1
|
Chang CCH, Bryce CL, Shneider BL, Yabes JG, Ren Y, Zenarosa GL, Tomko H, Donnell DM, Squires RH, Roberts MS. Accuracy of the Pediatric End-stage Liver Disease Score in Estimating Pretransplant Mortality Among Pediatric Liver Transplant Candidates. JAMA Pediatr 2018; 172:1070-1077. [PMID: 30242345 PMCID: PMC6248160 DOI: 10.1001/jamapediatrics.2018.2541] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Fair allocation of livers between pediatric and adult recipients is critically dependent on the accuracy of mortality estimates afforded by the Pediatric End-stage Liver Disease (PELD) and Model for End-stage Liver Disease, respectively. Widespread reliance on exceptions for pediatric recipients suggests that the 2 systems may not be comparable. OBJECTIVE To evaluate the accuracy of the PELD score in estimating 90-day pretransplant mortality among pediatric patients on the United Network for Organ Sharing (UNOS) waiting list. DESIGN, SETTING, AND PARTICIPANTS Patients who were listed from February 27, 2002, to March 31, 2014, for primary liver transplant were included in this retrospective analysis and were followed up for at least 2 years through June 17, 2016. The study analyzed 2 cohorts using the UNOS Standard Transplant Analysis and Research data files. The full cohort comprised 4298 patients (<18 years of age) who had chronic liver disease (excluding cancer). The reduced cohort (n = 2421) excluded patients receiving living donor transplantation or PELD exception points. MAIN OUTCOMES AND MEASURES Observed and expected 90-day pretransplant mortality rates evaluated at 10-point interval PELD levels. RESULTS Among the 4298 patients in the full cohort (mean [SD] age, 2.5 [4.2] years; 2251 [52.4%] female; 2201 [51.2%] white), PELD scores and mortality were concordant (C statistic, 0.8387 [95% CI, 0.8191-0.8584] for the full cohort and 0.8123 [95% CI, 0.7919-0.8327] for the reduced cohort). However, the estimated 90-day mortality using the PELD score underestimated the actual probability of death by as much as 17%. CONCLUSIONS AND RELEVANCE With use of the PELD score, the ranking of risk among children was preserved, but direct comparisons between adult and pediatric candidates were not accurate. Children with chronic liver disease who are in need of transplant may be at a disadvantage compared with adults in a similar situation.
Collapse
Affiliation(s)
- Chung-Chou H. Chang
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Cindy L. Bryce
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Jonathan G. Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yi Ren
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Gabriel L. Zenarosa
- Department of Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Heather Tomko
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Drew M. Donnell
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Robert H. Squires
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Mark S. Roberts
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania,Department of Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania
| |
Collapse
|
2
|
Martino RB, Waisberg DR, Dias APM, Inoue VBS, Arantes RM, Haddad LBP, Rocha-Santos V, Pinheiro RSN, Nacif LS, D'Albuquerque LAC. Access to Liver Transplantation in Different ABO-Blood Groups and "Exceptions Points" in a Model for End-Stage Liver Disease Allocation System: A Brazilian Single-Center Study. Transplant Proc 2018; 50:754-757. [PMID: 29661430 DOI: 10.1016/j.transproceed.2018.02.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND In the Model for End-Stage Liver Disease (MELD) system, patients with "MELD exceptions" points may have unfair privilege in the competition for liver grafts. Furthermore, organ distribution following identical ABO blood types may also result in unjust organ allocation. The aim of this study was to investigate access to liver transplantation in a tertiary Brazilian center, regarding "MELD exceptions" situations and among ABO-blood groups. METHODS A total of 465 adult patients on the liver waitlist from August 2015 to August 2016 were followed up until August 2017. Patients were divided into groups according to ABO-blood type and presence of "exceptions points." RESULTS No differences in outcomes were observed among ABO-blood groups. However, patients from B and AB blood types spent less time on the list than patients from A and O groups (median, 46, 176, 415, and 401 days, respectively; P = .03). "Exceptions points" were granted for 141 patients (30.1%), hepatocellular carcinoma being the most common reason (52.4%). Patients with "exceptions points" showed higher transplantation rate, lower mortality on the list, and lower delta-MELD than non-exceptions patients (56.7% vs 19.1% [P < .01]; 18.4% vs 38.5% [P < .01], and 2.0 ± 2.6 vs 6.9 ± 7.0 [P < .01], respectively). Patients with refractory ascites had a higher mortality rate than those with other "exceptions" or without (48%). CONCLUSIONS The MELD system provides equal access to liver transplantation among ABO-blood types, despite shorter time on the waitlist for AB and B groups. The current MELD exception system provides advantages for candidates with "exception points," resulting in superior outcomes compared with those without exceptions.
Collapse
Affiliation(s)
- R B Martino
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil.
| | - D R Waisberg
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - A P M Dias
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - V B S Inoue
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - R M Arantes
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - L B P Haddad
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - V Rocha-Santos
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - R S N Pinheiro
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - L S Nacif
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| | - L A C D'Albuquerque
- Department of Gastroenterology, Liver and Gastrointestinal Transplant Division, University of Sao Paulo School of Medicine, Sao Paulo, Brazil
| |
Collapse
|