS

Records of adults with MASH-HCC in the United States Organ Procurement and Transplantation Network database listed for LT between 1/2015 and 12/2021 were analyzed.

RESULTS

Most of the 3810 patients waitlisted for LT for MASH-HCC were non-Hispanic (NH) white (71.2%) or Hispanic (23.4%), with only 49 (1.1%) NH Black candidates. Hispanics underwent LT at lower rates than NH whites (71.6% vs 78.4%, P < 0.001), but race/ethnicity did not affect waitlist mortality (P = 0.06). Patients with Hispanic [hazard ratio (HR) = 0.85, 95%CI: 0.77-0.95, P = 0.002] or Asian (HR = 0.79, 95%CI: 0.63-0.98, P = 0.04) race/ethnicity were less likely to undergo LT. Women were also less likely to receive LT (male: HR = 1.16, 95%CI: 1.04-1.29, P = 0.01). Patients in regions 1 and 9 were less likely to be transplanted as well (P = 0.07).

CONCLUSION

Hispanic patients are less likely to undergo LT for MASH-HCC, concerning given their susceptibility to MASH and HCC. There were very few NH Black candidates. Disparities were also unequal across regions, which is particularly concerning in states where at-risk populations have rising cancer incidence. Additional research is needed to identify strategies for mitigating these differences in access to LT for MASH-HCC.

The liver allocation landscape: MELD 3.0 and continuous distribution

PURPOSE OF REVIEW

This review highlights recent advancements in liver organ allocation, specifically the transition to MELD 3.0 and the potential introduction of continuous distribution. These developments are timely, as they address the increasing need for a more efficient, equitable, and personalized system for prioritizing liver transplant candidates.

RECENT FINDINGS

The review covers two key innovations: MELD 3.0: A refined version of the original MELD score, designed to improve the prioritization process by incorporating additional factors that offer a more accurate and urgent measure of transplant need. This approach aims to better assess the severity of liver disease and the need for transplantation. Continuous distribution: A dynamic approach that shifts away from the static allocation model. It integrates multiple donor and recipient variables - such as geographic location, organ quality, and recipient condition - into a continuous, flexible allocation process. This framework seeks to make more nuanced decisions based on a broader set of factors that reflect transplant suitability.

SUMMARY

These innovations aim to enhance fairness and patient outcomes by refining candidate prioritization and reducing disparities in access to transplants. However, implementing these systems presents challenges, such as technical complexities and regional differences in access. Ongoing evaluation is necessary to ensure their effectiveness and equitable implementation across diverse patient populations.

Predicting Mortality and Cirrhosis-Related Complications with MELD3.0: A Multicenter Cohort Analysis

Background

/Aims: This study aimed to evaluate the performance of the Model for End-Stage Liver Disease (MELD) 3.0 for predicting mortality and liver-related complications compared with the Child-Pugh classification, albumin-bilirubin (ALBI) grade, the MELD, and the MELD sodium (MELDNa) score.

Methods

We evaluated a multicenter retrospective cohort of incorporated patients with cirrhosis between 2013 and 2019. We conducted comparisons of the area under the receiver operating characteristic curve (AUROC) of the MELD3.0 and other models for predicting 3-month mortality. Additionally, we assessed the risk of cirrhosis-related complications according to the MELD3.0 score.

Results

A total of 3,314 patients were included. The mean age was 55.9±11.3 years, and 70.2% of the patients were male. Within the initial 3 months, 220 patients (6.6%) died, and the MELD3.0 had the best predictive performance among the tested models, with an AUROC of 0.851, outperforming the Child-Pugh classification, ALBI grade, MELD, and MELDNa. A high MELD3.0 score was associated with an increased risk of mortality. Compared with that of the group with a MELD3.0 score <10 points, the adjusted hazard ratio of the group with a score of 10-20 points was 2.176, and that for the group with a score of ≥20 points was 4.892. Each 1-point increase in the MELD3.0 score increased the risk of cirrhosis-related complications by 1.033-fold. The risk of hepatorenal syndrome showed the highest increase, with an adjusted hazard ratio of 1.149, followed by hepatic encephalopathy and ascites.

Conclusions

The MELD3.0 demonstrated robust prognostic performance in predicting mortality in patients with cirrhosis. Moreover, the MELD3.0 score was linked to cirrhosis-related complications, particularly those involving kidney function, such as hepatorenal syndrome and ascites.

Diversity, Equity, Inclusion, and Belonging in Organ Transplantation

Diversity, equity, inclusion, and belonging (DEIB) have implications for transplant access and outcomes. Inequities in transplantation have been identified over the years for minoritized groups based on race, ethnicity, sex, sexual orientation, gender identity, disability status, and other sociocultural identities. While DEIB initiatives have demonstrated success in improving transplant outcomes for some minoritized groups, many gaps still exist, and additional work is needed. Concerns about these practices have also been brought up, and they may create barriers to achieving DEIB goals. This underscores the importance of transplant organizational commitment to practices that uphold the values of DEIB, as such efforts are effective in reducing transplant inequities and fostering an inclusive community. In this viewpoint, we reviewed existing inequalities in transplant, importance of DEIB, common concerns of DEIB initiatives, and commitment of the American Society of Transplant to DEIB initiatives, including the foundation of Inclusion, Diversity, Equity, and Access to Life (IDEAL) committee. Recommendations for cultivating DEIB practices, as well as tips for managing backlash against DEIB initiatives, were also provided. All professionals within the field of transplantation should carefully consider these recommendations to help promote an inclusive community for patients, providers, and all key stakeholders.

Prospective evaluation of cystatin C in the assessment of kidney dysfunction and survival in liver transplant candidates

Kidney dysfunction is associated with decreased survival in liver transplant (LT) candidates, yet serum creatinine (sCr) is a poor surrogate for glomerular filtration rate (GFR) in this population. Serum cystatin C (CysC) may provide a more accurate assessment of kidney function and predict outcomes. We performed a multicenter prospective cohort study of consecutive candidates for LT. CysC was obtained at LT evaluation (n = 244), and a subset underwent simultaneous I 125 -iothalamate clearance for measured GFR (mGFR) assessment (n = 137). Patients were followed to assess the need for pre-LT renal replacement therapy, simultaneous liver and kidney transplant, and survival. Estimated GFR (eGFR) based on MDRD-4, GRAIL, Royal Free Hospital Cirrhosis GFR, and the CKD-EPI equations was assessed for bias, precision, and accuracy in reference to mGFR. Receiver operator characteristic (AUROC) and competing risk survival analyses were performed. CysC more accurately discriminated mGFR than sCr at thresholds of ≤60 and ≤30 mL/min/1.73 m 2 with AUROC 0.92 ( p = 0.005) and 0.96 ( p =0.01), respectively. All eGFR equations overestimated GFR, especially among females ( p < 0.05). The GRAIL equation demonstrated the least bias, while CKD-EPI-cystatin C was associated with the greatest precision and lowest frequency of GFR overestimation. Among 165 recipients of LT, CysC discriminated pre-LT renal replacement therapy and the need for simultaneous liver and kidney transplant with AUROC of 0.70 and 0.85, respectively. Cumulative incidence of death, accounting for LT as a competing event, increased with CysC ( p = 0.002) but was not observed with sCr overall or among subgroups ( p = NS). CysC more accurately predicts thresholds of mGFR than sCr in candidates for LT. Elevated CysC discriminates pre-LT renal replacement therapy and simultaneous liver and kidney transplant and is strongly associated with survival in contrast with sCr. CysC is a promising tool to improve prognostication among candidates for LT.

Global epidemiology of acute kidney injury in hospitalised patients with decompensated cirrhosis: the International Club of Ascites GLOBAL AKI prospective, multicentre, cohort study

BACKGROUND

Acute kidney injury (AKI) is a serious complication of cirrhosis. A systematic, global characterisation of AKI occurring in patients with cirrhosis is lacking. We therefore aimed to assess global differences in the characteristics, management, and outcomes of AKI in hospitalised patients with cirrhosis.

METHODS

In this prospective, multicentre, cohort study, we enrolled adults (≥18 years) with decompensated cirrhosis who were hospitalised for a cirrhosis-related complication, with or without AKI, at 65 centres across five continents. We captured AKI prevalence, stage, phenotype, and details on AKI management and clinical course. Universal health coverage index and gross national income per capita were also collected. The primary outcome was 28-day mortality. Multivariable models including demographic and clinical variables, cirrhosis cause, cirrhosis severity, AKI severity, AKI management variables, universal health coverage, and gross national income were used to analyse independent associations with 28-day mortality. Secondary outcomes were AKI classification, progression, and resolution. This study is complete and registered with ClinicalTrials.gov (NCT05387811).

FINDINGS

Between July 1, 2022, and May 31, 2023, we enrolled 3821 patients who were hospitalised for decompensated cirrhosis. Mean age was 57·7 years (SD 13·1), 2467 (64·6%) were men, and 1354 (35·4%) were women. Most patients were White (2128 [55·7%]). 1456 (38·1%, 95% CI 36·6-39·6) of 3821 patients had AKI (943 [64·8%] men and 513 [35·2%] women). Globally, patients presented with similar AKI stages, but patients from North America and Asia had the highest MELD-Na scores at presentation and the highest rates of peak AKI stage 3. Overall, hypovolaemic AKI was the most common phenotype (858 [58·9%] of 1456), followed by HRS-AKI (253 [17·4%]) and acute tubular necrosis (216 [14·8%]). The prevalences of hypovolaemic AKI and HRS-AKI were similar across regions, but acute tubular necrosis was more frequent in Asia (p<0·0001 across regions). Additionally, regional differences in the management of AKI (use of albumin, vasopressors, and diuretics) were found. 335 (28·6%) of 1171 patients with initial AKI stages 1 or 2 had progression to higher stages during hospitalisation. AKI resolved in 862 (59·2%) cases during hospitalisation. 333 (22·9%) patients with AKI had died by 28 days. Multivariable analyses showed that increased age, female sex, presence of ascites, presence of hepatic encephalopathy, increased white blood cell count, increased MELD-Na, hospital-acquired AKI, a lower universal health coverage index (<80), and not being in a high-income country were independently associated with an increased risk of 28-day mortality. Increased serum albumin was associated with a decreased risk of 28-day mortality.

INTERPRETATION

This study found important regional differences in AKI severity, phenotype, management, and outcomes in patients with decompensated cirrhosis. Health-care coverage remains an important driver of survival in patients with cirrhosis and AKI.

FUNDING

European Association Study for the Study of the Liver and the Italian Society of Internal Medicine.

Sex-based Differences and Comparative Predictive Value of MELD 3.0 in Simultaneous Liver-Kidney Transplantation Waitlist Outcomes After Standardization of Listing Criteria in the United States

Background

Sex disparities in solid organ transplantation are well documented. Relative changes in sex-based outcome disparities after the 2017 standardization of simultaneous liver-kidney (SLK) listing criteria in the United States have not been reported. We hypothesized that this policy's objective measures of kidney dysfunction may differentially affect SLK patients by sex and that the use of MELD 3.0 in the SLK population might provide unique benefit to female transplant candidates.

Methods

Organ Procurement and Transplantation Network data were retrospectively analyzed comparing 2013-2016 with 2018-2021 SLK listings. Waitlist outcomes and Model for End-stage Liver Disease (MELD) 3.0 reclassifications were compared by sex and listing period.

Results

There were 2626 and 2609 male patients and 1670 and 1919 female patients pre- and post-policy changes, respectively. The proportion of female SLK listings post-policy change (42.4%) was higher than both female SLK listings pre-policy change (38.9%) and female single-organ liver listings post-policy change (36.8%; P < 0.01). A statistically significant interaction between sex and listing group (pre- versus post-policy change) was present in multivariable analysis (P = 0.02). Female patients were more likely to have a higher MELD 3.0 score than the listing MELD/MELD-Na score when the listing MELD score was <30 (P < 0.01). Among all patients who died on the waitlist, female patients were nearly twice as likely to be underrepresented by listing MELD compared with MELD 3.0 (23% female and 13% male patients; P < 0.01).

Conclusions

Waitlist outcomes were changed differentially between male and female patients after the 2017 SLK policy change. The application of MELD 3.0 to SLK patients is likely to benefit female patients.

AI-Cirrhosis-ECG (ACE) score for predicting decompensation and liver outcomes

Background & Aims

Accurate prediction of disease severity and prognosis are challenging in patients with cirrhosis. We evaluated whether the deep learning-based AI-Cirrhosis-ECG (ACE) score could detect hepatic decompensation and predict clinical outcomes in cirrhosis.

Methods

We analyzed 2,166 ECGs from 472 patients in a retrospective Mayo Clinic cohort, 420 patients in a prospective Mayo transplant cohort, and 341 patients in an external validation cohort from Hospital Clínic de Barcelona. The ACE score's performance was assessed using receiver-operating characteristic analysis for decompensation detection and competing risks Cox regression for outcome prediction.

Results

The ACE score showed high accuracy in detecting hepatic decompensation (area under the curve 0.933, 95% CI: 0.923-0.942) with 88.0% sensitivity and 84.3% specificity at an optimal threshold of 0.25. In multivariable analysis, each 0.1-point increase in ACE score was independently associated with increased risk of liver-related death (hazard ratio [HR] 1.44, 95% CI 1.32-1.58, p <0.001). Adding ACE to model for end-stage liver disease-sodium significantly improved prediction of adverse outcomes across all cohorts (c-statistics: retrospective cohort 0.903 vs. 0.844; prospective cohort 0.779 vs. 0.735; external validation 0.744 vs. 0.732; all p <0.001).

Conclusions

The ACE score accurately identifies hepatic decompensation and independently predicts liver-related outcomes in cirrhosis. This non-invasive tool enhances current prognostic models and may improve risk stratification in cirrhosis management.

Impact and implications

This study demonstrates the potential of artificial intelligence to enhance prognostication in liver disease, addressing the critical need for improved risk stratification in cirrhosis management. The AI-Cirrhosis-ECG (ACE) score, derived from widely available ECGs, shows promise as a non-invasive tool for detecting hepatic decompensation and predicting liver-related outcomes, which could significantly impact clinical decision-making and resource allocation in hepatology. These findings are particularly important for hepatologists, transplant surgeons, and patients with cirrhosis, as they offer a novel approach to complement existing prognostic models such as model for end-stage liver disease-sodium. In practical terms, the ACE score could be integrated into routine clinical assessments to provide more accurate risk predictions, potentially improving the timing of interventions, optimizing transplant listing decisions, and ultimately enhancing patient outcomes. However, further validation in diverse populations and integration with other established predictors is necessary before widespread clinical implementation.

Liver Transplantation in Alcohol-Associated Liver Disease

Alcohol-associated liver disease (ALD) is the foremost cause of liver-related mortality in the United States comprising a spectrum of conditions from simple hepatic steatosis to more severe alcohol-associated cirrhosis and alcohol-associated hepatitis. There has been growing acceptance and application of early liver transplantation (eLT) for ALD. There is robust evidence for excellent patient and graft survival rates for eLT for ALD. Nevertheless, recidivism remains a major concern. This article aims to explore the recent trends in liver transplantation for ALD, as well as the advances in practice and outcomes, with focus on eLT and emerging challenges in this field.

Differential Characteristics and Survival Outcomes of Patients With Cirrhosis According to Underlying Liver Aetiology

BACKGROUND AND AIMS

Updated data on the survival of patients with cirrhosis are limited, especially for subgroups by specific liver disease aetiology. To inform practice, future modelling studies, and public health planning, our study aimed to provide updated and granular data on survival outcomes of patients with cirrhosis stratified by liver disease aetiology. We also assessed their changes over time.

METHODS

We analysed 8726 consecutive adult patients with cirrhosis who presented at Stanford university medical center during 1/2005-1/2022.

RESULTS

8726 Patients had the following etiologies: hepatitis C virus (HCV) (28.1%), hepatitis B virus (HBV) (4.8%), alcohol-associated (ALD, 33.3%), metabolic-associated steatotic liver disease (MASLD) (9.5%), autoimmune (9.6%), cryptogenic (8.2%) and other etiologies (6.5%). Patients with cryptogenic cirrhosis had the lowest overall 5-, 10-, and 15-year cumulative survival (57.5%, 34.3% and 21.4%), as well as for liver and nonliver-related death, followed by ALD, MASLD, HCV, and autoimmune, while HBV patients had the best survival (86.0%, 70.1% and 65.1%), respectively. On multivariable Cox regression, cryptogenic cirrhosis (vs. HBV) was associated with the highest risk of all-cause death (aHR: 2.24, 95% CI 1.67-3.00), followed by MASLD and ALD (all p < 0.001). Post-2010 time was associated with a 33% lower risk of all-cause death (p = 0.0011); While in the post-2010 period, MASLD (vs. HBV) was associated with the highest risk of all-cause death (aHR: 1.92, 95% CI 1.32-2.80, p < 0.001) followed by cryptogenic and ALD.

CONCLUSIONS

Survival outcomes in patients with cirrhosis varied by aetiology and have changed over time, which should be taken into account for future practice guidelines and modelling studies.

Systemic treatment in patients with hepatocellular carcinoma and advanced liver dysfunction

Systemic therapy represents the standard of care treatment for patients with advanced hepatocellular carcinoma (HCC). Given the increased risk of death from cirrhosis-related complications in patients with advanced liver dysfunction, pivotal phase III trials traditionally limited inclusion to patients with Child-Pugh class A, where death is more likely to be attributed to HCC progression. Therefore, Western guidelines recommend the use of systemic therapies primarily in patients with preserved liver function. However, patients with HCC and Child-Pugh class B are commonly encountered in clinical practice, but due to limited prospective evidence, there is no clear guidance on their optimal management.In this recent advances article, we discuss how the clinical course of cirrhosis can affect eligibility to treatment in the modern era of systemic therapy for HCC, elaborate on strategies to improve liver function in HCC patients by targeting cirrhosis-related and tumour-related factors and summarise the current literature on systemic therapy in HCC patients with Child-Pugh class B. Based on this information, we finally propose a clinical algorithm on how to systematically approach patients with HCC and advanced liver dysfunction in clinical practice.

The role of rehabilitation across the continuum of liver disease from cirrhosis to transplantation and beyond: A narrative review

OBJECTIVE

The authors' objective with this narrative review is to explore the impact of rehabilitative interventions at each stage of liver disease. TYPE: Narrative review.

LITERATURE SURVEY

Literature search conducted in Medline, Embase, and Google Scholar databases.

METHODOLOGY

Articles were included if they were identified in one of the three database, written in English, peer-reviewed, and involved human participants without any restrictions on the publication date. Reference lists of these publications were also scrutinized for other articles that might be relevant. Elibigle articles were reviewed to determine whether they met inclusion crtieria.

SYNTHESIS

Authors synthesized findings in the eligible articles to create a narrative summary.

CONCLUSIONS

Chronic liver disease is a major cause of morbidity and mortality across the globe. Cirrhosis causes alterations in metabolic and circulatory functions that negatively affect nutritional status and exercise capacity. Frailty is identified in nearly half of patients with advanced liver disease and bears a poor prognosis. Exercise and nutritional interventions improve key components of physical frailty and quality of life in chronic liver disease and after liver transplantation. Early mobility is generally recommended following liver transplantation and deemed to be safe and feasible. Inpatient rehabilitation may be considered in patients who require ongoing daily medical management by a physician, demonstrate a significant functional decline from their baseline, tolerate intensive rehabilitation, and have functional goals that can be addressed by at least two skilled therapies. Rehabilitation is safe and improves outcomes at every stage of liver disease from cirrhosis to following transplantation. This literature review explores the impact of rehabilitative interventions at each stage of liver disease from cirrhosis to transplantation and beyond.

Mapping of rehabilitation interventions and assessment methods for patients with liver cirrhosis: a scoping review

BACKGROUND

This scoping review aimed to delineate the detailed components of exercise therapy and the evaluation methods used for patients with liver cirrhosis.

METHODS

The methodology involved searching the original PubMed, Web of Science, and Scopus for studies published between January 1975 and March 2025. The search was completed on 13 March 2025. Studies describing exercise therapy for liver cirrhosis patients were selected. Relevant information matching the study objectives, such as intervention duration, content, intensity setting, evaluation criteria, and outcomes, was extracted and documented.

RESULTS

Of the 2314 articles identified, 18 fit the inclusion and exclusion criteria, with a total of 950 participants. The most prevalent form of exercise therapy was a combined aerobic exercise and strength training program (55.6%). Commonly used assessment criteria included the 6-minute walking distance for endurance evaluation (44.4%) and the Chronic Liver Disease Questionnaire for quality of life assessment (33.3%). Intervention durations ranged from 30 to 60 min per day, 2 to 7 days per week, and 8 to 12 weeks. Concerning intensity setting, subjective fatigue levels and heart rate were frequently used (38.9%), though detailed descriptions were limited.

CONCLUSIONS

For the establishment of effective exercise therapy for patients with liver cirrhosis, future research should concentrate on tailoring intensity settings according to individual patient needs. Additionally, standardized reporting of intervention details and assessment methods is crucial for improving the quality and comparability of studies in this field.

Comparative Prognostic Utility of Updated Model for End-Stage Liver Disease Scores for Prediction of Early Mortality after Transjugular Intrahepatic Portosystemic Shunt Creation

PURPOSE

To compare the performance of updated model for end-stage liver disease (MELD) systems with that of the original MELD score for predicting early mortality after transjugular intrahepatic portosystemic shunt (TIPS) creation.

MATERIALS AND METHODS

In this single-center retrospective study, 6 MELD variations were quantified in 553 patients (n = 332; 60% male; mean age, 55 years) who underwent TIPS creation between 1998 and 2023. Scoring systems included original MELD, MELD-sodium (MELD-Na), MELD 3.0, MELD-lactate, MELD-glomerular filtration rate assessment in patients with liver disease-sodium (MELD-GRAIL-Na), and MELD-plus. Association of MELD schemes with 30-day, 6-week, and 90-day mortality was assessed using DeLong test, and the predictive capacity of MELD systems was evaluated by comparing area under receiver operating characteristic (AUROC) curves.

RESULTS

TIPS were created for ascites (n = 263, 47%), variceal hemorrhage (n = 247, 45%), or other indications (n = 43, 8%). All MELD systems statistically associated with mortality at each time point (P < .001). Based on 30-day, 6-week, and 90-day AUROC curves, none of the updated MELD systems showed superior predictive capacity for early mortality compared with original MELD-MELD: 0.847, 0.841, and 0.818; MELD-Na : 0.847, 0.846, and 0.829; MELD 3.0: 0.848, 0.850, and 0.842; MELD-lactate: 0.915, 0.881, and 0.866; MELD-GRAIL-Na: 0.851, 0.847, and 0.831; and MELD-Plus: 0.843-0.898, 0.853-0.910, and 0.814-0.829, respectively (P > .05). Findings were principally confirmed on subset analyses stratified by sex, TIPS indication, TIPS urgency, stent type, and TIPS date.

CONCLUSIONS

Updated MELD systems have prognostic value for early mortality after TIPS creation. However, in this study, these newer schemes did not offer additional predictive power beyond the original MELD, which still effectively estimates early post-TIPS survival.

PERFORMANCE OF SIX PREDICTIVE MODELS OF DEATH OF PATIENTS HOSPITALIZED FOR DECOMPENSATED CIRRHOSIS: A MULTICENTER STUDY

BACKGROUND

The natural history of cirrhosis is characterized by an asymptomatic phase (compensated cirrhosis) followed by a rapidly progressive phase (decompensated cirrhosis). The ability to predict the survival of patients with cirrhosis is crucial for decision-making, some as complex as the indication for a liver transplant. Several models have been developed and validated.

OBJECTIVE

To analyze and compare the performance of models in predicting 90-day mortality among patients hospitalized with decompensated cirrhosis.

METHODS

A sample of 481 hospitalized patients, with a mean age of 59.04 years 73% male, diagnosed with decompensated cirrhosis and a mean Child-Pugh score of 9. The prognostic models were calculated based on tests performed on admission: MELD-Na, MELD-Plus, MELD 3.0, ReMELD, Refit MELD, and Refit MELD-Na. The accuracy of the models was assessed by calculating the area under the receiver operating characteristic (AUROC) curve, and their respective 95% confidence intervals. Comparisons between the areas were conducted using the DeLong test. A comparison was conducted among all scores, with a primary focus on MELD 3.0 and MELD-Plus. These specific scores were the focal points of interest.

RESULTS

The scores presented AUROC curve values of 0.703-0.758, indicating a moderate capacity to discriminate between survivors and deceased patients during the considered period. The comparison between the models did not unequivocally establish the superiority of one model over the other.

CONCLUSION

The scores have a limited predictive ability for death within 90 days in patients with decompensated cirrhosis. Our study is unable to establish the prognostic superiority of a specific scoring system.

BACKGROUND

• This retrospective, multicenter study evaluated the accuracy of six predictive models of death within 90 days in 461 patients hospitalized for decompensated cirrhosis.

BACKGROUND

• The scores presented an area under the receiver operating characteristic curve of 0.703-0.758, indicating a good ability to discriminate between survivors and deceased patients during the considered period.

BACKGROUND

• The comparison between the models did not unequivocally establish the superiority of one model over the other.

Simulating the impact of survival benefit-based liver transplant organ allocation

BACKGROUND AND AIMS

In the United States and much of the world, prioritization for a deceased donor liver transplant focuses on sickest-first, based on allocating organs using the MELD score. There have been calls to instead allocate organs based on transplant survival benefit, but the impact of such a system on the broader waitlist population is unknown.

APPROACH AND RESULTS

We performed a simulation study using the Liver Simulated Allocation Model to compare the current US system of liver allocation to the one using different time horizons, focused on pretransplant survival only, posttransplant survival only, and survival benefit (difference of posttransplant survival and pretransplant survival). Changing liver allocation to a survival benefit-based system was simulated to lead to a small improvement in average patient-level posttransplant survival (mean survival over a 5-year time horizon of 4.24 y vs. 4.19 y in the current system). However, this small improvement was associated with a simulated decrease in transplants and an increase in waitlist mortality of 400 deaths per year. The resulting net benefit overall (pretransplant deaths and posttransplant survival) was negligible under a survival benefit-based allocation approach.

CONCLUSIONS

Our simulations predicted that survival benefit-based allocation would only increase posttransplant survival by an average of 18 days per recipient at the expense of a simulated increase in waitlist mortality of 400 deaths per year. In the current practice of liver transplantation, with the sickest-first allocation operating in a system where transplant physicians ration organs to maximize outcomes, the overall survival benefit is maintained and not compromised.

Referral to Liver Transplant: A National Survey from Portugal

Introduction

The referral of patients with cirrhosis to liver transplant (LT) is a multi-stage, complex process. There is a lack of data on potential challenges to this process. We aimed to characterize challenges faced by Portuguese referring clinicians.

Methods

This was a cross-sectional survey from Curry Cabral Hospital, Lisbon, Portugal. The survey was open for 90 days, from August to November 2024. The survey included 13 questions: characterization of participants with 5 questions and characterization of the process of referral to LT with 8 questions.

Results

Overall, 56 clinicians responded to the survey (response rate of 46.7%). Their median (IQR) age was 38.1 (33.2-42.1) years. Their level of training was specialist grade for 47 (83.9%) and fellow or intern grade for 9 (16.1%) individuals. The responders were from 21 different hospitals in Portugal; 8 (38.1%) provided tertiary care and 2 (9.5%) were LT centers. Among responders, there was heterogeneity regarding the following topics: referring criteria to LT, liver-related prognostic scores, contact channels with the LT center, tests and visits part of the LT workup. Many of them suggested the following improvements to develop national or regional referral criteria, to expedite communication with the LT team, to accelerate access to the tests or visits part of the LT workup, and to shorten the time to the first appointment with the LT team.

Conclusion

Portuguese clinicians identified several challenges and improvements to the referral of patients with cirrhosis to LT. These findings may inform future strategies to streamline the referral to LT.

Machine Learning Prediction Model of Waitlist Outcomes in Patients with Primary Sclerosing Cholangitis

Background

Liver transplantation is essential for many people with primary sclerosing cholangitis (PSC). People with PSC are less likely to receive a deceased donor liver transplant compared with other causes of chronic liver disease. This disparity may stem from the inaccuracy of the model for end-stage liver disease (MELD) in predicting waitlist mortality or dropout for PSC. The broad applicability of MELD across many causes comes at the expense of accuracy in prediction for certain causes that involve unique comorbidities. We aimed to develop a model that could more accurately predict dynamic changes in waitlist outcomes among patients with PSC while including complex clinical variables.

Methods

We developed 3 machine learning architectures using data from 4666 patients with PSC in the Scientific Registry of Transplant Recipients (SRTR) and tested our models on our institutional data set of 144 patients at the University Health Network (UHN). We evaluated their time-dependent concordance index (C-index) for mortality prediction and compared it against MELD-sodium and MELD 3.0.

Results

Random survival forest (RSF), a decision tree-based survival model, outperformed MELD-sodium and MELD 3.0 in both the SRTR and the UHN test data set using the same bloodwork variables and readily available demographic data. It achieved a C-index of 0.868 (SD 0.020) and 0.771 (SD 0.085) on the SRTR and UHN test data, respectively. Training a separate RSF model using the UHN data with PSC-specific achieved a C-index of 0.91. In addition to high MELD score, increased white blood cells, time on the waiting list, platelet count, presence of Autoimmune hepatitis-PSC overlap, aspartate aminotransferase, female sex, age, history of stricture dilation, and extremes of body weight were the top-ranked features predictive of the outcomes.

Conclusions

Our RSF model offers more accurate waitlist outcome prediction in PSC. The significant performance improvement with the inclusion of PSC-specific variables highlights the importance of disease-specific variables for predicting trajectories of clinically distinct presentations.

Association of Low BMI, Elevated Model for End-Stage Liver Disease Score, and Poor Functional Status With Increased 30-Day Readmission After Orthotopic Liver Transplant: A Retrospective Cohort Study

Background Liver transplantation is the ultimate treatment for end-stage liver disease. However, post-transplant management is very complex, with the need for meticulous immunosuppression regimens and multidisciplinary coordinated specialist care. This can be complicated by a higher risk of readmissions after transplant. Readmission rates are now being used as a measure of a facility's efficacy post-transplant. In this study, we investigated recipient characteristics that may place recipients at higher risk for 30-day readmission. Method Chi-square and independent t-test analyses of six variables were performed accordingly on liver transplant recipient data extracted from the Standard Transplant Analysis and Research (STAR) data. The variables were Model for End-Stage Liver Disease (MELD) score, body mass index (BMI), age, diabetes status, hepatitis C status, and functional status. The association between these variables and 30-day readmission rates was investigated. Results We observed six recipient risk factors, including elevated MELD score, positive diabetes mellitus status, positive hepatitis C status, and lower functional status, which increase hospitalization post-transplant. Of the six examined characteristics, lower BMI, elevated MELD score, and lower functional status were significantly associated with 30-day readmission. The t values and P values were as follows: t(38,180) = 4.080, P = 4.514E-05 for BMI; t(38,180) = 4.080, P = 4.514E-05 for MELD score; and t(38,180) = 2.729, P = 6.356E-03 for functional status. Conclusion Our study shows that liver transplant recipients with lower BMI, higher average MELD score, and lower functional status can be identified as high-risk recipients for readmission within 30 days after liver transplant. These findings might help transplant centers anticipate higher complication rates and possibly implement better nutritional optimization prior to transplant and closer follow-up after transplant. Further research could identify specific thresholds for these characteristics that are associated with significantly worse outcomes.

Rotational thromboelastometry predicts transplant-free survival in patients with liver cirrhosis

BACKGROUND AND AIMS

Emerging evidence suggests that rotational thromboelastometry (ROTEM) is superior to conventional haemostatic tests in the assessment and management of bleeding risk in patients with cirrhosis. Whether ROTEM may also be useful for assessing the prognosis of these patients is unknown. We aimed to explore the role of ROTEM in predicting the transplant-free survival of patients with cirrhosis.

METHODS

We conducted a prospective cohort study of patients with cirrhosis at two hospitals. All patients underwent ROTEM analysis at baseline and were followed up until death, liver transplantation or the end of follow-up (28 February 2023). Univariate and multivariate Cox regression analyses were performed to explore the association between transplant-free survivals.

RESULTS

Between April 2018 and October 2021, 162 patients with cirrhosis were recruited and followed-up for a median of 42 months. During follow-up, 36 patients died and 7 underwent liver transplantation. On univariate analysis, maximum clot firmness (MCF) using both EXTEM and INTEM tests was significantly reduced in the death/liver transplant group compared to the survivor group (52 vs. 57, P  = 0.02; and 51 vs. 55, P  = 0.01, respectively). After adjusting for age, sex, presence of clinically significant portal hypertension, hepatocellular carcinoma, care setting, bilirubin, sodium and creatinine, only albumin (hazard ratio: 0.92, 95% CI: 0.85-0.99, P  = 0.018) and MCF EXT (hazard ratio: 0.96, 95% CI: 0.92-0.99, P  = 0.032) remained significant predictors of transplant-free survival.

CONCLUSION

ROTEM may be useful in assessing the survival of patients with cirrhosis. Further research is needed to determine the clinical utility of ROTEM parameters as prognostic markers in cirrhosis.

Hepatocellular carcinoma: Revising the surgical approach in light of the concept of multiparametric therapeutic hierarchy

The clinical management of hepatocellular carcinoma (HCC) is strongly influenced by several prognostic factors, mainly tumor stage, patient's health, liver function and specific characteristics of each intervention. The interplay between these factors should be carefully evaluated by a multidisciplinary tumor board. To support this, the novel "multiparametric therapeutic hierarchy" (MTH) concept has been recently proposed. This review will present the main features of available surgical treatments for HCC (liver transplantation, liver resection, ablation). Strengths and weaknesses are reported in the light of clinical decision making and of treatment allocation, with a special focus on the collocation of each treatment in the MTH framework and on how MTH may be useful in supporting clinical decision. Sequential treatments and their role to allow further surgical treatments will also be analyzed.

Contingency management to promote treatment engagement in comorbid alcohol use disorder and alcohol-related liver disease: Findings from a pilot randomized controlled trial

BACKGROUND

Alcohol-related liver disease (ARLD) is a leading cause of preventable death and health inequalities. Evidence-based interventions for comorbid alcohol use disorder (AUD) and ARLD remain limited, and only a small proportion of this clinical population engages with treatment. There is a need to improve patient outcomes by bridging this gap through novel, person-centred interventions. Contingency management (CM) is a psychosocial intervention that involves gradual, increasing incentives upon the completion of treatment-related goals, such as treatment attendance. This single-centre, randomized pilot trial of voucher-based CM was conducted to promote treatment engagement in comorbid AUD and ARLD.

METHODS

Thirty service users were recruited from an inpatient setting, offered integrated liver care (ILC) and allocated to ILC only or ILC + CM. Primary outcomes included feasibility criteria (recruitment, study retention post-randomization, completeness of data and protocol fidelity). Secondary outcome data on engagement, alcohol intake, and liver function were also collected. Data were gathered at baseline, post-ILC, and 12 weeks post-ILC and analyzed through descriptive statistics.

RESULTS

The feasibility of the research was subject to challenges inherent to conducting applied health research in a real-world clinical setting. The recruitment and retention rates were 73.20% and 36.70%, respectively. All participants received CM per protocol. An increasing trend in engagement was observed in the ILC + CM compared to ILC only (67% vs. 33%). A trending 76% reduction in alcohol intake and an overall improvement in liver outcomes were observed among participants engaging with the trial, with no significant differences between control and treatment groups.

CONCLUSION

Overall, the CM intervention was feasible to deliver and appears promising in improving outcomes in individuals with comorbid AUD and ARLD. Aspects related to recruitment, study retention post-randomization, and protocol fidelity need to be further adapted before proceeding with a definitive trial.

Predictors of long-term clinical outcomes after TIPS: An ALTA group study

BACKGROUND AND AIMS

While TIPS is traditionally considered a bridge to liver transplant (LT), some patients achieve long-term transplant-free survival (TFS) with TIPS alone. Prognosis and need for LT should not only be assessed at time of procedure, but also re-evaluated in patients with favorable early outcomes.

APPROACH AND RESULTS

Adult recipients of TIPS in the multicenter advancing liver therapeutic approaches retrospective cohort study were included (N=1127 patients; 2040 person-years follow-up). Adjusted competing risk regressions were used to assess factors associated with long-term post-TIPS clinical outcomes at the time of procedure and 6 months post-TIPS. MELD-Na at TIPS was significantly associated with post-TIPS mortality (subdistribution hazards ratio of death 1.1 [ p =0.42], 1.3 [ p =0.04], and 1.7 [ p <0.01] for MELD-Na 15-19, 20-24, and ≥25 relative to MELD-Na <15, respectively). MELD 3.0 was also associated with post-TIPS outcomes. Among the 694 (62%) patients who achieved early (6 mo) post-TIPS TFS, rates of long-term TFS were 88% at 1 year and 57% at 3 years post-TIPS. Additionally, a within-individual increase in MELD-Na score of >3 points from TIPS to 6 months post-TIPS was significantly associated with long-term mortality, regardless of initial MELD-Na score (subdistribution hazards ratio of death 1.8, p <0.01). For patients with long-term post-TIPS TFS, rates of complications of the TIPS or portal hypertension were low.

CONCLUSIONS

Among patients with early post-TIPS TFS, prognosis and need for LT should be reassessed, informed by postprocedure changes in MELD-Na and clinical status. For selected patients, "destination TIPS" without LT may offer long-term survival with freedom from portal hypertensive complications.

Role of continuous renal replacement therapy in management of the preliver transplant patient

PURPOSE OF REVIEW

Highlight the importance of acute kidney injury (AKI) among liver transplant candidates, its importance of survival and the vital role of continuous renal replacement therapy (CRRT) as a supportive therapy.

RECENT FINDINGS

Kidney dysfunction is common in the preliver transplant patient. Early recognition, broad diagnostic work up, and therapeutic interventions are vital in minimizing morbidity and mortality in this critically ill group of patients. Liver dysfunction can impact kidney function in multiple ways, leading to worsening of clinical illness. High mortality and poor prognosis in those with AKI without CRRT and Liver Transplant are highlighted.

SUMMARY

Etiology of AKI may not be as important as is the potential for liver transplant (LT) listing in offering CRRT. Non eligibility for a LT does not by default imply non eligibility for CRRT. Multidisciplinary approach should be adopted among those with a need for CRRT in the setting of end-stage liver disease. Goals of care conversations are key, in evaluating the role of CRRT in this group of individuals as they have a very high risk of mortality.

Concordance Indices for Risk Scores With Policy Evaluations

OBJECTIVE

To demonstrate the differences between concordance index (C-index) methodologies and clarify the appropriate usage for risk score evaluations in health services applications.

STUDY SETTING AND DESIGN

We performed a methodological comparison of C-index metrics and illustrated the consequences of these differences through a study of liver failure patients.

DATA SOURCES AND ANALYTIC SAMPLE

We analyzed secondary adult liver transplant registry data from the Organ Procurement and Transplantation Network (OPTN), including all waitlist registrations from 2002 to 2022.

PRINCIPAL FINDINGS

The recommended concordance metric based on Gerds' weighting was higher for the original model for end-stage liver disease (MELD) than Harrell's C-Index, Uno's C-Index, and naïve binary outcome metrics (0.864 [95% confidence interval (CI): 0.840, 0.888] versus 0.854 [95% CI: 0.844, 0.864], 0.832 [95% CI: 0.819, 0.844], and 0.727 [95% CI: 0.715, 0.740]), and it did not increase after the latest MELD formula update (0.874 [95% CI: 0.859, 0.889] to 0.869 [95% CI: 0.853, 0.885]).

CONCLUSIONS

The concordance indices that are often used in health services applications have important deficiencies under policy-related dependent censoring, and researchers must apply appropriate weighting schemes to avoid bias. The findings uncover new interpretations of past evaluation results that have shaped national liver transplant policies.

Correlations of three scoring systems with the prognosis of patients with liver cirrhosis complicated with sepsis syndrome

BACKGROUND

Severe symptoms associated with sepsis syndrome (SS) are considered a severe threat, which not only increases therapeutic difficulty but also causes a prognostic mortality rate. However, at present, few related studies focused on the application of different score scales for disease and prognosis assessment in liver cirrhosis (LC) complicated with SS.

AIM

To determine the correlations of the model for end-stage liver disease (MELD), sequential organ failure assessment (SOFA), and modified early warning score (MEWS) points with the prognosis of patients with LC complicated with SS.

METHODS

This retrospective analysis included 426 LC cases from February 2019 to April 2022. Of them, 225 cases that were complicated with SS were assigned to the LC + SS group, and 201 simple LC cases were included in the LC group. Intergroup differences in MELD, SOFA, and MEWS scores were compared, as well as their diagnostic value for LC + SS. The correlations of the three scores with the prognosis of patients with LC + SS were further analyzed, as well as the related risk factors affecting patients' outcomes, after the follow-up investigation.

RESULTS

MELD, SOFA, and MEWS scores were all higher in the LC + SS group vs the LC group, and their combined assessment for LC + SS revealed a diagnostic sensitivity and a specificity of 89.66% and 90.84%, respectively (P < 0.05). The LC + SS group reported 58 deaths, with an overall mortality rate of 25.78%. Deceased patients presented higher MELD, SOFA, and MEWS points than those who survived (P < 0.05). MELD, SOFA, and MEWS scores were determined by COX analysis as factors independently affecting the prognosis of patients with LC + SS (P < 0.05).

CONCLUSION

MELD, SOFA, and MEWS effectively diagnosed LC in patients complicated with SS, and they demonstrated great significance in assessing prognosis, which provides a reliable prognosis guarantee for patients with LC + SS. However, their assessment effects remain limited, which is worthy of further investigation by more in-depth and rigorous experimental analysis.

Anaesthesia evaluation and perioperative strategies in liver disease patients with cardiohepatic syndrome

Cardiohepatic syndrome (CHS) presents a significant challenge in perioperative management due to the complex interaction between liver and heart dysfunction. CHS, analogous to cardiorenal syndrome, encompasses various conditions where hepatic and cardiovascular pathologies exacerbate one another. Patients with chronic liver disease, cirrhosis, or heart failure often exhibit increased perioperative morbidity and mortality, necessitating tailored anesthetic strategies. A comprehensive understanding of CHS pathophysiology is crucial, as it informs risk assessment and guides perioperative management. Risk stratification tools such as the Child-Pugh and MELD scores are commonly used, but they have limitations in fully capturing perioperative risks. The updated STS 2024 model includes liver-specific parameters, improving risk prediction in cardiac surgeries. Additionally, the VOCAL-Penn score addresses gaps in traditional risk models, providing a more accurate assessment for patients with advanced liver disease. Perioperative management focuses on minimizing hemodynamic stress and avoiding drugs metabolized by the liver. Agents like Remifentanil, Atracurium, and Esmolol are preferred for their minimal hepatic metabolism. Vasopressors such as terlipressin and vasopressin, which target the splanchnic circulation, improve hemodynamics in these patients. Within the Enhanced Recovery After Surgery (ERAS) framework, optimizing nutrition and fluid management is essential for reducing perioperative complications. Effective management of patients with CHS requires a multidisciplinary approach that integrates comprehensive risk assessment and individualized anesthetic strategies. This approach improves outcomes by reducing perioperative complications and mortality in this high-risk population.

Automated abdominal CT imaging biomarkers and clinical frailty measures associated with postoperative deceased-donor liver transplant outcomes

OBJECTIVE

To quantify the potential of fully automated CT-based body composition metrics and clinical frailty data in predicting liver transplant recipient postoperative outcomes.

METHODS

AI-enabled body composition tools were applied to pre-transplant abdominal CT scans in a retrospective cohort of first-time deceased-donor liver transplant recipients. Clinical frailty data (Fried frailty score) was obtained from an established transplant database. Age- and sex-corrected hazard ratios (HRs) were analyzed according to highest-risk quartiles compared with the other three quartiles combined. Area under the receiver operating characteristic curve (ROC AUC) analysis in univariate and multivariate scenarios was also performed.

RESULTS

598 liver transplant recipients (median age, 56 years [IQR, 49-61]; 383 men/215 women) were included from 2005 to 2021. Mean clinical follow-up interval after transplant was 8.6 ± 4.5 years, with 224 deaths (mean interval, 5.3 ± 3.9 years post-transplant) and 246 graft failures (mean interval, 4.7 ± 4.0 years post-transplant) observed. Univariate HRs for post-transplant survival included 1.53 (95% CI, 1.14-2.06) for muscle attenuation, 1.66 (95% Cl, 1.24-2.22) for aortic Agatston score, 1.35 (1.02-1.80) for SAT area, and 1.82 (1.35-2.46) for liver volume. For those meeting the frailty criteria, HR was 2.14 (1.08-4.22). Multivariate 10-year AUC for predicting mortality was 0.675 using liver volume, aortic Agatston score, and muscle attenuation. 10-year univariate AUC for clinical frailty assessment was 0.601 but increased to 0.878 when combined with CT measures.

CONCLUSION

Automated CT measurements of muscle density (myosteatosis), aortic calcification, subcutaneous fat, and liver volume are predictive of mortality in liver transplant recipients. Frailty was likewise predictive. Combining CT and clinical frailty assessment was complementary.

KEY POINTS

Question What is the prognostic value of pre-transplant CT-based body composition measures for deceased-donor liver transplant outcomes, and how do they correlate with frailty assessment? Findings Increased post-transplant mortality was associated with pre-transplant increased liver volume, increased abdominal aortic Agatston score, decreased skeletal muscle attenuation, and decreased subcutaneous adipose tissue area. Clinical relevance Pre-transplant AI-enabled body composition measures have predictive value for post-transplant survival, offering a novel and objective diagnostic tool to identify high-risk transplant recipients that are complementary to clinical assessments.

Comparison of Mortality Prediction Between the Model for End-Stage Liver Disease-3.0 (MELD-3.0) and the Model for End-Stage Liver Disease-Lactate (MELD-La) in Korean Patients with Liver Cirrhosis

Background and Objectives: The Model for End-Stage Liver Disease (MELD) score has widely been used for mortality prediction in liver cirrhosis (LC) patients and transplantation allocation. There have been recent modifications of MELD scores, such as MELD-Lactate (MELD-La) and MELD-3.0. The goal of this study was to compare MELD, MELD-La, and MELD-3.0 in predicting mortality among LC patients in Korea. Materials and Methods: This is a retrospective, single-centered study in which LC patients admitted to Konkuk University Hospital between January 2011 and December 2022 were enrolled and reviewed. Predictive values for 1- and 3-month mortality for MELD, MELD-La, and MELD-3.0 were calculated using the area under the receiver operating characteristic (AUROC) curve. Differences between AUROCs were statistically analyzed using DeLong's test. Results: A total of 1152 patients were initially included in this study. Among them, 165 (14.3%) patients died within one month, and 211 (19.7%) died within three months. The AUROCs for 1-month mortality of MELD, MELD-La, and MELD-3.0 were 0.808, 0.79, and 0.807, respectively. For the 3-month mortality of MELD, MELD-La, and MELD-3.0, the AUROCs were 0.805, 0.753, and 0.817, respectively. Multiple comparisons of ROC curves demonstrated that MELD and MELD-3.0 reflected the 3-month mortality prediction of LC patients better than MELD-La (p = 0.0018, p = 0.0003, respectively). Conclusions: This study demonstrated that MELD and MELD-3.0 outperformed MELD-La in predicting the 3-month mortality for LC patients. However, there was no significant difference between MELD and MELD-3.0 in predicting LC patient mortality.

Preliminary experience of combined dual plasma molecular adsorption system and plasma exchange in pediatric acute liver failure: a retrospective case series

BACKGROUND

Pediatric acute liver failure (PALF) is a life-threatening condition with no definitive treatment. This study evaluated the combined use of the dual plasma molecular adsorption system (DPMAS) and plasma exchange (PE) to improve liver function and survival outcomes in PALF patients.

METHODS

A retrospective study was conducted on 7 PALF patients treated with DPMAS and PE. Data on liver function scores (Liver Injury Unit [LIU], Model for End-Stage Liver Disease [MELD], Model for End-Stage Liver Disease with Sodium [MELD-Na], MELD 3.0), bilirubin levels, and coagulation indices were collected before and after treatment.

RESULTS

DPMAS and PE treatments significantly reduced total bilirubin (382.2 µmol/L to 52.0 µmol/L) and improved coagulation indices. Liver injury scores decreased notably (e.g., LIU from 184 to 52 in one case). Five patients recovered, while two with severe comorbidities showed limited improvement.

CONCLUSION

The combination of DPMAS and PE therapy improves liver function and survival outcomes in PALF. These results support its use as a bridge to recovery or transplantation in PALF patients, though further studies with larger sample sizes are needed.

Decreasing Case Fatality Rates for Patients With Cirrhosis Infected With SARS-CoV-2: A National COVID Cohort Collaborative Study

BACKGROUND & AIMS

The virulence and severity of SARS-CoV-2 infections have decreased over time in the general population due to vaccinations and improved antiviral treatments. Whether a similar trend has occurred in patients with cirrhosis is unclear. We used the National COVID Cohort Collaborative (N3C) to describe the outcomes over time.

METHODS

We utilized the N3C level 3 data set with uncensored dates to identify all patients with chronic liver disease (CLD) with and without cirrhosis who had SARS-CoV-2 infection as of November 2023. We described the observed 30-day case fatality rate (CFR) by month of infection. We used adjusted survival analyses to calculate relative hazard of death by month of infection compared with infection at the onset of the COVID-19 pandemic.

RESULTS

We identified 117,811 total patients with CLD infected with SARS-CoV-2 between March 2020 and November 2023: 27,428 (23%) with cirrhosis and 90,383 (77%) without cirrhosis. The observed 30-day CFRs during the entire study period were 1.1% (1016) for patients with CLD without cirrhosis and 6.3% (1732) with cirrhosis. Observed 30-day CFRs by month of infection varied throughout the pandemic and showed a sustained downward trend since 2022. Compared with infection in Quarter 2 of 2020 (at the beginning of the pandemic), the adjusted hazards of death at 30 days for infection in Quarter 3 of 2023 were 0.20 (95% confidence interval [CI], 0.08-0.50) for patients with CLD without cirrhosis and 0.35 (95% CI, 0.18-0.69) for patients with CLD with cirrhosis.

CONCLUSIONS

In this N3C study, we found that the observed 30-day CFR decreased progressively for patients with CLD both with and without cirrhosis, consistent with broader trends seen in the general population.

Clinical outcomes and predictors in patients with acute on chronic liver failure in Southern Taiwan

BACKGROUND/AIMS

The study is to analyze the clinical characteristics and identify prognostic factors as well as evaluate predictive models in patients with acute-on-chronic liver failure (ACLF) from Southern Taiwan.

METHODS

The cohort study was conducted using the Chang Gung Research Database. We included patients with ACLF based on the definition provided by the Asian-Pacific Association for the Study of the Liver ACLF Research Consortium (AARC).

RESULTS

A total of 231 patients diagnosed with ACLF were included in this study, out of which 26 patients underwent liver transplantation (LT). The primary cause of ACLF was acute exacerbation of hepatitis B virus (HBV) in 68.4% of cases and followed by severe alcoholic hepatitis (20.8%). Among LT-free patients, the 28-day mortality rate was observed to be 31%. Older age, higher INR and ammonia levels, and the presence of severe hepatic encephalopathy on 3-6 days of treatment were independent predictors of 28-day mortality. The CLIF-C ACLF and COSSH-ACLF scores, evaluated on 3-6 days, demonstrated the highest predictive performance for 28-day mortality. The optimal cut-off values for the CLIF-C ACLF and COSSH-ACLF scores were determined to be 47 and 6.3, respectively. Patients with CLIF-C ACLF score >63 or COSSH-ACLF score >8.1 experienced 100% mortality by day 28.

CONCLUSION

The CLIF-C ACLF and COSSH-ACLF scores, evaluated within one week after treatment, exhibit strong predictive capabilities for short-term mortality in ACLF patients. These models are valuable tools for guiding timely decision-making, including the consideration of liver transplantation or withdrawal from treatment.

Prognosis algorithms for acute decompensation of cirrhosis and ACLF

Accurate prediction of survival in patients with cirrhosis is crucial, as patients who are unlikely to survive in the short-term need to be oriented to liver transplantation and to novel therapeutic approaches. Patients with acute decompensation of cirrhosis without or with organ dysfunction/failure, the so-called acute-on-chronic liver failure (ACLF), have a particularly high short-term mortality. Recognizing the specificity of this clinical situation, dedicated classifications and scores have been developed over the last 15 years, including variables (e.g. organ failures and systemic inflammation) not part of the formerly available cirrhosis severity scores, namely Child-Pugh score or MELD. For patients with acute decompensation of cirrhosis, it led to the development of a dedicated score, the Clif-C-AD score, independently validated. For more severe patients, three different scoring systems have been proposed, by European, Asian and North American societies namely Clif-C-ACLF, AARC score and NASCELD-ACLF respectively. These scores have been validated, and are widely used across the world. The differences and similarities between these scores, as well as their validation and limitations are discussed here. Even if these scores and classifications have been a step forward in favouring homogeneity between studies, and in helping making decisions for individual patients, their predictive value for mortality can still be improved as their area under the ROC curve does not exceed .8. Novel scores including biomarkers reflecting the pathophysiology of acute decompensation of cirrhosis might help reach that goal.

Noninvasive assessment of hepatic decompensation

Noninvasive tests (NITs) are used in all aspects of liver disease management. Their most prominent break-through since the millennium has been in advancing early detection of liver fibrosis, but their use is not limited to this. In contrast to the symptom-driven assessment of decompensation in patients with cirrhosis, NITs provide not only opportunities for earlier diagnoses but also accurate prognostication, targeted treatment decisions, and a means of monitoring disease. NITs can inform disease management and decision-making based on validated cutoffs and standardized interpretations as a valuable supplement to clinical acumen. The Baveno VI and VII consensus meetings resulted in tangible improvements to pathways of care for patients with compensated and decompensated advanced chronic liver disease, including the combination of platelet count and transient elastography to diagnose clinically significant portal hypertension. Furthermore, circulating NITs will play increasingly important roles in assessing the response to interventions against ascites, variceal bleeding, HE, acute kidney injury, and infections. However, due to NITs' wide availability, there is a risk of inaccurate use, leading to a waste of resources and flawed decisions. In this review, we describe the uses and pitfalls of NITs for hepatic decompensation, from risk stratification in primary care to treatment decisions in outpatient clinics, as well as for the in-hospital management of patients with acute-on-chronic liver failure. We summarize which NITs to use when, for what indications, and how to maximize the potential of NITs for improved patient management.

Effectiveness of liver transplant mortality scales in a Mexican population

BACKGROUND

Liver transplantation is the treatment of choice in patients with chronic liver disease and acute liver failure of any etiology. Scales such as the Survival Outcome Following Transplantation (SOFT) score and the Balance of Risk (BAR) score can be used to predict survival. In this study, we compared these scales in the Mexican population.

METHODS

A cross-sectional analytical study was carried out in a Mexican third-level transplant center. The MELD, SOFT, and BAR scales were adopted. The ROC curves of the three predictive scores were constructed, and the areas under the curve were obtained and compared. A bivariate analysis and Cox regression were performed. Finally, a survival analysis was performed using Kaplan-Meier curves.

RESULTS

We analyzed 123 liver transplant (LT) recipients. The bivariate analysis and Cox regression indicated that portal thrombosis, with an HR of 3.36 (IC 1.069-10.59, p = 0.038), and the number of red blood cells transfused, with an HR of 1.084 (CI 1.039-1.130, p < 0.000), were significantly associated with mortality. The receiver height was a protective factor, with an HR of 0.001 (CI 0.000-0.761, p = 0.041). Regarding the Pearson correlation analysis, the BAR scale had a coefficient of 0.199 (p = 0.032) for transfusion, while the SOFT scale's correlation coefficients for cold ischemia and transfusion were 0.236 (p = 0.011) and 0.274 (p = 0.003), respectively, all indicating weak correlations. The areas under the curve (AUCs) of MELD, SOFT, and BAR in predicting 3-month mortality were 0.495 (P = 0.94), 0.608 (p = 0.129), and 0.502 (p = 0.97), respectively. Finally, in the survival analysis using Kaplan-Meier curves, an estimated mean survival period of 71.52 months was obtained, with a survival rate of 89.3 % at 30 days and 81.1 % at five years.

CONCLUSION

In this study, it was found that all three scales were deficient in discriminating among the outcomes obtained in the Mexican population.

Exploring the Viability of Matching Marginal Donors With Low Renal Function Recipients in Liver Transplantation

BACKGROUND

Renal function varies among liver transplantation (LT) candidates with the same Model for End-Stage Liver Disease (MELD)3.0 score. The impact of marginal grafts on post-LT renal function and prognosis varies based on the pre-LT renal function. We explored the effects of matching recipients with low renal function to marginal donors on graft survival (GS) and post-LT kidney function.

METHODS

We analyzed data from the Scientific Registry of Transplant Recipients (SRTR), categorizing pre-LT renal function by estimated glomerular filtration rate (eGFR) into low (<30 mL/min/1.73 m2) and high (≥30 mL/min/1.73 m2). Marginal donors were defined by criteria including donation after cardiac death, age ≥ 65, severe macrosteatosis (≥30%), or body mass index ≥ 40 kg/m2. The primary outcome was to compare 3-year post-LT GS between patients with low and high pre-LT renal function. Additionally, we examined post-LT eGFR 1-3 months post-LT.

RESULTS

Of 13 279 LT recipients, 12 851 had high pre-LT eGFR and 428 had low pre-LT eGFR. Kaplan-Meier survival analysis showed that recipients with low pre-LT eGFR had significantly lower 3-year GS compared to those with high eGFR (p < 0.01). Recipients of organs from marginal donors also exhibited a significant reduction in 3-year GS (p < 0.01). This adverse effect persisted within the same MELD3.0 category. Additionally, lower pre-LT eGFR was associated with an increased risk of post-LT kidney function deterioration, especially among those receiving grafts from marginal donors. Multivariable logistic regression identified recipient age > 65 as a significant risk factor for post-LT kidney function decline (OR 3.34 [1.05-10.7]; p = 0.03).

DISCUSSION

GS was notably worse in recipients with low pre-LT eGFR, particularly when matched with marginal donors. A recipient age > 65 is a risk indicator for post-LT kidney function deterioration with marginal donors, underscoring the importance of careful donor-recipient matching, especially with compromised pre-LT kidney function.

Association between lactate-to-albumin ratio and short-term prognosis of acute-on-chronic liver failure treated with artificial liver support system

BACKGROUND

The impact of lactate-to-albumin ratio (LAR) on the outcome of acute-on-chronic liver failure (ACLF) is scant.

AIMS

To investigate the relationship between LAR and short-term prognosis in patients with COSSH (Chinese Group on the Study of Severe Hepatitis B) ACLF.

METHODS

A retrospective cohort study was conducted in patients with COSSH ACLF treated with an artificial liver support system. Restricted cubic splines, linear regression models, and Cox regression models were used to investigate the relationships of LAR with disease severity and 28-day prognosis.

RESULTS

The 28-day transplant-free and overall survival rates in the 258 eligible patients were 76.4% and 82.2%, respectively. The LAR in 28-day transplant-free survivors was lower than that in transplant or death patients [0.74 (0.58-0.98) vs. 1.03 (0.79-1.35), P <  0.001]. The LAR was positively associated with disease severity, 28-day transplant-free survival [adjusted hazard ratio (HR) (95% confidence interval (CI)) for transplant or death: 2.18 (1.37-3.46), P =  0.001], and overall survival [adjusted HR (95% CI) for death: 2.14 (1.21-3.80), P =  0.009]. Compared with patients with LAR < 1.01, patients with LAR ≥ 1.01 had poor 28-day prognosis [all adjusted HR (95% CI) > 1, P  < 0.05]. Lactate was not a potential modifier of the relationship between LAR and short-term prognosis.

CONCLUSION

LAR was positively associated with disease severity and poor short-term prognosis in patients with COSSH ACLF.

Association between lactate-to-albumin ratio and all-cause mortality in critically ill cirrhotic patients with sepsis: a retrospective analysis of the MIMIC-IV database

BACKGROUND

The impact of lactate-to-albumin ratio (LAR) on mortality of critically ill cirrhotic patients with sepsis is scant.

METHODS

Critically ill cirrhotic patients with sepsis were obtained from the MIMIC-IV database (v3.0). Cox regression models alone and in combination with restricted cubic splines, generalized additive models and smoothed curve fitting were used to investigate the relationship between LAR and all-cause mortality.

RESULTS

A total of 1864 patients were included. The 30-day, 90-day, and 180-day all-cause mortality rates were 38.0%, 46.3%, and 49.5%, respectively. Higher LAR were significantly and nonlinearly associated with higher risks of 30-day, 90-day, and 180-day all-cause mortality (all adjusted HR = 1.17, P < 0.001). L-shaped associations between LAR and 30-day, 90-day, and 180-day all-cause mortality were observed, with an inflection point of 1.05 (P for log-likelihood ratio < 0.01). Compared with patients with LAR < 1.05, patients with LAR ≥ 1.05 had higher risks of 30-day, 90-day, and 180-day all-cause mortality (adjusted HR (95% CI): 1.48 (1.27-1.72), 1.44 (1.25-1.66), and 1.38 (1.21-1.57), respectively). No potential modifiers were found in the relationship between LAR and mortality.

CONCLUSIONS

LAR was positively and nonlinearly associated with all-cause mortality in critically ill cirrhotic patients with sepsis. Thus, it could be used as a prognostic biomarker.

The prognostic nutritional index is an effective prognostic and nutritional status indicator for cirrhosis

BACKGROUND AND AIM

Malnutrition is an important clinical feature of cirrhotic patients and is closely associated with prognosis. The prognostic nutritional index (PNI) is a measure of nutritional status. This study was conducted to clarify whether the PNI is related to the severity and prognosis of cirrhosis.

METHODS

In this study, we retrospectively analysed the clinical data of patients who were hospitalized with a primary diagnosis of liver cirrhosis from January 2020 to December 2023 at Tianmen Hospital affiliated with Wuhan University of Science and Technology. Cox regression was used to analyse the independent risk factors for prognosis in patients with decompensated cirrhosis, and the predictive value of the PNI for assessing cirrhosis severity and prognosis was analysed via receiver operating characteristic (ROC) curves.

RESULTS

A total of 513 patients with cirrhosis were included in the study. The patients were divided according to disease severity into compensated (28) and decompensated (485) groups, where the decompensated group consisted of the ascites-only group (63), the complications group (381), and the death group (41). The PNI [hazard ratio (HR) = 0.925, 95% confidence interval (CI): 0.858-0.997, P = 0.041] and platelet count (HR = 1.006, 95% CI: 1.002-1.01, P = 0.002) were found to be independent factors influencing poor prognosis in patients with decompensated cirrhosis. The PNI has predictive value for mortality in decompensated cirrhosis patients. Moreover, a significant disparity was observed in the PNI between the compensated and decompensated groups, and the PNI in the compensated group [47.03(42.85,51.50)] was markedly greater than that in the decompensated group [34.15(30.05,37.93)]. As the severity of the disease increased, the PNI progressively decreased in the ascites-only group [36.40 (32.15, 40.80)], the complication group [34.05 (30.08, 37.80)], and the death group [30.15 (27.05, 35.58)].The ROC curves revealed that the PNI had a high predictive value for decompensated cirrhosis [area under the curve (AUC) = 0.897] and the highest predictive value for mortality outcome (AUC = 0.943). This research also demonstrated that the PNI is strongly correlated with the occurrence and number of complications.

CONCLUSION

The prognostic nutritional index is a good indicator of the severity and prognosis of cirrhotic disease and warrants clinical promotion.

Association between neutrophil percentage to albumin ratio and short term prognosis of acute on chronic liver failure treated with artificial liver support system

The impact of neutrophil percentage-to-albumin ratio (NPAR) on the outcome of acute-on-chronic liver failure (ACLF) is scant. A retrospective cohort study was conducted in patients with ACLF treated with artificial liver support system (ALSS). The ACLF was diagnosed according to the Chinese Group on the Study of Severe Hepatitis B-ACLF (COSSH ACLF) criteria. Disease severity was rated according to the COSSH ACLF score. Restricted cubic splines, linear or Cox regression models were used to investigate the relationships of baseline NPAR with disease severity and 90-day prognosis. The 90-day transplant-free and overall survival rates of 258 eligible patients were 58.5% and 66.3%, respectively. The NPAR in transplant-free survivors was lower than that in transplant or death patients (22.8 ± 4.4 vs. 25.3 ± 3.7, P < 0.001). NPAR was positively associated with COSSH ACLF score (adjusted β (95% CI) > 0, P < 0.001), transplant-free survival (adjusted HR (95% CI) for transplant or death: 1.07 (1.02-1.13), P = 0.007), and overall survival (adjusted HR (95% CI) for death: 1.09 (1.03-1.15), P = 0.003). Patients with NPAR ≥ 22.4 had poor 90-day prognosis compared to the rest (all adjusted HR (95% CI) > 1, P < 0.05). NPAR was positively associated with disease severity and poor short-term prognosis in patients with COSSH ACLF who underwent ALSS treatment. Thus, it could be used as a prognostic biomarker for COSSH ACLF.

Survival benefit of liver transplantation utilizing marginal donor organ according to ABO blood type

The current liver transplantation (LT) allocation policy focuses on the MELD scores, often overlooking factors like blood type and survival benefits. Understanding blood types' impact on survival benefits is crucial for optimizing the MELD 3.0 classification. This study used the United Network for Organ Sharing national registry database (2003-2020) to identify LT characteristics per ABO blood type and to determine the optimal MELD 3.0 scores for each blood type, based on survival benefits. The study included candidates of LT aged 18 years or older listed for LT (total N=150,815; A: 56,546, AB: 5841, B: 18,500, O: 69,928). Among these, 87,409 individuals (58.0%) underwent LT (A:32,156, AB: 4,362, B: 11,786, O: 39,105). Higher transplantation rates were observed in AB and B groups, with lower median MELD 3.0 scores at transplantation (AB: 21, B: 24 vs. A/O: 26, p <0.01) and shorter waiting times (AB: 101 d, B:172 d vs. A: 211 d, O: 201 d, p <0.01). A preference for donation after cardiac death (DCD) was seen in A and O recipients. Survival benefit analysis indicated that B blood type required higher MELD 3.0 scores for transplantation than A and O (donation after brain death transplantation: ≥15 in B vs. ≥11 in A/O; DCD transplantation: ≥21 in B vs. ≥11 in A, ≥15 in O). The study suggests revising the allocation policy to consider blood type for improved post-LT survival. This calls for personalized LT policies, recommending higher MELD 3.0 thresholds, particularly for individuals with type B blood.

The importance of equity in transplant oncology

PURPOSE OF REVIEW

Transplant oncology encompasses and utilizes liver transplantation (LT) in combination with other aspects of cancer care to offer improved long-term outcomes for patients with liver cancer, but not all patients have equal access and ability to undergo LT. Social determinants of health may negatively impact a patient's ability to receive liver-related oncologic care, including LT. This review highlights recent work exposing gaps in access to LT, including transplant oncology, and interventions to ameliorate these disparities.

RECENT FINDINGS

Members of racial and ethnic minorities and indigenous groups, females, socioeconomically disadvantaged persons, and patients from rural areas are less likely to undergo LT. Recent studies have also described programs that have successfully mitigated some of the barriers in access to transplant oncology that these patients experience, including targeted outreach programs and access to virtual healthcare.

SUMMARY

Disparities in access to LT for liver cancer are increasingly well described, but additional research is needed to find effective ways to ameliorate these differences.

Variation in intention-to-treat survival by MELD subtypes: All models created for end-stage liver disease are not equal

BACKGROUND & AIMS

Kidney dysfunction is a major determinant of prognosis in patients with decompensated cirrhosis awaiting transplantation. We hypothesized that for identical model for end-stage liver disease (MELD) scores at listing, outcomes before and after liver transplantation may vary if the predominant driver of the MELD score is serum creatinine (Cr) vs. serum bilirubin (Br) or international normalized ratio (INR).

METHODS

We evaluated all adult patients registered for liver transplantation (LT) between 2016-2020 and excluded patients receiving MELD exceptions or undergoing dual organ transplantation. Using K-Means clustering analysis, we classified each patient as MELD-Br, MELD-INR or MELD-Cr depending on the dominant variable for their MELD score. The primary outcome was intent-to-treat (ITT) survival, defined as survival within 1 year from listing with or without LT.

RESULTS

MELD scores of LT waitlist registrants were clustered into three subtypes: MELD-Br (n = 13,658), MELD-INR (n = 13,809), and MELD-Cr (n = 12,412). One-year ITT survival rates were 78% (MELD-Br), 75% (MELD-INR), and 65% (MELD-Cr), p <0.01. ITT survival was lower for each MELD subtype for females compared to males (e.g. MELD-Cr: 63% females vs. 67% males, p <0.0001). The MELD-Cr subtype had the highest MELD at listing (MELD-Cr 23.4 vs. MELD-Br 19.2 vs. MELD-INR 21.0) and the largest decline in MELD over 3 months (23% vs. 12% vs. 21%). In adjusted analyses including MELD-Na, MELD-Cr was associated with higher waitlist mortality (hazard ratio 1.339, 95% CI 1.279-1.402) and lower LT rates (hazard ratio 0.688, 95% CI 0.664-0.713) compaed to the other subtypes.

CONCLUSIONS

For equivalent listing practices, registrants with the MELD-Cr subtype have lower ITT survival. MELD subtype may serve as a more sophisticated variable for dynamic assessment of mortality risk and to guide organ allocation.

IMPACT AND IMPLICATIONS

The model for end-stage liver disease (MELD) score is an excellent predictor of waitlist mortality; however, our work highlights that the driver of a patient's MELD score matters and particularly those driven by elevated creatinine are associated with lower 1-year intent-to-treat survival. The 1-year intent-to-treat survival is also lower for women compared to men within the Cr-dominant subtype. These results are important for physicians and patients undergoing LT evaluation as creatinine may serve as a marker of prognosis and even if creatinine levels improve the prognosis remains poor, necessitating discussion about alternative pathways for transplant. Our work also highlights that the type of kidney injury matters, in that those with acute kidney injury were more likely to die or remain on the waitlist than those with chronic kidney disease within the creatinine-dominant subtype.

Health disparities in cirrhosis care and liver transplantation

Morbidity and mortality from cirrhosis are substantial and increasing. Health disparities in cirrhosis and liver transplantation are reflective of inequities along the entire spectrum of chronic liver disease care, from screening and diagnosis to prevention and treatment of liver-related complications. The key populations experiencing disparities in health status and healthcare delivery include racial and ethnic minority groups, sexual and gender minorities, people of lower socioeconomic status and underserved rural communities. These disparities lead to delayed diagnosis of chronic liver disease and complications of cirrhosis (for example, hepatocellular carcinoma), to differences in treatment of chronic liver disease and its complications, and ultimately to unequal access to transplantation for those with end-stage liver disease. Calling out these disparities is only the first step towards implementing solutions that can improve health equity and clinical outcomes for everyone. Multi-level interventions along the care continuum for chronic liver disease are needed to mitigate these disparities and provide equitable access to care.