Relationship between donor ejection fraction, left ventricular wall thickness and mortality in heart transplants recipients

This study explored the impact of donor left ventricular ejection fraction (EF) and left ventricular wall thickness (LVWT) on mortality among heart transplant (HTx) recipients. Utilizing data from the United Network for Organ Sharing (UNOS) registry, adult HTx recipients between 2006-2022 were analyzed. Patients were categorized into four groups based on donor EF(>50 % or ≤50 %) and LVWT(<1.4 cm or ≥1.4 cm). 21,012 patients were included. There were significant differences in baseline characteristics among the groups. Unadjusted mortality was 6.3 %, 6.0 %, 6.0 %, and 2.4 %(p=0.86) at 30-days; 16.2 %, 13.5 %, 16.8 %, and 7.3 %(p=0.08) at 1-year; and 32.2 %, 29.2 %, 35.4 %, and 29.0 %(p=0.18) at 5-years, respectively. In addition, adjusted mortality did not differ across the groups. There were no significant differences in recipient mortality in groups based on donor EF and LVWT. Expanding the donor selection criteria would allow for increase in the donor pool and assist in decreasing the mortality, while on the waitlist for HTx.

Predicting wait time for pediatric kidney transplant: a novel index

BACKGROUND

Over one thousand pediatric kidney transplant candidates are added to the waitlist annually, yet the prospective time spent waiting is unknown for many. Our study fills this gap by identifying variables that impact waitlist time and by creating an index to predict the likelihood of a pediatric candidate receiving a transplant within 1 year of listing. This index could be used to guide patient management by giving clinicians a potential timeline for each candidate's listing based on a unique combination of risk factors.

METHODS

A retrospective analysis of 3757 pediatric kidney transplant candidates from the 2014 to 2020 OPTN/UNOS database was performed. The data was randomly divided into a training set, comprising two-thirds of the data, and a testing set, comprising one-third of the data. From the training set, univariable and multivariable logistic regressions were used to identify significant predictive factors affecting wait times. A predictive index was created using variables significant in the multivariable analysis. The index's ability to predict likelihood of transplantation within 1 year of listing was validated using ROC analysis on the training set. Validation of the index using ROC analysis was repeated on the testing set.

RESULTS

A total of 10 variables were found to be significant. The five most significant variables include the following: blood group, B (OR 0.65); dialysis status (OR 3.67); kidney disease etiology, SLE (OR 0.38); and OPTN region, 5 (OR 0.54) and 6 (OR 0.46). ROC analysis of the index on the training set yielded a c-statistic of 0.71. ROC analysis of the index on the testing set yielded a c-statistic of 0.68.

CONCLUSIONS

This index is a modest prognostic model to assess time to pediatric kidney transplantation. It is intended as a supplementary tool to guide patient management by providing clinicians with an individualized prospective timeline for each candidate. Early identification of candidates with potential for prolonged waiting times may help encourage more living donation including paired donation chains.

New UNOS allocation system associated with no added benefit in waitlist outcomes and worse post-transplant survival in heart-kidney patients

BACKGROUND

The 2018 United Network for Organ Sharing (UNOS) heart transplant policy change (PC) sought to improve waitlist risk stratification to decrease waitlist mortality and promote geographically broader sharing for high-acuity patients awaiting heart transplantation. Our analysis sought to determine the effect of the UNOS PC on outcomes in patients waiting for, or who have received, a heart-kidney transplantation.

METHODS

We analyzed adult (≥18 years old), first-time, heart-only and heart-kidney transplant candidates and recipients from the UNOS Registry. Patients were divided into pre-PC (PRE: October 18, 2016-May 30, 2018) and post-PC (POST: October 18, 2018-May 30, 2020) groups for comparison. Competing risks analysis (subdistribution and cause-specific hazards analyses) was performed to assess for differences in waitlist death/deterioration or heart transplantation. One-year post-transplant survival was assessed with Kaplan-Meier and Cox analyses. We included an interaction term (policy era × heart ± kidney) in our analyses to evaluate the effect of PC on outcomes in heart-kidney patients.

RESULTS

One-year post-transplant survival was similar (p = 0.83) for PRE heart-kidney and heart-only recipients, but worse (p < 0.001) for POST heart-kidney vs heart-only recipients. There was a policy-era interaction between heart-kidney and heart-only recipients (HR 1.92[1.04,3.55], p = 0.038) indicating a detrimental effect of policy on 1-year survival in POST vs PRE heart-kidney recipients. No added beneficial effect of PC on waitlist outcomes in heart-kidney vs heart-only candidates was observed.

CONCLUSIONS

There was no added policy-era benefit on waitlist outcomes for heart-kidney candidates when compared to heart-only candidates. POST heart-kidney recipients experienced worse 1-year survival compared to PRE heart-kidney recipients with no policy effect on heart-only recipients.

National Trends, Risk Factors, and Outcomes of Acute In-Hospital Stroke Following Lung Transplantation in the United States: Analysis of the United Network for Organ Sharing Registry

BACKGROUND

Lung transplantation (LTx) is the definitive treatment for end-stage lung failure. However, there have been no large, long-term studies on the impact of acute in-hospital stroke in this population.

RESEARCH QUESTION

What are the trends, risk factors, and outcomes of acute stroke in patients undergoing LTx in the United States?

STUDY DESIGN AND METHODS

We identified adult first-time isolated LTx recipients from the United Network for Organ Sharing database, which comprehensively captures every transplant in the United States, between May 2005 and December 2020. Stroke was defined as occurring at any time after LTx but prior to discharge. Multivariable logistic regression with stepwise feature elimination was used to identify risk factors for stroke. Freedom from death in patients with a stroke vs those without a stroke was evaluated with Kaplan-Meier analysis. Cox proportional hazards analysis was used to identify predictors of death at 24 months.

RESULTS

Of 28,564 patients (median age, 60 years; 60% male), 653 (2.3%) experienced an acute in-hospital stroke after LTx. Median follow-up was 1.2 (stroke) and 3.0 (non-stroke) years. Annual incidence of stroke increased (1.5% in 2005 to 2.4% in 2020; P for trend = .007), as did lung allocation score and utilization of post-LTx extracorporeal membrane oxygenation (P = .01 and P < .001, respectively). Compared with those without stroke, patients with stroke had lower survival at 1 month (84% vs 98%), 12 months (61% vs 88%), and 24 months (52% vs 80%) (log-rank test, P < .001 for all). In Cox analysis, acute stroke conferred a high hazard of mortality (hazard ratio, 3.01; 95% CI, 2.67-3.41). Post-LTx extracorporeal membrane oxygenation was the strongest risk factor for stroke (adjusted OR, 2.98; 95% CI, 2.19-4.06).

INTERPRETATION

Acute in-hospital stroke post-LTx has been increasing over time and is associated with markedly worse short- and long-term survival. As increasingly sicker patients undergo LTx as well as experience stroke, further research on stroke characteristics, prevention, and management strategies is warranted.

Effect of the UNOS policy change on rates of rejection, infection, and hospital readmission following heart transplantation

BACKGROUND

The 2018 adult heart allocation policy sought to improve waitlist risk stratification, reduce waitlist mortality, and increase organ access. This system prioritized patients at greatest risk for waitlist mortality, especially individuals requiring temporary mechanical circulatory support (tMCS). Posttransplant complications are significantly higher in patients on tMCS before transplantation, and early posttransplant complications impact long-term mortality. We sought to determine if policy change affected early posttransplant complication rates of rejection, infection, and hospitalization.

METHODS

We included all adult, heart-only, single-organ heart transplant recipients from the UNOS registry with pre-policy (PRE) individuals transplanted between November 1, 2016, and October 31, 2017, and post-policy (POST) between November 1, 2018, and October 31, 2019. We used a multivariable logistic regression analysis to assess the effect of policy change on posttransplant rejection, infection, and hospitalization. Two COVID-19 eras (2019-2020, 2020-2021) were included in our analysis.

RESULTS

The majority of baseline characteristics were comparable between PRE and POST era recipients. The odds of treated rejection (p = 0.8), hospitalization (p = 0.69), and hospitalization due to rejection (p = 0.76) and infection (p = 0.66) were similar between PRE and POST eras; there was a trend towards reduced odds of rejection (p = 0.08). In both COVID eras, there was a clear reduction in rejection and treated rejection with no effect on hospitalization for rejection or infection. Odds of all-cause hospitalization was increased in both COVID eras.

CONCLUSIONS

The UNOS policy change improves access to heart transplantation for higher acuity patients without increasing early posttransplant rates of treated rejection or hospitalization for rejection or infection, factors which portend risk for long-term posttransplant mortality.

Increased-risk versus standard-risk donation in lung transplantation: A United Network of Organ Sharing analysis

OBJECTIVES

Donors with characteristics that increase risk of hepatitis B virus, hepatitis C virus, and HIV transmission are deemed increased-risk donors (IRDs) per Public Health Service guidelines. Compared with organs from standard-risk donors (SRDs), IRD organs are more frequently declined. We sought to investigate the outcomes of IRD lung transplant recipients following the 2013 guideline change.

METHODS

We retrospectively identified lung transplant recipients using the United Network of Organ Sharing registry (February 2014 to March 2020). Patients were divided into 2 cohorts, based on Centers for Disease Control and Prevention risk status of the donor: SRD or IRD. Demographics and clinical parameters were compared across groups. Survival was compared using Kaplan-Meier curves and log-rank tests. Cox proportional hazard model was performed to identify variables associated with survival outcome.

RESULTS

We identified 13,205 lung transplant recipients, 9963 who received allografts from SRDs and 3242 who received allografts from IRDs. In both groups, most donors were White, male, and <30 years old. IRDs demonstrated greater rates of heavy alcohol, cigarette, and cocaine use. SRDs had greater rates of cancer, hypertension, previous myocardial infarction, and diabetes. Survival analysis demonstrated no significant difference in 90-day, 1-year, 3-year, or 5-year survival outcome between SRD and IRD recipients (P = .34, P = .67, P = .40, P = .52, respectively). Cox regression demonstrated that double-lung transplants were associated with 13% decreased mortality risk compared with single-lung (P = .0009).

CONCLUSIONS

IRD and SRD recipients demonstrated equivalent survival outcomes. Our study suggests that IRDs offer a safe approach to expand the donor pool and increase availability of lungs for transplantation.

Extracorporeal membrane oxygenation as a bridge to advanced heart failure therapies

BACKGROUND

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) is a key support modality for cardiogenic shock. The 2018 United Network for Organ Sharing (UNOS) heart transplant allocation algorithm prioritizes VA-ECMO patients.

OBJECTIVE

To evaluate the role of VA-ECMO in bridging to advanced heart failure therapies.

METHODS

We analyzed adult patients from the multicenter Extracorporeal Life Support Organization registry receiving VA-ECMO for cardiac support or resuscitation between 2016 and 2021 in the United States, comparing bridge-to-transplant (BTT) and non-BTT intent patients, as well as pre- vs post-2018 patients, on a wide range of demographic and clinical outcome predictors.

RESULTS

Of 17,087 patients, 797 received left ventricular assist device (LVAD)/heart transplant, 7,931 died or had poor prognosis, and 8,359 had expected recovery at ECMO discontinuation. Patients supported with BTT intent had lower clinical acuity than non-BTT candidates and were more likely to receive LVAD/transplant. The proportion of patients who received VA-ECMO as BTT and received LVAD/transplant increased after 2018. Post-2018 BTT patients had significantly lower clinical acuity and higher likelihood of transplant than both post-2018 non-BTT patients and pre-2018 BTT patients. ECMO complications were associated with lower likelihood of transplant but were significantly less common post-2018 than pre-2018.

CONCLUSIONS

After implementation of the 2018 UNOS allocation system, ECMO utilization as BTT or LVAD has increased, and the acuity of BTT intent patients cannulated for ECMO has decreased. There has not yet been an increase in more acute ECMO patients getting transplanted. This may partially explain the post-transplant outcomes of ECMO patients in the current era reported in UNOS.

Liver transplantation for alcohol-associated liver disease: A call for national standards of best practices to monitor and bridge disparities in access and outcomes

Early (ie, without a mandated abstinence period) liver transplantation for alcohol-associated liver disease is the fastest-growing indication for liver transplantation in the United States. Despite widespread adoption, there is no standardization of practice or policies across transplant centers, nor are there any quality metrics from regulatory organizations specific to alcohol, all of which have likely contributed to confirmed disparities in transplant access and patient outcomes. In this article, we propose new mandates and best practices that could be put forth by the organ procurement and transplantation network regarding processes related to candidate selection, monitoring of alcohol use, and services to prevent and treat harmful alcohol use among early transplant candidates and recipients. We hope that this article stimulates discussion and leads to policy changes to maximize equity and quality of transplant care.

Impact of donor ventricular function on heart transplantation outcomes

BACKGROUND

Some heart transplant (HTx) centers have expanded their donor eligibility criteria in response to the organ shortage; one area of active interest involves utilizing hearts with ventricular dysfunction. Our study seeks to identify if a relationship exists between donor left ventricular ejection fraction (LVEF) and ischemic time or donor age on HTx outcomes.

METHODS

We performed a retrospective analysis on adult patients who had a HTx between 1996 and 2021 (n = 46,936). Donor LVEF (dLVEF) values were categorized into three groups: <50%, 50%-70%, and >70%. Ischemic time and donor age were stratified into four groups: ≤2.0, 2.1-3.0, 3.1-4.0, >4.0 h, and ≤30, 31-40, 41-50, >50 years, respectively. The outcome of interest was long-term survival.

RESULTS

Multivariable survival analysis found a slight increase in overall mortality risk for patients with donor ejection fractions <50% (HR = 1.16, p = .013). However, subsequent subgroup investigation discovered that this elevated hazard was only applicable when ischemic time was prolonged to >3.0 h (3.1-4.0 h: HR = 1.23, p = .024; > 4.0 h: HR = 1.52, p < .001). There was no significant difference in survival between dLVEF groups when ischemic time was limited to ≤3.0 h or when stratified by donor age.

CONCLUSION

HTx patients with a low donor ejection fraction have comparable survival to recipients with a normal dLVEF when ischemic time is limited to ≤3.0 h. Reduced dLVEF does not appear to be sensitive to advanced donor age. The clinical implications of our study may encourage the recruitment of more donor hearts for transplantation.

1-Year Outcomes of Lung Transplantation for Coronavirus Disease 2019-Associated End-Stage Lung Disease in the United States

BACKGROUND

Lung transplantation can provide quality of life and survival benefits for patients with coronavirus disease 2019 (COVID-19)-associated end-stage lung disease. Characteristics and outcomes of these lung transplant recipients are limited to mostly single-center experiences or provide a short-term follow-up.

METHODS

Characteristics of deceased donors and adult lung transplant recipients for COVID-19-associated end-stage lung disease between August-2020 and June-2022 were analyzed using deidentified United Network for Organ Sharing database. Post-transplant patient survival of COVID-19 recipients was analyzed and compared with non-COVID-19 recipients. Secondary outcomes were length of hospitalization, post-transplant complications, and rates of organ rejection.

RESULTS

During the study period, 400 lung transplants for COVID-associated end-stage lung disease comprised 8.7% of all lung transplants performed in United States. In the COVID-19 group, Hispanic males received lung transplants at significantly higher rates. The COVID-19 group was younger and had greater need for intensive care unit stay, mechanical ventilation, hemodialysis, extracorporeal membrane oxygenation support, and receipt of antibiotics pre-lung transplant. They had higher lung allocation score, with a shorter wait-list time and received more double lung transplants compared with non-COVID-19 recipients. Post-transplant, the COVID-19 cohort had longer hospital stays, with similar 1-year patient survival (COVID, 86.6% vs non-COVID, 86.3%). Post-transplant, COVID-19-associated deaths were 9.2% of all deaths among lung transplant recipients.

CONCLUSIONS

Lung transplantation offers a effective option for carefully selected patients with end-stage lung disease from prior COVID-19, with short-term and long-term outcomes similar to those for lung transplant recipients of non-COVID-19 etiology.

Mechanical circulatory support device selection for bridging to cardiac transplantation: a clinical guide

INTRODUCTION

Many patients listed for transplant require temporary or durable mechanical circulatory support (MCS) devices for bridging to cardiac transplantation. The choice of device for bridging to heart depends on a number of factors including level of support desired and patient-device hemocompatibility.

AREAS COVERED

The authors summarize the current heart transplant landscape including the new UNOS listing criteria as well as indications for bridging to transplant with MCS devices. The authors also review the characteristics of commonly used MCS devices and discuss the limited evidence supporting their use in cardiogenic shock and specifically as a bridge to heart transplant.

EXPERT OPINION

The new UNOS heart organ allocation policy has resulted in a growth in the use of temporary MCS devices as bridge to transplantation for patients with cardiogenic shock, while bridging with durable MCS devices have become more challenging. Patients supported on temporary MCS devices should be routinely assessed for potential of myocardial recovery prior to urgent transplantation. Emerging machine learning algorithms may help better identify individuals who are likely to recover on temporary or durable MCS therapy. Modifications to the current heart allocation policy may facilitate bridging of patients with durable left ventricular assist devices.

Analysis of heart retransplantation outcomes in the new donor heart allocation system

Cardiac graft failure may require repeat heart transplantation (HTx). Outcomes of patients that undergo repeat HTx have not been well described. We compared patients that received repeat HTx with patients that received initial HTx by inquiring the United Network for Organ Sharing (UNOS) database between 2015 and 2021. The primary endpoint was all-cause mortality, while the role of baseline characteristics was also investigated. Patients were stratified according to whether they received initial HTx (n = 19,727, 97%) or repeat HTx (n = 578, 3%). Among the study population, 10,860 (53.5%) patients received a HTx using the old UNOS allocation system, whereas 9445 (46.5%) patients received a HTx after the implementation of the new UNOS donor allocation system in October 2018. In this sub-group of HTx recipients in the new allocation system era, the adjusted 1-year survival of repeat HTx patients remained lower than that of initial HTx patients (hazard ratio (HR): 1.19; 95% confidence interval (CI): 1.15, 3.18; p = 0.013). When we compared the 1-year survival of repeat HTx patients before and after the implementation of the new allocation system, the adjusted 1-year survival was similar between groups (HR: 1.14; 95% CI: 0.71, 1.84; p = 0.591). The unadjusted risk of 30-day mortality was not significantly different in the new vs old allocation system. Mortality associated with repeat HTx remained higher than initial HTx but the new donor allocation system implementation did not affect outcomes.

Center expansion of liver transplants using donation after circulatory death organs is associated with reduced overall waitlist mortality

INTRODUCTION

Waitlist outcomes in liver transplantation (LT) for individual recipients are improved by use of allografts procured through donation after circulatory death (DCD). However, the impact of increased DCD acceptance on overall center outcomes is unknown.

METHODS

Using the United Network for Organ Sharing database, 88 centers performing an average of ≥10 LTs/year between 1/2004 and 12/2019 were compared by percent DCD use quartile and categorized into four phenotypes according to temporal usage trends. Overall center median Model for End-stage Liver Disease at LT (MMaT), waitlist mortality, and waiting time were evaluated.

RESULTS

The overall DCD rate was 6.1% (N = 4906/80,709), ranging from 0% to 25.5%. Centers in the top DCD use quartile had lower MMaT (24 vs. 26; p < .001) and shorter overall waiting times (median 66 days vs. 90 days; p < .001) compared to bottom quartile centers. MMaT increased less over time at centers with increasing DCD use and was lower than at centers with declining DCD use (27 vs. 32; p = .017). Overall waitlist mortality between 2016 and 2019 was lower at increasing DCD use centers (17.8% vs. 22.5%, p = .034), yet did not affect 1-year mortality (p = .747).

CONCLUSIONS

The improved waitlist outcomes at centers with expanded DCD use extend beyond DCD recipients alone without negative consequences to overall post-LT center metrics.

Factors Associated With Complete Pathologic Necrosis of Hepatocellular Carcinoma on Explant Evaluation After Locoregional Therapy: A National Analysis Using the UNOS Database

BACKGROUND. Complete pathologic necrosis (CPN) is associated with improved survival in patients who undergo liver transplant (LT) after locoregional therapy (LRT) for hepatocellular carcinoma (HCC). OBJECTIVE. The purpose of this article was to identify patient, HCC, and transplant center characteristics associated with rates of CPN on explant evaluation using a large national sample of patients undergoing LT after LRT for HCC measuring 3 cm or smaller. METHODS. This retrospective study used data from the United Network for Organ Sharing database. The study included 6265 adults (median age, 62 years; 1505 women, 4760 men) who underwent LT after a single type LRT (either transarterial chemoembolization [TACE], thermal ablation, or transarterial radioembolization [TARE]) for HCCs measuring 3 cm or smaller at one of 118 U.S. transplant centers from April 12, 2012, to March 31, 2020. Patients were classified as having CPN if explant evaluation showed 100% necrosis of all HCCs. Associations with CPN were explored. Centers were categorized into tertiles on the basis of center-level CPN rates, and tertiles were compared. RESULTS. LRT was performed by TACE in 69.5% (4352/6265), thermal ablation in 19.4% (1217/6265), and TARE in 11.1% (696/6265) of patients. CPN rate was 18.5% (805/4352) after TACE, 35.8% (436/1217) after thermal ablation, 33.6% (234/696) after TARE, and 23.5% (1475/6265) overall. In multivariable analysis incorporating age, sex, model for end-stage liver disease score, α-fetoprotein level before LRT, wait list time, number of HCCs, HCC size, and the transplant center (as a random factor), use of thermal ablation (OR, 2.19; 95% CI, 1.86-2.57; p < .001) or TARE (OR, 1.92; 95% CI, 1.57-2.36; p < .001), with TACE as reference, independently predicted greater likelihood of CPN. Center-level CPN rates ranged from 0.0% to 50.0%. Stratifying centers by CPN rates, ablation was performed more frequently than TACE in 5.0% of centers in the first, 15.4% in the second, and 23.1% in the third tertiles (p = .07). CONCLUSION. CPN rate on explant evaluation was low. Thermal ablation or TARE, rather than TACE, was associated with higher likelihood of CPN in patient-level and center-level analyses. CLINICAL IMPACT. Findings from this large national sample support a potential role of thermal ablation or TARE for achieving CPN of HCC measuring 3 cm or smaller.

Impact of COVID-19 on Liver Transplant Activity in the USA: Variation by Etiology and Cirrhosis Complications

BACKGROUND AND AIMS

The COVID-19 pandemic has impacted the care of patients with liver disease. We examined impact of COVID-19 on liver transplant (LT) activity in the USA.

METHODS

LT listings in the United Network for Organ Sharing (UNOS) database (April 2018-May 2021) were analyzed to examine the impact of COVID-19 pandemic on the LT activity based on etiology: hepatitis C virus (HCV), alcohol-associated liver disease (ALD), alcoholic hepatitis (AH), and nonalcoholic steatohepatitis (NASH) complications: hepatocellular carcinoma (HCC) and acute-on-chronic liver failure (ACLF) grade 2 or 3) and Model for End-Stage Liver Disease (MELD) score. Joinpoint regression models assessed time trend changes on a log scale.

RESULTS

Of 23,871 recipients (8,995 in the COVID era, April 2018-February 2020), mean age 52 years, 62% men, 61% Caucasian, 32% ALD, 15% HCC, 30% ACLF grades 2-3, and mean MELD score 20.5), monthly LT changes were a decrease of 3.4% for overall LTs and 22% for HCC after September 2020, and increase of 4.5% for ALD since 11/2020 and 17% since 03/2021 for ACLF grade 2-3. Monthly MELD scores increased by 0.7 and 0.36 after June 2020 for HCV and HCC respectively.

CONCLUSIONS

The COVID-19 pandemic has impacted LT activity, with a decrease of LTs especially for HCC, and an increase of LTs for ALD and severe ACLF. Strategies are needed to reorganize cirrhosis patients to overcome the aftereffects of COVID-19 pandemic.

The Impact of the COVID-19 Pandemic on Kidney Transplant Candidate Waitlist Status across Demographic and Geographic Groups: A National Analysis of UNOS STAR Data

The primary goal of this retrospective study is to understand how the COVID-19 pandemic differentially impacted transplant status across race, sex, age, primary insurance, and geographic regions by examining which candidates: (i) remained on the waitlist, (ii) received transplants, or (iii) were removed from the waitlist due to severe sickness or death on a national level. Methods: The trend analysis aggregated by monthly transplant data from 1 December 2019 to 31 May 2021 (18 months) at the transplant center level. Ten variables about every transplant candidate were extracted from UNOS standard transplant analysis and research (STAR) data and analyzed. Characteristics of demographical groups were analyzed bivariately using t-test or Mann-Whitney U test for continuous variables and using Chi-sq/Fishers exact tests for categorical variables. Results: The trend analysis with the study period of 18 months included 31,336 transplants across 327 transplant centers. Patients experienced a longer waiting time when their registration centers in a county where high numbers of COVID-19 deaths were observed (SHR < 0.9999, p < 0.01). White candidates had a more significant transplant rate reduction than minority candidates (-32.19% vs. -20.15%) while minority candidates were found to have a higher waitlist removal rate than White candidates (9.23% vs. 9.45%). Compared to minority patients, White candidates' sub-distribution hazard ratio of the transplant waiting time was reduced by 55% during the pandemic period. Candidates in the Northwest United States had a more significant reduction in the transplant rate and a greater increase in the removal rate during the pandemic period. Conclusions: Based on this study, waitlist status and disposition varied significantly based on patient sociodemographic factors. During the pandemic period, minority patients, those with public insurance, older patients, and those in counties with high numbers of COVID-19 deaths experienced longer wait times. In contrast, older, White, male, Medicare, and high CPRA patients had a statistically significant higher risk of waitlist removal due to severe sickness or death. The results of this study should be considered carefully as we approach a reopening world post-COVID-19, and further studies should be conducted to elucidate the relationship between transplant candidate sociodemographic status and medical outcomes during this era.

Outcomes after liver transplantation using deceased after circulatory death donors: A comparison of outcomes in the UK and the US

BACKGROUND AND AIMS

Identifying international differences in utilization and outcomes of liver transplantation (LT) after donation after circulatory death (DCD) donation provides a unique opportunity for benchmarking and population-level insight.

METHODS

Adult (≥18 years) LT data between 2008 and 2018 from the UK and US were used to assess mortality and graft failure after DCD LT. We used time-dependent Cox-regression methods to estimate hazard ratios (HR) for risk-adjusted short-term (0-90 days) and longer-term (90 days-5 years) outcomes.

RESULTS

One-thousand five-hundred-and-sixty LT receipts from the UK and 3426 from the US were included. Over the study period, the use of DCD livers increased from 15.7% to 23.9% in the UK compared to 5.1% to 7.6% in the US. In the UK, DCD donors were older (UK:51 vs. US:33 years) with longer cold ischaemia time (UK: 437 vs. US: 333 min). Recipients in the US had higher Model for End-stage Liver Disease (MELD) scores, higher body mass index, higher proportions of ascites, encephalopathy, diabetes and previous abdominal surgeries. No difference in the risk-adjusted short-term mortality or graft failure was observed between the countries. In the longer-term (90 days-5 years), the UK had lower mortality and graft failure (adj.mortality HR:UK: 0.63 (95% CI: 0.49-0.80); graft failure HR: UK: 0.72, 95% CI: 0.58-0.91). The cumulative incidence of retransplantation was higher in the UK (5 years: UK: 11.9% vs. 4.6%; p < .001).

CONCLUSIONS

For those receiving a DCD LT, longer-term post-transplant outcomes in the UK are superior to the US, however, significant differences in recipient illness, graft quality and access to retransplantation were seen between the two countries.

Utilization and outcomes of rescue hepatectomy among U.S. liver retransplant candidates

INTRODUCTION

The frequency and outcomes of anhepatic patients listed for transplantation in the United States have not been studied. The United Network for Organ Sharing (UNOS) records anhepatic status for patients listed as Status 1A for hepatic artery thrombosis (HAT) or primary non-function (PNF).

METHODS

Using the UNOS database from 2005 to 2020, demographics and waitlist outcomes of anhepatic candidates relisted as Status 1A for HAT or PNF were assessed.

RESULTS

Among 1364 adult Status 1A patients relisted for PNF or HAT across 120 distinct transplant centres, 75 (5.5%) patients were anhepatic and 1289 (94.5%) were non-anhepatic. A substantial number of centres (n = 51) had experience with ≥1 anhepatic patient relisted for either PNF or HAT, with individual centre rates ranging from 0% to 11.4%. Waitlist mortality was more than twice as high for anhepatic patients: 42.5% versus 17.0% non-anhepatic patients (p < .001). The post-transplant outcomes of anhepatic patients were markedly inferior to non-anhepatic patients. For example, 41.9% of anhepatic patients died during the index admission versus 23.4% of the non-anhepatic group (p = .006). Patient survival for the anhepatic and non-anhepatic groups was 48.3% versus 66.2% at 1-year and 29.3% versus 46.2% at 5-years, respectively (log-rank test for overall survival p = .014).

CONCLUSIONS

Rescue hepatectomy after initial liver transplantation is not only associated with high waitlist mortality, but also markedly worse post-transplant outcomes. With less than half of anhepatic patients surviving to the first year post-LT, further research is warranted to better delineate which patients should be considered for rescue hepatectomy.

Interrupted Time Series Analysis of Donor Heart Use Before and After the 2018 UNOS Heart Allocation Policy Change

BACKGROUND

Donor heart scarcity remains the fundamental barrier to increased transplant access. We examined whether 2018 United Network for Organ Sharing (UNOS) policy changes have had an impact on donor heart acceptance rates.

METHODS AND RESULTS

We performed an interrupted time series analysis in UNOS to evaluate for abrupt changes in donor heart-acceptance rates associated with the new policy. All adult donor offers were evaluated between 2015 and 2021 (n = 66,654 donors). Donor volumes and transplants increased during this period, but the donor acceptance rate declined significantly from 31% in quarter 3 of 2018 to 26% acceptance in quarter 3 of 2021 (slope change -0.4% per quarter; P < 0.001). We identified 2 trends associated with this decline: (1) a growing number of donors with high-risk features, and (2) decreased acceptance of donors with certain high-risk features in the new allocation system.

CONCLUSIONS

Heart transplant volumes have increased in recent years as a result of increased donor volumes, but donor heart acceptance rates began decreasing under the current allocation system. Changes in the donor pool and acceptance patterns for certain donor-risk features may explain this shift and warrant further evaluation to maximize donor heart use.

Patterns and outcomes of COVID-19 donor utilization for heart transplant

BACKGROUND

The outcomes following COVID-19 positive donor (CPD) utilization for heart transplant are unknown.

METHODS

UNOS database was analyzed for heart transplants performed from the declaration of COVID-19 pandemic until September 30, 2022.

RESULT

Since the onset of pandemic, there were 9876 heart transplants reported. COVID-19 antigen or NAT results were available in 7698 adult donors within 14 days of donation, of which 177 (2.3%) were positive. There was no difference in recipient demographics, including age (COVID positive donor vs. negative: 55 vs. 56 years, p = .2) and BMI. Listing status 1 and 2 were similar in both groups (7% vs. 10% and 48% vs. 49% respectively, p = .4). Durable and temporary mechanical support were similar in both groups pre-transplant (both groups 33%, p = .9). There was no difference in days on the waitlist (median 31 days, p = .9). Simultaneous renal transplant rates were similar (11% vs. 10%, p = .9). CPD utilization has increased since the onset of the pandemic, and the adoption is present across most UNOS regions. Post-transplant, there was no difference in length of stay (median 16 vs. 17 days, p = .9) and acute rejection episodes prior to discharge (3% vs. 8%, p = .1). In survival analysis of 90-day follow up, number of deaths reported were comparable (5% in both groups, p = .9) Follow-up LVEF was comparable (62% vs. 60%, p = .4).

CONCLUSION

Active COVID-19 infection in donors did not affect survival or rejection rates in the short-term post-heart transplant.

Machine learning-based prediction of mortality after heart transplantation in adults with congenital heart disease: A UNOS database analysis

BACKGROUND

Machine learning (ML) is increasingly being applied in Cardiology to predict outcomes and assist in clinical decision-making. We sought to develop and validate an ML model for the prediction of mortality after heart transplantation (HT) in adults with congenital heart disease (ACHD).

METHODS

The United Network for Organ Sharing (UNOS) database was queried from 2000 to 2020 for ACHD patients who underwent isolated HT. The study cohort was randomly split into derivation (70%) and validation (30%) datasets that were used to train and test a CatBoost ML model. Feature selection was performed using SHapley Additive exPlanations (SHAP). Recipient, donor, procedural, and post-transplant characteristics were tested for their ability to predict mortality. We additionally used SHAP for explainability analysis, as well as individualized mortality risk assessment.

RESULTS

The study cohort included 1033 recipients (median age 34 years, 61% male). At 1 year after HT, there were 205 deaths (19.9%). Out of a total of 49 variables, 10 were selected as highly predictive of 1-year mortality and were used to train the ML model. Area under the curve (AUC) and predictive accuracy for the 1-year ML model were .80 and 75.2%, respectively, and .69 and 74.2% for the 3-year model, respectively. Based on SHAP analysis, hemodialysis of the recipient post-HT had overall the strongest relative impact on 1-year mortality after HΤ, followed by recipient-estimated glomerular filtration rate, age and ischemic time.

CONCLUSIONS

ML models showed satisfactory predictive accuracy of mortality after HT in ACHD and allowed for individualized mortality risk assessment.

Low utilization of adult-to-adult LDLT in Western countries despite excellent outcomes: International multicenter analysis of the US, the UK, and Canada

BACKGROUND & AIMS

Adult-to-adult living donor liver transplantation (LDLT) offers an opportunity to decrease the liver transplant waitlist and reduce waitlist mortality. We sought to compare donor and recipient characteristics and post-transplant outcomes after LDLT in the US, the UK, and Canada.

METHODS

This is a retrospective multicenter cohort-study of adults (≥18-years) who underwent primary LDLT between Jan-2008 and Dec-2018 from three national liver transplantation registries: United Network for Organ Sharing (US), National Health Service Blood and Transplantation (UK), and the Canadian Organ Replacement Registry (Canada). Patients undergoing retransplantation or multi-organ transplantation were excluded. Post-transplant survival was evaluated using the Kaplan-Meier method, and multivariable adjustments were performed using Cox proportional-hazards models with mixed-effect modeling.

RESULTS

A total of 2,954 living donor liver transplants were performed (US: n = 2,328; Canada: n = 529; UK: n = 97). Canada has maintained the highest proportion of LDLT utilization over time (proportion of LDLT in 2008 - US: 3.3%; Canada: 19.5%; UK: 1.7%; p <0.001 - in 2018 - US: 5.0%; Canada: 13.6%; UK: 0.4%; p <0.001). The 1-, 5-, and 10-year patient survival was 92.6%, 82.8%, and 70.0% in the US vs. 96.1%, 89.9%, and 82.2% in Canada vs. 91.4%, 85.4%, and 66.7% in the UK. After adjustment for characteristics of donors, recipients, transplant year, and treating transplant center as a random effect, all countries had a non-statistically significantly different mortality hazard post-LDLT (Ref US: Canada hazard ratio 0.53, 95% CI 0.28-1.01, p = 0.05; UK hazard ratio 1.09, 95% CI 0.59-2.02, p = 0.78).

CONCLUSIONS

The use of LDLT has remained low in the US, the UK and Canada. Despite this, long-term survival is excellent. Continued efforts to increase LDLT utilization in these countries may be warranted due to the growing waitlist and differences in allocation that may disadvantage patients currently awaiting liver transplantation.

LAY SUMMARY

This multicenter international comparative analysis of living donor liver transplantation in the United States, the United Kingdom, and Canada demonstrates that despite low use of the procedure, the long-term outcomes are excellent. In addition, the mortality risk is not statistically significantly different between the evaluated countries. However, the incidence and risk of retransplantation differs between the countries, being the highest in the United Kingdom and lowest in the United States.

Regional and National Trends of Adult Living Donor Liver Transplantation in the United States Over the Last Two Decades

BACKGROUND AND AIMS

Liver organ shortage remains a major health burden in the US, with more patients being waitlisted than the number of liver transplants (LTs) performed. This study investigated US national and regional trends in living donor LT (LDLT) and identified factors associated with recipient survival.

METHODS

We retrospectively analyzed LDLT recipients and donors from the United Network Organ Sharing/Organ Procurement Transplant Network database from 1998 until 2019 for clinical characteristics, demographic differences, and survival rate. National and regional trends in LDLT, recipient outcomes, and predictors of survival were analyzed.

RESULTS

Of the 223,571 candidates listed for an LT, 57.5% received an organ, of which only 4.2% were LDLTs. Annual adult LDLTs first peaked at 412 in 2001 but experienced a significant decline to 168 by 2009. LDLTs then gradually increased to 445 in 2019. Region 2 had the highest LDLT numbers (n=919), while region 1 had the highest proportion (11.1%). Overall, post-LT mortality was 21.4% among LDLT recipients. Post-LDLT survival rates after 1-, 5-, and 10-years were 92%, 87%, and 70%, respectively. Interval analysis (2004-2019) showed that patients undergoing LDLT in recent years had lower mortality than in earlier years (hazard ratio=0.81, 95% confidence interval=0.75-0.88).

CONCLUSIONS

Following a substantial decline after a peak in 2001, the number of adult LDLTs steadily increased from 2011 to 2019. However, LDLTs still constitute the minority of the transplant pool in the US. Life-saving policies to increase the use of LDLTs, particularly in regions of high organ demand, should be implemented.

Lost potential and missed opportunities for DCD liver transplantation in the United States

BACKGROUND

Donation after cardiac death(DCD) has been proposed as an avenue to expand the liver donor pool.

METHODS

We examined factors associated with nonrecovery of DCD livers using UNOS data from 2015 to 2019.

RESULTS

There 265 non-recovered potential(NRP) DCD livers. Blood type AB (7.8% vs. 1.1%) and B (16.9% vs. 9.8%) were more frequent in the NRP versus actual donors (p < 0.001). The median driving time between donor hospital and transplant center was similar for NRP and actual donors (30.1 min vs. 30.0 min; p = 0.689), as was the percentage located within a transplant hospital (20.8% vs. 20.9%; p = 0.984).The donation service area(DSA) of a donor hospital explained 27.9% (p = 0.001) of the variability in whether a DCD liver was recovered.

CONCLUSION

A number of potentially high quality DCD donor livers go unrecovered each year, which may be partially explained by donor blood type and variation in regional and DSA level practice patterns.

Characteristics and Outcomes of Left Ventricular Assist Device Recipients Transplanted Before and After the New Donor Heart Allocation System

BACKGROUND

Concerns about the impact of the new donor heart allocation system on post-transplant outcomes have emerged after its implementation. We sought to evaluate the characteristics and outcomes of left ventricular assist device (LVAD) recipients transplanted before and after the implantation of the new policy on October 18, 2018.

METHODS

Data on bridge to transplantation adult LVAD patients January 2015 and October 2021, with durable LVAD as a (BTT), was queried from the United Network of Organ Sharing (UNOS) registry. The main outcomes were 30-day all-cause mortality, 30-day fatal graft failure, 1-year all-cause mortality, treated acute rejection at one year and renal replacement therapy (RRT) for acute renal failure.

RESULTS

In our study, 7096 patients met the inclusion criteria including 2,435 in the new allocation system. The transplanted patients in the new allocation system era had older donor age, longer ischemic time and higher proportion of newer generation LVADs. Adjusted 30-day all-cause mortality was significantly lower for LVAD recipients in the new allocation system era (2.5% vs 3.6%; sub-hazard ratio [SHR] 0.36, 95% Confidence intervals [CI] 0.27-0.48, p<0.001) without differences in the risk of fatal graft failure and one-year mortality (7.8% vs 9.6%). Significantly lower adjusted 30-day mortality with HVAD and HM3 devices than HM2 in the new allocation system era was found, without differences in one-year mortality. Acute allograft rejection requiring treatment was significantly lower (Odds Ratio 0.78, 95% CI 0.65-0.94, p=0.01) whereas a trend towards higher risk of renal failure requiring RRT was identified.

CONCLUSIONS

Despite changing donor characteristics and longer ischemic times, post-transplant outcomes in LVAD recipients have not worsened with the implementation of the new allocation system and this finding is related to the use of newer generation continuous flow LVADs.

Gender Differences in Liver Transplantation Outcomes in Polycystic Liver Disease

BACKGROUND

In this study, our objective was to determine gender differences in the outcomes of patients with PLD undergoing liver (LT) or liver/kidney transplantation (SLK).

METHODS

We analyzed the UNOS datasets of all adults who had transplanted for PLD between 1988 and 2018.

RESULTS

During the study period, 663 LT/SLK (51% LT only and 49% SLK) were done for PLD patients and of these 500 (75%) were in women. Women were younger (52.8 vs. 56.7 years, p < 0.001), had lower MELD at transplant (16.6 vs. 19.4, p < 0.001), had higher serum albumin (3.7 vs. 3.5, p < 0.001), and had a lower CTP class (p < 0.008). During the follow-up, 18% (n = 89) women and 29% (n = 47) men died (p = 0.002). Kaplan-Meier (KM) survival estimates showed similar survival rate for patients who had LT and SLK (p = 0.459), but survival rate was significantly higher for women compared to men (p < 0.001). Multivariable analysis showed that female gender (aHR 0.54, 95% CI 0.33-0.90) was associated with a lower mortality. Moreover, Karnofsky Performance Status was excellent for 70% of women and 55% of men (p = 0.03) after LT. Women had better survival whether they received liver or SLK. The era of transplant, whether they were transplanted with MELD exception points or whether they were on dialysis at the time of transplant, did not have an effect on the gender differences in outcomes.

CONCLUSIONS

Women had 46% lower risk of mortality after adjusting for other covariates compared to men after LT/SLK for PLD.

High-risk liver transplant recipients with grade 3 acute on chronic liver failure should receive the good quality graft

BACKGROUND & AIM

We aimed to develop a risk score for LT recipients and donor selection among patients with ACLF-3.

METHODS AND RESULTS

A total of 7166 adult LT recipients (mean age 53 years, 63% males, 56% Caucasians, 42% obese, median MELD score 36.5) using deceased donor grafts in the UNOS database (01/2002-06/2018) who were in ACLF-3 at LT as per EASL-CLIF criteria were analysed. Cox regression model on the derivation dataset (N = 3583) showed recipient age, non-alcohol aetiology, pulmonary failure, brain failure and cardiovascular failure to be associated with 1-year patient survival. Observed and expected post-transplant 1-year survival showed excellent correlation (R = .920). Risk score from cox model on derivation dataset stratified 3583 recipients in validation cohort using cut-off scores 7.55 and 11.57 to low (N = 1211), medium (N = 1168) and high risk (N = 1199), with 1-year patient survival of 89%, 82% and 80% respectively. Based on poor versus good quality graft (donor risk index cut-off at 1.50), 1-year patient survival for low, medium and high-risk categories were 90 versus 89% (p = .490), 83 versus 82% (p = .390) and 83 versus 78% (p = .038) respectively. Among recipients with a high-risk score, donor factors of age ≥60 years, grafts obtained from national sharing and macro-steatosis >15% were associated with 1-year patient survival below 66%.

CONCLUSION

Among ACLF-3 liver transplant recipients, those with high risk at the time of transplant receiving better quality graft will improve post-transplant outcomes. Prospective studies using additional characteristics are needed to derive an accurate risk score model in predicting post-transplant outcomes among recipients with ACLF-3.

Organ allocation in pediatric abdominal transplant

Pediatric patients constitute an important group within the general transplant population, given the opportunity to significantly extend their lives with successful transplantation. Children have historically received special consideration under the various abdominal solid organ allocation algorithms, but matching patients with size and weight restrictions with appropriate donors remains an ongoing issue. Here, we describe the historical trends in pediatric organ allocation policies for liver, kidney, intestine, and pancreas transplantation. We also review recent changes to these allocation policies, with particular attention to recent amendments to geographical prioritization, with the dissolution of donor service areas and United Network for Organ Sharing (UNOS) regions and the subsequent creation of acuity circles.

Validation of existing risk scores for mortality prediction after a heart transplant in a Chinese population

OBJECTIVES

The objectives of this study were to validate 3 existing heart transplant risk scores with a single-centre cohort in China and evaluate the efficacy of the 3 systems in predicting mortality.

METHODS

We retrospectively studied 428 patients from a single centre who underwent heart transplants from January 2015 to December 2019. All patients were scored using the Index for Mortality Prediction After Cardiac Transplantation (IMPACT) and the United Network for Organ Sharing (UNOS) and risk stratification scores (RSSs). We assessed the efficacy of the risk scores by comparing the observed and the predicted 1-year mortality. Binary logistic regression was used to evaluate the predictive accuracy of the 3 risk scores. Model discrimination was assessed by measuring the area under the receiver operating curves. Kaplan-Meier survival analyses were performed after the patients were divided into different risk groups.

RESULTS

Based on our cohort, the observed mortality was 6.54%, whereas the predicted mortality of the IMPACT and UNOS scores and the RSSs was 10.59%, 10.74% and 12.89%, respectively. Logistic regression analysis showed that the IMPACT [odds ratio (OR), 1.25; 95% confidence interval (CI), 1.15-1.36; P < 0.001], UNOS (OR, 1.68; 95% CI, 1.37-2.07; P < 0.001) and risk stratification (OR, 1.61; 95% CI, 1.30-2.00; P < 0.001) scores were predictive of 1-year mortality. The discriminative power was numerically higher for the IMPACT score [area under the curve (AUC) of 0.691)] than for the UNOS score (AUC 0.685) and the RSS (AUC 0.648).

CONCLUSIONS

We validated the IMPACT and UNOS scores and the RSSs as predictors of 1-year mortality after a heart transplant, but all 3 risk scores had unsatisfactory discriminative powers that overestimated the observed mortality for the Chinese cohort.

Discordance in categorization of acute-on-chronic liver failure in the United Network for Organ Sharing database

BACKGROUND & AIMS

Studies regarding acute-on-chronic liver failure (ACLF) among liver transplant (LT) candidates from the United Network for Organ Sharing (UNOS) database are being used to inform LT policy changes worldwide. We assessed the validity of identifying ACLF in UNOS.

METHODS

We performed stratified random sampling among 3 US LT centers between 2013-2019 to obtain a representative patient sample across ACLF grades. We compared the concordance of ACLF classification by UNOS vs. blinded manual chart review, according to EASL-CLIF.

RESULTS

Among 481 sampled LT registrants, 250 (52%) had no ACLF, 75 (16%) had ACLF grade 1, 79 (16%) had ACLF grade 2, and 77 (16%) had ACLF grade 3 per UNOS categorization. Concordance of ACLF grade by UNOS vs. chart review was: 72%, 64%, 56%, and 64% for no ACLF, grade 1, grade 2, and grade 3, respectively, with an overall Cohen's kappa coefficient of 0.48 (95% CI 0.42-0.54). Absence of acute decompensation was the most common reason for overestimation, and discordant brain and respiratory failure categorization were the most common reasons for underestimation of ACLF by UNOS.

CONCLUSIONS

In this retrospective multi-center study, ACLF categorization by UNOS showed weak agreement with manual chart review. These findings are informative for ongoing allocation policy discussions, highlight the importance of prospective studies regarding ACLF in LT, and should encourage UNOS reform.

LAY SUMMARY

Acute-on-chronic-liver-failure (ACLF) is a specific and common form of liver failure associated with high death rates. Studies have been published using the United States transplant registry (UNOS) to identify and describe outcomes of transplant candidates and recipients with ACLF, and these data are driving policy changes for transplant allocation around the world, but nobody has shown whether these data are reliable. We found that UNOS was not categorizing ACLF in concordance or accurately when compared to chart review, which shows the need for UNOS reform and non-UNOS studies to appropriately inform policies regarding the transplantation of patients with ACLF.

Impact of Temporary Percutaneous Mechanical Circulatory Support Before Transplantation in the 2018 Heart Allocation System

OBJECTIVES

This analysis sought to investigate the waitlist and post-transplant outcomes of individuals bridged to transplantation by using temporary percutaneous endovascular mechanical circulatory support (tMCS) through a status 2 designation (cardiogenic shock and exception).

BACKGROUND

The 2018 donor heart allocation policy change granted a status 2 designation to patients supported with tMCS.

METHODS

Adult patients in the United Network for Organ Sharing registry after October 18, 2018 who received a status 2 designation for tMCS were included and grouped by their status 2 criteria: cardiogenic shock with hemodynamic criteria (CS-HD), cardiogenic shock without hemodynamic criteria before tMCS (CS-woHD), and exception. Baseline characteristics, waitlist events (death and delisting), and post-transplant outcomes were compared.

RESULTS

A total of 2,279 patients met inclusion criteria: 68.6% (n = 1,564) with CS-HD, 3.2% (n = 73) with CS-woHD, and 28.2% (n = 642) with exceptions. A total of 64.2% of patients underwent heart transplantation within 14 days of status 2 listing or upgrade, and 1.9% died or were delisted for worsening clinical condition. Among the 35.8% who did not undergo transplantation following 14 days, only 2.8% went on to receive a left ventricular assist device (LVAD). The 30-day transplantation likelihood was similar among groups: 80.1% for the CS-HD group vs 79.7% for the exception group vs 73.3% for the CS-woHD group; P = 0.31. However, patients who met criteria for CS-woHD had 2.3-fold greater risk of death or delisting (95% CI: 1.10-4.75; P = 0.03) compared with CS-HD patients after multivariable adjustment. Pre-tMCS hemodynamics were not associated with adverse waitlist events.

CONCLUSIONS

The use of tMCS is an efficient, safe, and effective strategy as a bridge to transplantation; however, patients with CS-woHD may represent a high-risk cohort. Transition to a durable LVAD was a rare event in this group.

Transplant surgery departmental leaders do not represent workforce demographics especially among women and underrepresented minorities - A retrospective analysis

INTRODUCTION

The diversity among surgical directors for liver, kidney, and pancreas transplant departments has not been previously evaluated. We aim to quantify the sex and racial demographics of transplant department leaders and assess the impact on patient outcomes.

METHODS

Demographics were collected for 116 liver, 192 kidney, and 113 pancreas transplant directors using Organ Procurement and Transplantation Network (OPTN) directory and program websites. Scientific Registry of Transplant Recipients (SRTR) 5-tier program outcomes rankings were obtained for each program and matched to leader demographics. A retrospective analysis of transplant recipients from 2010 to 2019 was performed using the United Network for Organ Sharing (UNOS) database.

RESULTS

91.5% of transplant surgical directors were male. 55% of departments had a Non-Hispanic White leader. Asian, Hispanic and Black transplant chiefs were at the helm of 23.3%, 9%, and 5% of divisions respectively. Multivariate cox regression analysis did not identify any differences in patient outcomes by transplant director demographics.

CONCLUSION

There is a paucity of female and URM leaders in transplant surgery. Initiatives to promote research, mentorship, and career advancement opportunities for women and URM are necessary to address the current leadership disparity.

Trends and Outcomes of Cardiac Transplantation in the Lowest Urgency Candidates

Background Due to discrepancies between donor supply and recipient demand, the cardiac transplantation process aims to prioritize the most medically urgent patients. It remains unknown how recipients with the lowest medical urgency compare to others in the allocation process. We aimed to examine differences in clinical characteristics, organ allocation patterns, and outcomes between cardiac transplantation candidates with the lowest and highest medical urgency. Methods and Results We performed a retrospective analysis of the United Network for Organ Sharing database. Patients listed for cardiac transplantation between January 2011 and May 2020 were stratified according to status at time of transplantation. Baseline recipient and donor characteristics, waitlist survival, and post-transplantation outcomes were compared in the years before and after the 2018 allocation system change. Lower urgency patients in the old system were older (58.5 vs. 56 years) and more likely female (54.4% vs. 23.8%) compared to the highest urgency patients, and these trends persisted in the new system (p<0.001, all). Donors for the lowest urgency patients were more likely older, female, or have a history of CMV, hepatitis C, or diabetes (p<0.01, all). The lowest urgency patients had longer waitlist times, and under the new allocation system received organs from shorter distances with decreased ischemic times (178 vs. 269 miles, 3.1 vs 3.5 hours, p<0,001, all). There was no difference in post-transplantation survival (p<0.01, all). Conclusions Patients transplanted as lower urgency receive hearts from donors with additional comorbidities compared to higher urgency patients, but outcomes are similar at one year.

Primary biliary cholangitis has the highest waitlist mortality in patients with cirrhosis and acute on chronic liver failure awaiting liver transplant

BACKGROUND

Data are sparse on etiology specific outcomes on waitlist (WL) and post-transplant outcomes among patients with acute on chronic liver failure (ACLF).

METHODS AND RESULTS

In a retrospective cohort of 14,774 adults from United network for organ sharing (UNOS) database listed for Liver transplantation (LT) with cirrhosis and ACLF (January 2013-June 2019), 40% were due to alcohol-associated liver disease (ALD), followed by hepatitis C virus (HCV) at 20%, non-alcoholic steatohepatitis (19%), cryptogenic cirrhosis (7%), autoimmune hepatitis (5%), primary sclerosing cholangitis (PSC) at 3%, and 2% each for hepatitis B, primary biliary cholangitis (PBC), and metabolic etiology. Using competing risk analysis, cumulative risk of WL mortality was highest for PBC at 20.5% and lowest for PSC at 13.3%, P < .001. Compared with ALD as reference, WL mortality was higher for PBC (1.45 [1.16-1.82]), and similar for other etiologies, P < .001. Of this cohort, 9650 (65.3%) patients received LT, with 1-year. patient survival of 91.6% for PBC, worst for cryptogenic cirrhosis (89.5%) and best for PSC and ALD (93.4%), P < .001.

CONCLUSION

Among listed candidates with ACLF, those with PBC have highest WL mortality 1-year. post-transplant survival was excellent among recipients for PBC. If these findings are validated in prospective studies, liver disease etiology should be considered for LT selection among patients in ACLF.

Impact of induction therapy on outcomes after heart transplantation

BACKGROUND

Approximately 50% of heart transplant (HT) programs utilize induction therapy (IT) with interleukin-2 receptor antagonists (IL2RA) or polyclonal anti-thymocyte antibodies (ATG).

METHODS

Adult HT recipients were identified in the UNOS Registry between 2010 and 2020. We compared mortality between IT strategies with competing risk analysis.

RESULTS

A total of 28 634 HT recipients were included in the study (50.1% no IT, 21.3% ATG, 27.9% IL2RA, .7% alemtuzumab, .01% OKT3). Adjusted all-cause, 30 day and 1 year mortality were lower among those treated with IT than no IT (sub-hazard ratio [SHR] .87, 95% CI .79-.96, SHR .86, .76-.97, SHR .76, .63-.93, P = .007, respectively). In propensity score matching analysis IT was associated with lower 30-day and 1-year mortality. IL2RA had higher all-cause and 1-year mortality than ATG (SHR 1.41, 95% CI 1.23-1.69 and 1.55, 95% CI 1.29-1.88, respectively). Utilization of IT was associated with significantly lower risk of treated rejection at 1 year after HT compared with no IT (relative risk ratio [RRR] .79) and similarly ATG compared with IL2RA (RRR .51).

CONCLUSION

IT was associated with lower mortality and treated rejection episodes than no IT. IL2RA is the most used IT approach but ATG has lower risk of treated rejection and mortality.

The modified US heart allocation system improves transplant rates and decreases status upgrade utilization for patients with hypertrophic cardiomyopathy

BACKGROUND

On October 18, 2018, the US heart allocation policy was restructured to improve transplant waitlist outcomes. Previously, hypertrophic cardiomyopathy (HCM) patients experienced significant waitlist mortality and functional decline, often requiring status exemptions to be transplanted. This study aims to examine changes in waitlist mortality and transplant rates of HCM patients in the new system.

METHODS

Retrospective analysis was performed of the United Network for Organ Sharing Transplant Database for all isolated adult single-organ first-time heart transplant patients with HCM listed between October 17, 2013 and September 4, 2020. Patients were divided by listing date into eras based on allocation system. Era 1 spanned October 17, 2013 to October 17th, 2018 and Era 2 spanned October 18th, 2018 to September 4, 2020.

RESULTS

During the study period, 436 and 212 HCM patients were listed in Eras 1 and 2, respectively. Across eras, no differences in gender, ethnicity, BMI or functional status were noted (p>0.05). LVAD utilization remained low (Era 1: 3.7% vs Era 2: 3.3%, p = 0.297). Status upgrades decreased from 49.1% to 31.6% across eras (p = 0.001). There was no statistically significant difference in waitlist mortality across eras (p = 0.332). Transplant rates were improved in Era 2 (p = 0.005). Waitlist time among transplanted patients decreased in Era 2 from 97.1 to 63.9 days (p<0.001). There was no difference in one-year survival post-transplant (p = 0.602).

CONCLUSIONS

The new allocation system has significantly increased transplant rates, shortened waitlist times, and decreased status upgrade utilization for HCM patients. Moreover, waitlist mortality remained unchanged in the new system.

Survival After Orthotopic Heart Transplantation In Patients With BMI > = 35 With And Without Diabetes

BACKGROUND

OHT recipients with a BMI > = 35 have worse survival than those with a BMI < 35. Diabetes is a risk factor for mortality. We evaluated the impact of diabetes on mortality rates after OHT in patients with a BMI > 35.

METHODS

Patients > 18 years who underwent OHT 2008-2017 with a BMI > = 35 were identified in the UNOS database. Recipient and donor characteristics were compared. A Kaplan Meier analysis was performed. A multivariable Cox proportional hazards model examined the relationship between diabetes and survival. The equivalence of survival outcomes was examined by an unadjusted Cox proportional hazards model and the two one-sided test procedure, using a pre-specified equivalence region.

RESULTS

Patients with diabetes were older, had a higher creatinine, lower bilirubin, fewer months on the waitlist, and the donor was less likely to be on inotropes. Kaplan-Meier analysis showed no difference in patient survival. Recipient factors associated with an increased risk of death were increasing bilirubin and machine ventilation. Increasing ischemic time resulted in an increased hazard of death. Long-term survival outcomes were equivalent.

CONCLUSIONS

In OHT recipients with a BMI >35, there is no statistical difference in longterm survival in recipients with or without diabetes. These results encourage continued consideration for OHT in patients BMI >35 with coexisting diabetes. This article is protected by copyright. All rights reserved.

State-of-the-art machine learning algorithms for the prediction of outcomes after contemporary heart transplantation: Results from the UNOS database

PURPOSE

We sought to develop and validate machine learning (ML) models to increase the predictive accuracy of mortality after heart transplantation (HT).

METHODS AND RESULTS

We included adult HT recipients from the United Network for Organ Sharing (UNOS) database between 2010 and 2018 using solely pre-transplant variables. The study cohort comprised 18 625 patients (53 ± 13 years, 73% males) and was randomly split into a derivation and a validation cohort with a 3:1 ratio. At 1-year after HT, there were 2334 (12.5%) deaths. Out of a total of 134 pre-transplant variables, 39 were selected as highly predictive of 1-year mortality via feature selection algorithm and were used to train five ML models. AUC for the prediction of 1-year survival was .689, .642, .649, .637, .526 for the Adaboost, Logistic Regression, Decision Tree, Support Vector Machine, and K-nearest neighbor models, respectively, whereas the Index for Mortality Prediction after Cardiac Transplantation (IMPACT) score had an AUC of .569. Local interpretable model-agnostic explanations (LIME) analysis was used in the best performing model to identify the relative impact of key predictors. ML models for 3- and 5-year survival as well as acute rejection were also developed in a secondary analysis and yielded AUCs of .629, .609, and .610 using 27, 31, and 91 selected variables respectively.

CONCLUSION

Machine learning models showed good predictive accuracy of outcomes after heart transplantation.

Validating a novel score based on interaction between ACLF grade and MELD score to predict waitlist mortality

BACKGROUND & AIMS

Among candidates listed for liver transplant (LT), the model for end-stage liver disease (MELD) score may not capture acute-on-chronic liver failure (ACLF) severity. Data on the interaction between ACLF and MELD score in predicting waitlist mortality are scarce.

METHODS

We analyzed the UNOS database (01/2002 to 06/2018) for LT listings in adults with cirrhosis and ACLF (without hepatocellular carcinoma). ACLF grades 1, 2, 3a, and 3b- were defined using the modified EASL-CLIF criteria.

RESULTS

Of 18,416 candidates with ACLF at listing (mean age 54 years, 69% males, 63% Caucasians), 90-day waitlist mortality (patient death or being too sick for LT) was 21.6% (18%, 20%, 25%, and 39% for ACLF grades 1, 2, 3a, and 3b, respectively). Using a Fine and Gray regression model, we identified an interaction between MELD and ACLF grade, with ACLF having a higher impact at lower MELD scores. Other variables included candidate's age, sex, liver disease etiology, listing MELD, ACLF grade, obesity, and performance status. A score developed using parameter estimates from the interaction model on the derivation cohort (n = 9,181) stratified the validation cohort (n = 9,235) into quartiles: Q1 (score <10.42), Q2 (10.42-12.81), Q3 (12.82-15.50), and Q4 (>15.50). Waitlist mortality increased with each quartile from 13%, 18%, 23%, and 36%, respectively. Observed vs. expected waitlist mortality deciles in the validation cohort showed good calibration (goodness of fit p = 0.98) and correlation (R = 0.99).

CONCLUSION

Among selected candidates who have ACLF at listing, MELD score and ACLF interact in predicting cumulative risk of 90-day waitlist mortality, with higher impact of ACLF grade at lower listing MELD score. Validating these findings in large prospective studies will support consideration of both MELD and ACLF when prioritizing transplant candidates and allocating liver grafts.

LAY SUMMARY

In patients with cirrhosis listed for liver transplantation, the presence of multiorgan failure, a condition referred to as acute-on-chronic liver failure, is associated with high waiting list mortality rates. Current organ allocation policy disadvantages patients with this condition. This study describes and validates a new scoring method that performs better than the currently available scoring systems. Further validation of this approach may reduce the deaths of patients with cirrhosis and acute-on-chronic liver failure on the transplant waiting list.

Long-term adult congenital heart disease survival after heart transplantation: A restricted mean survival time analysis

BACKGROUND

Adult Congenital Heart Disease (ACHD) heart transplant recipients may have lower post-transplant survival resulting from higher peri-operative mortality than non-ACHD patients. However, the late risk of mortality appears lower in ACHD recipients. This study seeks to establish whether long-term heart transplant survival is reduced among ACHD recipients relative to non-ACHD recipients.

METHODS

Adult patients who received a heart transplant between January, 2000 and December, 2019 in the United Network for Organ Sharing database were stratified by the presence of ACHD. Propensity-matched cohorts (1:4) were created to adjust for differences between groups. Graft survival at time points from 1 to 18 years was compared between groups using restricted mean survival time (RMST) analysis.

RESULTS

The matched cohort included 1,139 ACHD and 4,293 non-ACHD patients. Median age was 35 years and 61% were male. Average survival time at 1 year was 0.85 years for ACHD patients and 0.93 years for non-ACHD patients (average difference: -0.08 years, 95% Confidence Interval [CI] -0.10 to -0.06, p < 0.001), reflecting higher immediate post-transplant mortality. Average survival time at 18 years was not clinically or statistically different: 11.14 years for ACHD patients and 11.40 years for non-ACHD patients (average difference: -0.26 years, 95% CI: -0.85 to + 0.32 years, p = 0.38).

CONCLUSIONS

Despite increased medium-term mortality among ACHD patients after heart transplant, differences in long-term survival are minimal. Allocation of hearts to ACHD patients results in acceptable utility of donor hearts.

Donor Gamma-Glutamyl Transferase Is Associated With Liver Allograft Discard and Failure

INTRODUCTION

The disparity between the number of individuals on the wait list and available liver allografts creates the need for a system that maximizes donor liver utilization and predicts graft failure.

RESEARCH QUESTION

This study aimed to determine the relationship between donor Gamma-Glutamyl Transferase (GGT), liver discard, and graft failure.

DESIGN

Through multivariate analysis from 53 966 deceased liver donors, we adjusted for donor clinical and demographic characteristics and compared donor GGT with allograft discard. We compared donor GGT ranges with graft failure and analyzed data from 47 269 liver recipients.

RESULTS

After adjusting for other factors, donor GGT was significantly associated with liver discard, with GGT over 200 U/L being most significant (OR 2.74, CI 2.51-2.99). Donor GGT under 20 U/L was also found to be a protective factor for post-transplant graft failure (HR 0.91, CI 0.83 - 1.00).

CONCLUSION

Going forward, GGT should be included among other characteristics associated with allograft discard considered during the procurement process.

Machine learning-based prediction of health outcomes in pediatric organ transplantation recipients

OBJECTIVES

Prediction of post-transplant health outcomes and identification of key factors remain important issues for pediatric transplant teams and researchers. Outcomes research has generally relied on general linear modeling or similar techniques offering limited predictive validity. Thus far, data-driven modeling and machine learning (ML) approaches have had limited application and success in pediatric transplant outcomes research. The purpose of the current study was to examine ML models predicting post-transplant hospitalization in a sample of pediatric kidney, liver, and heart transplant recipients from a large solid organ transplant program.

MATERIALS AND METHODS

Various logistic regression, naive Bayes, support vector machine, and deep learning (DL) methods were used to predict 1-, 3-, and 5-year post-transplant hospitalization using patient and administrative data from a large pediatric organ transplant center.

RESULTS

DL models generally outperformed traditional ML models across organtypes and prediction windows with area under the receiver operating characteristic curve values ranging from 0.750 to 0.851. Shapley additive explanations (SHAP) were used to increase the interpretability of DL model results. Various medical, patient, and social variables were identified as salient predictors across organ types.

DISCUSSION

Results demonstrate the utility of DL modeling for health outcome prediction with pediatric patients, and its use represents an important development in the prediction of post-transplant outcomes in pediatric transplantation compared to prior research.

CONCLUSION

Results point to DL models as potentially useful tools in decision-support systems assisting physicians and transplant teams in identifying patients at a greater risk for poor post-transplant outcomes.

Transplant and mechanical circulatory support in patients with adult congenital heart disease

Advances in surgery and pediatric care over the past decades have achieved improved survival for children born with congenital heart disease (CHD) and have produced a large, growing population of patients with adult congenital heart disease (ACHD). Heart failure has emerged as the leading cause of death and a major cause of morbidity among the ACHD population, while as little evidence supports the efficacy of guideline-directed medical therapies in this population. It is increasingly important that clinicians caring for these patients understand how to utilize mechanical circulatory support (MCS) in ACHD. In this review, we summarize the data on transplantation and MCS in the ACHD-heart failure population and provide a framework for how ACHD patients may benefit from advanced heart failure therapies like transplantation and MCS.

Outcomes of Liver Transplant Candidates with Primary Biliary Cholangitis: The Data from the Scientific Registry of Transplant Recipients

BACKGROUND

Primary biliary cholangitis (PBC) is progressive and can cause end-stage liver disease necessitating a liver transplant (LT). PBC patients may be disadvantaged on LT waitlist due to MELD-based priority listing or other factors.

AIM

The aim was to assess waitlist duration, waitlist mortality, and post-LT outcomes of PBC patients.

METHODS

The Scientific Registry of Transplant Recipients data for 1994-2016 was utilized. Adult patients with PBC without hepatocellular carcinoma (HCC) were selected. Their clinico-demographic parameters and waitlist and post-transplant outcomes were compared to those of patients with hepatitis C (HCV) without HCC.

RESULTS

Out of 223,391 listings for LT in 1994-2016, 8133 (3.6%) was for PBC without HCC. Mean age was 55.5 years, 76.9% white, 86.2% female, mean MELD score 21, 6.6% retransplants. There were 52,017 patients with hepatitis C included for comparison. The mean waitlist mortality was 17.9% for PBC and 17.6% for HCV (p > 0.05). The average transplantation rate was 57.7% for PBC and 53.3% for HCV (p < 0.0001), while waitlist dropout (death or removal due to deterioration) rate was 25.0% for PBC and 25.4% for HCV (p > 0.05). There was no significant difference in median waiting duration till transplantation between PBC patients and HCV after 2002 (103 vs. 95 days, p > 0.05). Post-LT mortality and graft loss rates were significantly lower in PBC than in HCV patients (all p < 0.02).

CONCLUSIONS

Despite no evidence of impaired waitlist outcomes and favorable post-transplant survival in patients with PBC, there is still a high waitlist dropout rate suggesting the presence of an unmet need for effective treatment.

Predicted heart mass-based size matching among recipients with moderate pulmonary hypertension: Outcomes and sex effect

BACKGROUND

There is a lack of evidence to guide appropriate donor sizing in recipients with moderate pulmonary hypertension (pHTN) awaiting heart transplantation (HTx). It is common practice to oversize donor hearts for such recipients to prevent post-operative right ventricular failure. Therefore, our objective was to determine if oversizing in pre-transplant moderate pHTN provides a survival advantage.

METHODS

The United Network for Organ Sharing database was analyzed to include HTx recipients from 1994 to 2016. Recipients were considered as having moderate pHTN if the pulmonary vascular resistance (PVR) was 2.5 to 5 Wood units (WU) or transpulmonary gradient (TPG) was 10 to 18 mm Hg. Heart size mismatch was determined using the predicted heart mass equations. A size mismatch of ≥15% in either direction was considered undersized or oversized, respectively. Ninety-day and 1-year survival were analyzed based on size matching via univariate and Cox regression analysis. Propensity matching was performed to specifically evaluate the effect of donor sex among male transplant recipients.

RESULTS

Among 29,441 HTx recipients, 10,666 had moderate pHTN by PVR criteria and 12,624 HTx patients had moderate pHTN according to TPG criteria. Among patients with a PVR of 2.5 to 5 WU, oversizing was not associated with lower mortality compared with matched hearts at 90 days (7.6% vs 7.4%; p = 0.75) and 1 year (12.1% vs 11.3%; p = 0.26). Conversely, undersizing the donor was associated with a higher 90-day (10.6% vs 7.6% vs 7.4%; p < 0.01) and 1-year (15.3% vs 12.1% vs 11.3%; p < 0.01) mortality than recipients receiving oversized or matched hearts, respectively. On Cox regression analysis, there was no benefit with oversizing at 90 days (hazard ratio [HR] 0.88; p = 0.23) and 1 year (HR 0.99; p = 0.90), whereas undersizing was associated with higher 90-day (HR 1.32; p = 0.02) and 1-year mortality (HR 1.23; p = 0.03) compared to size-matched controls. Among patients with moderate pHTN based on TPG of 10 to 18 mm Hg, neither undersizing nor oversizing was predictive of mortality at 90 days and 1 year according to Cox regression analysis. Propensity matching revealed that female-to-male transplantation had similar 1-year mortality to male-to-male transplantation, and there was no advantage to oversizing female donors for male recipients.

CONCLUSIONS

In this registry-based analysis, there was no benefit to oversizing donors for cardiac transplant recipients with moderate pHTN. Elimination of this restriction could increase the donor pool and reduce wait times for such recipients.

Karnofsky Performance Status Following Liver Transplantation in Patients With Multiple Organ Failures and Probable Acute-on-Chronic Liver Failure

BACKGROUND & AIMS

Little is known about outcomes of patients who underwent liver transplantation for acute on chronic liver failure (ACLF) and multiple organ failures. We compared Karnofsky Performance Status (KPS) before and after liver transplantation among patients with different numbers of organ failures and probable ACLF.

METHODS

We performed a retrospective cohort study of adults who underwent liver transplantation within 30 days of listing with the United Network for Organ Sharing (UNOS) network from January 1, 2006, through September 30, 2016. We determined the prevalence of organ failures using a modified version of the Chronic Liver Failure-Sequential Organ Failure Assessment scale and collected KPS scores at the time of transplantation and at intervals of 3 to 12 months after liver transplantation. Multivariate analyses were performed to adjust for confounders including UNOS region.

RESULTS

At the time of liver transplantation, 2838 patients had no organ failure, 2944 had 1 to 2 organ failures, and 1342 patients had 3 or more organ failures. KPS scores following liver transplantation improved significantly in all groups; scores ranged from 81 in patients with no organ failure to 72 in patients with 5 to 6 organ failures. Excellent performance status (KPS score, ≥80) by 1 year after transplantation was achieved by 60% of patients with 5 to 6 organ failures, 64% to 66% of patients with 3 to 4 organ failures, and 70% to 71% of patients with 1 to 2 organ failures, compared with 72.5% of patients without organ failure. Patients with 1 to 4 organ failure were more likely to achieve KPS scores of 80 or more than patients without organ failure, after we adjusted for other covariates and UNOS region. In addition, black patients were less likely, and patients with alcoholic cirrhosis were more likely, to have KPS scores of 80 or more after liver transplantation.

CONCLUSIONS

In a retrospective cohort study of patients with probable ACLF who underwent liver transplantation within 30 days of listing with the UNOS network, 60% to 66% of patients with 3 or more organ failures achieved excellent performance 3 to 12 months later.

Functional Status at Liver Transplant Waitlisting Correlates With Greater Odds of Encephalopathy, Ascites, and Spontaneous Bacterial Peritonitis

BACKGROUND & AIMS

Whether higher liver transplant (LT) waitlist mortality in patients with poor functional status (FS) is mediated by higher prevalence of cirrhosis complications is not clear. We aim to evaluate the impact of FS on risk of hepatic encephalopathy (HE), ascites, and spontaneous bacterial peritonitis (SBP) among adults listed for LT.

METHODS

Using 2005-2018 United Network for Organ Sharing LT data, we retrospectively evaluated the impact of FS on prevalence of ascites, HE, and SBP among adults listed for LT using Karnofsky Performance Status Score categories (KPSS-1: FS 80-100%, KPSS-2: 60-70%, KPSS-3: 40-50%, KPSS-4: 10-30%), stratified by underlying liver disease etiology. Between-group comparisons used chi-squared methods and adjusted multivariate logistic regression.

RESULTS

Among 100,618 adults listed for LT (68.8% male, 72.4% non-Hispanic white) 35.2% were KPSS-1, 36.6% KPSS-2, 15.7% KPSS-3, and 12.6% KPSS-4 at time of LT waitlist registration. Patients with worse FS were significantly more likely to have ascites, HE, and SBP at time of waitlist registration (KPSS-1 vs. KPSS-4: ascites, 66% vs. 93%; HE, 81% vs. 49%; SBP, 4% vs. 16%, p < 0.001 for all). On multivariate regression, compared with patients with KPSS-1, those with KPSS-4 had significantly higher odds of ascites (odds ratio [OR]: 1.49, 95% confidence interval [CI]: 1.37-1.62, p < 0.01), HE (OR: 1.69, 95% CI: 1.59-1.80, p < 0.01), and SBP (OR: 2.17, 95% CI: 1.98-2.38, p < 0.01), which was observed across all liver disease etiologies.

CONCLUSION

Worse FS is associated with higher odds of cirrhosis complications including ascites, HE, and SBP, which was observed across all liver disease etiologies.