Survival Benefit of Repeat Liver Transplantation in US
Survival Benefit of Repeat Liver Transplantation in US
Survival benefit (SB) for first liver transplantation (LT) is favorable at Model for End-Stage Liver Disease (MELD) ≥15. Herein, we identify the MELD threshold for SB from repeat liver transplantation (ReLT) by recipient hepatitis C virus (HCV) status and donor risk index (DRI). We analyzed lab MELD scores in new United Network for Organ Sharing registrants for ReLT from March 2002 to January 2010. Risk of ReLT graft failure ≤1 year versus waitlist mortality was calculated using Cox regression, adjusting for recipient characteristics. Of 3057 ReLT candidates, 54% had HCV and 606 died while listed. There were 1985 ReLT recipients, 52% had HCV and 567 ReLT graft failures by 1 year. Unadjusted waitlist mortality and post-ReLT graft failure rates were 416 (95% confidence interval [CI] 384–450) and 375 (95% CI 345–407) per 1000 patient-years, respectively. Waitlist mortality was higher with increasing waitlist MELD (p < 0.001). The MELD for SB from ReLT overall was 21 (21 in non-HCV and 24 in HCV patients). MELD for SB varied by DRI in HCV patients (MELD 21, 24 and 27 for low, medium and high DRI, respectively) but did not vary for non-HCV patients. Compared to first LT, ReLT requires a higher MELD threshold to achieve an SB resulting in a narrower therapeutic window to optimize the utility of scarce liver grafts.
Liver transplantation (LT) can be a lifesaving intervention for patients with acute or chronic liver disease. The need for LT far exceeds the supply of liver grafts. Optimizing the use of available liver grafts is therefore part of a rational approach to decision making in patient and graft selection. This is particularly important when posttransplant outcomes are known to be inferior such as in patients with advanced hepatocellular carcinoma (i.e. beyond Milan or University of California, San Francisco criteria) or repeat liver transplantation (ReLT). Posttransplant outcome is utilized by a predominately urgency-based allocation in the United States by limiting the standard Model for End-Stage Liver Disease (MELD) exception score for hepatocellular carcinoma by tumor burden to within the Milan criteria to mitigate the risk for post-LT recurrent hepatocellular carcinoma. Although ReLT has inferior outcomes to first LT, post-ReLT outcome is not explicitly incorporated into current liver graft allocation. For first LT, Merion et al characterized the survival benefit (SB; when waitlist mortality exceeds post-LT mortality) as occurring when the MELD score at LT is 15 or greater. However, the SB from ReLT has not been characterized. Better understanding of the circumstances where ReLT candidates may achieve an SB from the procedure could optimize the use of scarce liver grafts. In this study, we examine the MELD threshold for SB from ReLT and assess the influence of graft quality and hepatitis C virus (HCV).
Abstract and Introduction
Abstract
Survival benefit (SB) for first liver transplantation (LT) is favorable at Model for End-Stage Liver Disease (MELD) ≥15. Herein, we identify the MELD threshold for SB from repeat liver transplantation (ReLT) by recipient hepatitis C virus (HCV) status and donor risk index (DRI). We analyzed lab MELD scores in new United Network for Organ Sharing registrants for ReLT from March 2002 to January 2010. Risk of ReLT graft failure ≤1 year versus waitlist mortality was calculated using Cox regression, adjusting for recipient characteristics. Of 3057 ReLT candidates, 54% had HCV and 606 died while listed. There were 1985 ReLT recipients, 52% had HCV and 567 ReLT graft failures by 1 year. Unadjusted waitlist mortality and post-ReLT graft failure rates were 416 (95% confidence interval [CI] 384–450) and 375 (95% CI 345–407) per 1000 patient-years, respectively. Waitlist mortality was higher with increasing waitlist MELD (p < 0.001). The MELD for SB from ReLT overall was 21 (21 in non-HCV and 24 in HCV patients). MELD for SB varied by DRI in HCV patients (MELD 21, 24 and 27 for low, medium and high DRI, respectively) but did not vary for non-HCV patients. Compared to first LT, ReLT requires a higher MELD threshold to achieve an SB resulting in a narrower therapeutic window to optimize the utility of scarce liver grafts.
Introduction
Liver transplantation (LT) can be a lifesaving intervention for patients with acute or chronic liver disease. The need for LT far exceeds the supply of liver grafts. Optimizing the use of available liver grafts is therefore part of a rational approach to decision making in patient and graft selection. This is particularly important when posttransplant outcomes are known to be inferior such as in patients with advanced hepatocellular carcinoma (i.e. beyond Milan or University of California, San Francisco criteria) or repeat liver transplantation (ReLT). Posttransplant outcome is utilized by a predominately urgency-based allocation in the United States by limiting the standard Model for End-Stage Liver Disease (MELD) exception score for hepatocellular carcinoma by tumor burden to within the Milan criteria to mitigate the risk for post-LT recurrent hepatocellular carcinoma. Although ReLT has inferior outcomes to first LT, post-ReLT outcome is not explicitly incorporated into current liver graft allocation. For first LT, Merion et al characterized the survival benefit (SB; when waitlist mortality exceeds post-LT mortality) as occurring when the MELD score at LT is 15 or greater. However, the SB from ReLT has not been characterized. Better understanding of the circumstances where ReLT candidates may achieve an SB from the procedure could optimize the use of scarce liver grafts. In this study, we examine the MELD threshold for SB from ReLT and assess the influence of graft quality and hepatitis C virus (HCV).
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