Model for End-Stage Liver Disease score does not predict patient or graft survival in living donor liver transplant recipients

Although living donor liver transplantation (LDLT) is a successful procedure for most recipients, outcomes in patients who undergo transplantation as United Network for Organ Sharing status 2A are marginal. There are no published data on living donor liver transplant recipient outcomes relative to Model for End-Stage Liver Disease (MELD) scores. Such information could be useful in living donor liver transplant recipient selection. We retrospectively analyzed all non-fulminant hepatic failure, right hepatic lobe, adult-to-adult living donor liver transplant recipients at our center between August 1997 and March 2002. We calculated MELD scores at the time of LDLT and correlated scores with 1-year patient and graft survival and hospital days during the 90-day post-LDLT period. There were 62 recipients with greater than 6 months of follow-up: 38 men, 24 women; mean age, 47.9 years; 42 white, 1 black, 17 Hispanic, and 2 Asian patients. Twenty-nine patients had hepatitis C virus infection; 4 patients, hepatitis C virus infection and alcoholic liver disease; 4 patients, alcoholic liver disease; 4 patients, cryptogenic cirrhosis; 13 patients, primary sclerosing cholangitis; 5 patients, autoimmune hepatitis; and 3 patients, primary biliary cirrhosis. Mean and median MELD scores were 15.2 and 13, respectively (range, 6 to 40). One-year patient and graft survival were 59 of 62 patients (95%) and 52 of 62 patients (84%), respectively. There was no statistically significant difference between median MELD scores of dead versus living patients (15 v 13; P = .15) or patients who underwent retransplantation versus those who did not (16.5 v 13; P = .30). Mean and median hospital days in the 90-day post-LDLT period were 23.7 and 16.0 days, respectively. Living donor liver transplant recipients with a MELD score of 18 or greater had significantly more hospital days compared with recipients with a MELD score less than 18 (35.2 v 19.8 days; P = .01). In conclusion, MELD scores did not predict post-LDLT patient or graft survival at 1 year. However, higher MELD scores (≥18) were associated with more hospital days during the 3-month post-LDLT period. (Liver Transpl 2003;9:737-740.)     

Geographic Differences in Event Rates by Model for End-Stage Liver Disease Score

The ability of the model for end-stage liver disease (MELD) score to accurately predict death among liver transplant candidates allows for evaluation of geographic differences in transplant access for patients with similar death risk. Adjusted models of time to transplant and death for adult liver transplant candidates listed between 2002 and 2003 were developed to test for differences in MELD score among Organ Procurement and Transplantation Network (OPTN) regions and Donation Service Areas (DSA). The average MELD and relative risk (RR) of death varied somewhat by region (from 0.82 to 1.28), with only two regions having significant differences in RRs. Greater variability existed in adjusted transplant rates by region; 7 of 11 regions differed significantly from the national average. Simulation results indicate that an allocation system providing regional priority to candidates at MELD scores > or = 15 would increase the median MELD score at transplant and reduce the total number of deaths across DSA quintiles. Simulation results also indicate that increasing priority to higher MELD candidates would reduce the percentage variation among DSAs of transplants to patients with MELD scores > or = 15. The variation decrease was due to increasing the MELD score at time of transplantation in the DSAs with the lowest MELD scores at transplant.     

Outcome stagnation of liver transplantation for primary sclerosing cholangitis in the Model for End-Stage Liver Disease era

Purpose

Survival after liver transplantation (LTX) has decreased in Germany since the implementation of Model for end-stage liver disease (MELD)-based liver allocation. Primary sclerosing cholangitis (PSC) is known for its otherwise excellent outcome after LTX. The influence of MELD-based liver allocation and subsequent allocation policy alterations on the outcome of LTX for PSC is analyzed.

Methods

This is a retrospective observational study including 126 consecutive patients treated with LTX for PSC between January 1, 1999 and August 31, 2012. The PSC cohort was further compared to all other indications for LTX in the study period (n?=?1420) with a mean follow-up of 7.9 years (SD 3.2). Multivariate risk-adjusted analyses were performed. Alterations of allocation policy have been taken into account systematically.

Results

Transplant recipients suffering from PSC are significantly younger (p?p?=?0.018), and have lower 3-month mortality than patients with other indications (p?=?0.044). The observed time on the waiting list is significantly longer for patients with PSC (p?MELD points in the PSC cohort (p?=?0.052). No improvement in means of short-term mortality could be shown in relation to alterations of allocation policy within the MELD era (p?=?0.375). Survival rates of the pre-MELD era did not differ significantly from those of the MELD era (p?=?0.097) in multivariate risk-adjusted analysis. Patients in the MELD era suffered pre-transplant significantly more frequently from dominant bile duct stenosis (p?=?0.071, p?=?0.059, p?=?0.048, respectively; chi²).

Conclusions

Progress is stagnating in LTX for PSC. Current liver allocation for PSC patients should be reconsidered.     

Donor-Model for End-Stage Liver Disease and donor-recipient matching in liver transplantation

Background

The product between donor (D) age and recipient (R) Model for End-Stage Liver Disease (MELD) score at the moment of liver transplantation (LT) has been proposed as a potential D-R matching tool to reduce the risk of “futile” LT from using the MELD score as the main allocation tool. The aim of this study was to evaluate the prognostic ability of D-MELD among a cohort of Italian patients already selected for LT on the basis of a D-R matching philosophy.

Methods

We studied 303 consecutive adult patients undergoing first LT for chronic liver diseases with available D-MELD at the moment of LT from 2003 to 2009. Optimal donors were assigned to more severe cirrhotic patients (MELD ≥20); suboptimal organs were allocated to patients with hepatocellular carcinoma (HCC) not responsive to bridging therapies (specific priority score) or other exceptions with MELD <20. A suboptimal donor had age >70 years, severe steatosis by ultrasound, and/or body mass index >30 kg/m², partial liver, or hepatitis C (HCV) or B virus positivity.

Results

Characteristics of the study group were a median age of 55 years (range, 27-68 years), HCV positivity in 164 patients (54%), HCC in 134 patients (44%), partial liver use in 25 (8%), MELD 15 (range, 6-40), D-age of 56 years (range, 18-87 years), and median D-MELD score 826 (range, 126-2,988). Overall graft survival was 84%, 79%, and 77% at 1, 3, and 5 years after LT, respectively. Logistic regression did not show a significant correlation between graft failure and D-MELD score in the absence of a significant D-MELD cutoff. Cox regression with D-MELD as the continuous variable showed a hazard ratio (HR) of 0.99 (95% confidence interval [CI], 0.99-1.00; P = NS); and with D-MELD as a dichotomic variable (≥0 to <1,600) an HR of 0.98 (95% CI, 0.63-1.77; P = NS).

Conclusion

The prognostic ability of D-MELD fails in OLT centers that use a more complex D-R matching policy.     

Chronic Kidney Disease-Epidemiology Formula and Model for End-Stage Liver Disease Score in the Assessment of Renal Function in Candidates for Liver Transplantation

Assessment of renal function in patients with end-stage liver disease (ESLD) awaiting liver transplantation (OLT) is critical. Various conditions may cause renal damage in ESLD. Renal and liver functions are intertwined due to splanchnic hemodynamic relationships; renal failure rarely occurs in patients without advanced decompensated cirrhosis. The recent literature suggests that evaluation of renal function should include an assessment of liver function. The aim of this study was to evaluate different methods to estimate glomerular filtration rate (GFR) in patient among ESLD candidates for OLT over 1 year. We also correlated renal and hepatic functions. Fifty-two cirrhotic patients Model for End-Stage Liver Disease [MELD] > 10) were enrolled in the study. All patients were evaluated at baseline and every 4 months (T1-T4) thereafter for 1 year. The GFR was calculated by creatinine clearance, and estimated by Cockroft and Gault, Modified Diet Renal Disease (MDRD) 4 and 6 variable and Chronic Kidney Disease-Epidemiology (CKD-EPI) formulae. Hepatic functions were evaluated by MELD score, albumin, bilirubin, and International Normalized Ratio (INR). We observed not statistically significant increase mean value of MELD score, bilirubin, serum creatinine, and blood urea nitrogen and a reduced serum sodium. There were no significant differences among various methods to evaluate GFR at each time over 1 year. We did not observe any association between renal and hepatic function, except at T4 for MELD and GFR estimated with MDRD 4 (P = .009) and 6 (P = .008) parameters or CKD-EPI (P = .036), and MELD and sodium (P = .001). Our results showed that evaluation of renal function in cirrhosis should include an evaluation of hepatic function. In our case, MDRD and CKD-EPI seemed to be the more accurate formulae to evaluate renal function in relation to hepatic function.     

Impact of Model for End-Stage Liver Disease Score on Transfusion Rates in Liver Transplantation

Background

Liver transplantation (OLT) can entail a high risk of blood loss requiring transfusions, which increase morbidity and mortality. In recent years many efforts have been spent to improve the surgical and anesthetic management to decrease transfusion rates during OLT. Preoperative predictors for transfusion in OLT, remain uncertain.

Methods

We retrospectively reviewed the 219 OLT performed from 2005 to 2011 focusing on blood product (BP) transfusions. Statistical analysis sought the impact of transfusions on OLT outcomes to identify possible independent predictors of higher BP requirements.

Results

The 1- and 3-year survival rates were 86.6% and 76.45% for patients and 81.0% and 71.8% for grafts respectively. The mean intra- and perioperative red blood cell (RBC) transfusion rates were 12.3 ± 11.7 U and 15.5 ± 13.0 U respectively. A statistical analysis demonstrated a significant influence of BP transfusion on post-OLT complications and survivals. Multivariate logistic regression analysis showed the Model for End-Stage Liver Disease (MELD) score to be the only independent predictor of perioperative RBC transfusions.

Conclusions

Our results confirmed the link between intra- and perioperative transfusions and outcome of OLT patients. MELD score resulted the only independent variable associated with increased perioperative RBC transfusions.     

Analysis of Model for End-Stage Liver Disease (MELD) score in a liver transplantation waiting list

BACKGROUND: The Model for End-Stage Liver Disease (MELD) was introduced in 1999 to quantify the 3-month prognosis of cirrhotic patients after a transjugular intrahepatic portosystemic shunt (TIPS). Because of the imbalance between organ donors and patients on the waiting list, the MELD was adopted by the United States in 2002 to allocate liver grafts for transplantation. Preliminary results have indicated a reduction in waiting list deaths and an increase in transplantation rates for candidates. Seeking to find a new model to predict death on the waiting list and after liver transplantation, retrospective studies have examined MELD scores in waiting list patients. The aim of this study was to analyze the MELD scores of patients on the liver waiting list for comparisons between transplanted patients. PATIENTS AND METHODS: A retrospective study was performed analyzing 131 registrations of 127 orthotopic liver transplant (OLT) patients (4 underwent retransplantation) grafted between November 2000 and January 2006, excluding 24 patients: 2 had urgent retransplantations due to hepatic artery thrombosis and 22 had incomplete data. These patients were divided into 3 groups: group I (transplanted patients)-53 patients underwent 55 OLT; group II-29 patients who died on the waiting list; group III-patients on the waiting list including 23 patients still waiting as of the date of the study. RESULTS: The main indication for OLT was hepatitis C virus cirrhosis (50.50%), followed by alcoholic liver cirrhosis (23.30%), cryptogenic cirrhosis (12.60%), autoimmune hepatitis (5.80%), hepatitis B virus cirrhosis (4.85%), and primary biliary cirrhosis (2.91%). Group I: MELD score 15.62 (range, 6-39) on admission to the list, and 18.87 (range, 7-39) at transplantation. The mean waiting time for OLT was 478.39 days (range, 2-1270 days). The 38 patients who survived underwent 39 OLT (1 retransplantation). The MELD score at entrance to the list was 14.62 (range, 7-30) and at transplantation, 17.70 (range, 7-39). The mean time between admission to the list and transplantation was 505.37 days (range, 6-1270 days). The 15 patients who died had received 16 OLT (1 retransplantation). Their MELD scores were 17.80 (range, 6-39) and 21.81 (range, 9-39) at admission to the list and at transplantation, respectively, with a mean time on the waiting list of 417.93 days (range, 2-872 days). Group II: 29 patients died before OLT, at a mean age of 52.60 years (range, 22-67 years). Their MELD score was 19.24 (range, 7-45), and the interval between admission to the waiting list and death was 249.55 days (range, 3-1247 days). Group III: 23 patients still active on the OLT waiting list at the time of study displayed a mean MELD score of 13.65 (range, 6-28) and 354.30 days (range, 2-905 days) waiting until the moment. In conclusion, MELD score at the time of admission to the waiting list was higher among those patients who died either awaiting a liver graft (19.24) or after OLT (17.80) compared with those who survived after OLT (14.60) or are still awaiting OLT (13.65).     

Albumin-Bilirubin Score vs Model for End-Stage Liver Disease in Predicting Post-Hepatectomy Outcomes

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Impact of the Model for End-Stage Liver Disease (MELD) Score on Liver Transplantation in Greece

IntroductionThe impact of preoperative Model for End-stage Liver Disease (MELD) score in postoperative mortality remains unclear. The assumption that patients with a higher MELD score will have a higher mortality rate is not confirmed and studies are contradictory.AimThe study of the clinical course of patients with a higher MELD score and its impact in immediate and later mortality in comparison with patients with a lower MELD score in the only liver transplantation center in Greece.MethodWe retrospectively studied 71 patients who underwent orthotopic liver transplantation (OLT) in the time period between 1-1-2011 and 31-12-2013. The patients were divided into 2 groups: Group A with a MELD score ≥23 and Group B with a MELD score <23.ResultsIn the patients with a MELD score ≥23 the duration of mechanical ventilation and length of stay in the ICU were prolonged (P = .013 and .009, respectively), the transfusions were more (P = .005), and the rates of ICU readmissions (22.5% vs 7.31%, P = .001) and infections (42.5% vs 17.5%, P = .011) were higher. Thirty-day mortality did not differ between the 2 groups (P = .420), but there was a statistically significant difference in morbidity and in 180-day mortality.ConclusionThe patients with a higher MELD score have more complex pathophysiology. This score seems to affect morbidity and late, but not early, mortality.     

Regional Variation in Appropriateness of Non-Hepatocellular Carcinoma Model for End-Stage Liver Disease Exception

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Pretransplant Model for End-Stage Liver Disease Score as a Predictor of Postoperative Complications After Liver Transplantation

The model for end-stage liver disease (MELD) is used to determine organ allocation priorities for orthotopic liver transplantation (OLT), although its value to predict posttransplantation mortality and morbility is controversial. The aim of this study was to analyze postoperative courses and (to evaluate the relationships between MELD score and postoperative) complications. We retrospectively examined the courses of 242 patients including 186 males and 56 females of overall mean age of 53 ± 10 years who underwent primary liver transplantation. The classification of Dindo-characterized 5 grades of severity to evaluate postoperative events. The data showed that 171 patients (70.7%) experienced complications, while 71 (29.3%) had none. We observed that MELD score and complications were related (P < .05). Patients with complicated courses post-OLT displayed a 22.80 mean value of the MELD score, while those without complications showed a 17.64 mean value. The MELD score was also significantly associated with the time of intensive care unit stay and in hospital. Finally, we noted that MELD score and mortality were significantly correlated (P < .05). In conclusion, MELD score can be considered to be an objective system to predict the prevalence and severity of postoperative complications after liver transplantation.     

Application of Postoperative Model for End-Stage Liver Disease Scoring System for Evaluating Liver Graft Function After Living Donor Liver Transplantation

Background

The Model for End-Stage Liver Disease (MELD) score has been validated to predict the mortality rate of patients with various chronic liver diseases on the waiting list for liver transplantation (LT). The aim of this study was to assess the value of the postoperative MELD scoring system as an early postoperative predictor of outcome in patients undergoing living donor LT (LDLT).

Methods

A retrospective analysis of 217 adult-to-adult LDLT patients was performed. The values of the MELD score on various postoperative days (PODs) as predictors of graft loss within 6 months after LDLT were examined by calculating the areas under the receiver operating characteristic (AUROC) curves. The 6-months graft survival rates were compared between patients with (n = 22) and without (n = 195) graft loss. Univariate and multivariate analyses were performed to identify the factors associated with mortality.

Results

The MELD score on POD2 was a predictor of graft loss, with an AUROC c-statistic of 0.779, a specificity of 79.5%, and a sensitivity of 68.2% at optimal cutoff, whereas the preoperative MELD score c-statistic was 0.605 with 44.6% sensitivity. Multivariate analyses for postoperative mortality revealed MELD-POD2 ≥19 (odds ratio, 5.601; 95% confidence interval [CI], 1.395–4.508; P = .0009) as an independent predictor of short-term graft loss following LDLT, in addition to preoperative hospitalization status. Later MELD POD scores were also predictive of graft loss.

Conclusions

The early postoperative MELD scoring system is feasible as an index for prediction of postoperative mortality following LDLT.     

Correlation Between Functional Capacity and Respiratory Assessment of End-Stage Liver Disease Patients Waiting for Transplant

IntroductionEnd-stage liver disease has metabolic complications associated with malnutrition, which involves a great loss of muscle mass. This complication can lead to changes in the diaphragm, which along with ascites may impair daily activities and result in global motor disability and physical inactivity of patients on the waiting list for liver transplantation.ObjectivesThis study sought to delineate the profile of candidates for liver transplantation while on the waiting list at the Clinical Hospital of State University Campinas (UNICAMP), and to assess and verify whether there is a correlation between functional status of the individuals tested using the 6-minute walk test (6MWT), pulmonary function test (PFT), and respiratory muscle strength with end-stage liver disease candidates for liver transplantation.MethodsThis study was carried out in the Liver Transplantation Unit of the State University of Campinas (UNICAMP). We included 46 patients with end-stage liver disease who underwent the following evaluations: medical history, 6MWT, PFT, maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP), and SF-36.ResultsCorrelations were found between the respiratory variables 6MWT and PFT. The walked distance was correlated with MIP and MEP. There was no correlation between the 6MWT and the variables body mass index and age.ConclusionCandidates for liver transplantation have decreased muscle strength, normal lung function, and impaired quality of life, mainly due to physical limitations. Functional status may be correlated with the respiratory assessment (muscle strength and pulmonary function test) in liver disease candidates for transplantation.     

Combination of extended donor criteria and changes in the Model for End-Stage Liver Disease score predict patient survival and primary dysfunction in liver transplantation: a retrospective analysis

BACKGROUND: The purpose of this study was to analyze the impact of extended donor criteria (EDC) and of changes in the Model for End-Stage Liver Disease (MELD) score while waiting for liver-transplantation (Delta-MELD) on patient survival and initial graft function. METHODS: We included 386 consecutive patients with end-stage liver disease who underwent orthotopic liver transplantation at the Medical University Vienna between 1997 and 2003. Primary outcome was patient survival and secondary outcome was initial graft function. EDC included: age >60 years, >4 days intensive medical care, cold ischemia time >10 hr, need for noradrenalin >0.2 microg/kg/min or doputamin >6 microg/kg/min, a donor peak serum sodium >155 mEq/L, a donor serum creatinine >1.2 mg/100 mL, and a body mass index >30. RESULTS: Delta-MELD was significantly higher in the nonsurvivor population (P=0.01) and EDC showed a significant influence on initial graft function (P=0.01). Worsening in either Delta-MELD or the presence of at least two EDC was not associated with an increased risk of primary graft dysfunction and death. Worsening in Delta-MELD and the presence of at least two EDC was significantly associated with primary graft dysfunction (P=0.01) and death (P=0.008). CONCLUSION: The combination of a liver recipient with worsening Delta-MELD and a potential donor with at least two EDC should be avoided.     

Prognostic Value of Model for End-Stage Liver Disease Scores in Patients with Fulminant Hepatic Failure

Background

This study was undertaken to investigate risk factors of mortality in patients with fulminant hepatic failure (FHF).

Methods

Fifty-three patients with FHF treated from January 2006 to April 2011 were allocated to a spontaneous survival group (group 1), a death without liver transplantation (LT) group (group 2), and an LT group (group 3). To analyze risk factors associated with mortality in FHF, we excluded group 3 patients. Clinical features, Model for End-Stage Liver Disease (MELD) scores, and King's College Hospital criteria at the time of hepatic encephalopathy in group 2 were compared with those of group 1.

Results

The causes of FHF were acute viral infection (n = 29, hepatitis A:B, 28:1), drugs (n = 18; including 4 acetaminophen and 14 herbal medication), autoimmune (n = 4), and miscellaneous (n = 2). Of the 53 patients, 19 were allocated to group 1, 18 to group 2, and 16 to group 3. According to univariate analysis, risk factors for mortality in group 2 were acute renal failure requiring renal replacement therapy and a MELD score ≥30 at the time of hepatic encephalopathy. However, by multivariate analysis, a MELD score ≥30 was the only independent risk factor for mortality in group 2 (P = .042; hazard ratio, 4.500).

Conclusions

A MELD score ≥30 was found to be the only independent risk factor of mortality in FHF patients without LT. Therefore, the findings of this study suggest that these patients may need emergent LT for survival.     

Predicting Operative Outcomes in Patients with Liver Disease: Albumin-Bilirubin Score vs Model for End-Stage Liver Disease-Sodium Score

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