Downgrading MELD Improves the Outcomes after Liver Transplantation in Patients with Acute-on-Chronic Hepatitis B Liver Failure

Abstract

BackgroundHigh score of model for end-stage liver diseases (MELD) before liver transplantation (LT) indicates poor prognosis. Artificial liver support system (ALSS) has been proved to effectively improve liver and kidney functions, and thus reduce the MELD score. We aim to evaluate whether downgrading MELD score could improve patient survival after LT.Methodology/Principal FindingsOne hundred and twenty-six LT candidates with acute-on-chronic hepatitis B liver failure and MELD score ≥30 were included in this prospective study. Of the 126 patients, 42 received emergency LT within 72 h (ELT group) and the other 84 were given ALSS as salvage treatment. Of the 84 patients, 33 were found to have reduced MELD score (<30) on the day of LT (DGM group), 51 underwent LT with persistent high MELD score (N-DGM group). The median waiting time for a donor was 10 for DGM group and 9.5 days for N-DGM group. In N-DGM group there is a significantly higher overall mortality (43.1%) than that in ELT group (16.7%) and DGM group (15.2%). N-DGM (vs. ECT and DGM) was the only independent risk factor of overall mortality (P = 0.003). Age >40 years and the interval from last ALSS to LT >48 h were independent negative influence factors of downgrading MELD.Conclusions/SignificanceDowngrading MELD for liver transplant candidates with MELD score ≥30 was effective in improving patient prognosis. An appropriate ALSS treatment within 48 h prior to LT is potentially beneficial.

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL) 2014

“…However, contrary results were shown by systematic review by Kjaergard et al where it was seen that ALS reduced mortality by 33 % in patients with ACLF as compared to SMT [131]. More recently, studies have shown that ALS could be an effective form of bridging therapy in patients with ACLF with high MELD scores awaiting liver transplantation and many believe it is a futile exercise in the absence of liver transplant [119,120]. These results have been substantiated by the recently published two large European randomized multicentric controlled trials, i.e., HELIOS (for Prometheus) [125] and RELIEF trial (for MARS) [124], that failed to show any benefit with these modalities on short-term transplant-free survival, which was the primary end point of these studies.…”

“…Whether these could be considered for transplant and what is the outcome when compared with those without organ failure is not clear. Ling et al and Xu et al found that downgrading MELD (to \ 30) in ACLF using an artificial liver support system as bridging therapy improved outcomes in the responders to levels similar to those who had upfront liver transplant [119,120].…”

Model for End-stage Liver Disease

“…39 Worsening MELD score or delta-MELD (current MELD-maximum score in the last 3 months) has been shown to impact post-transplant outcome, 40 and one should avoid graft with >1 EDC for such patients. 41 Similar observations by another study on patients with Hepatitis B virus (HBV) related liver disease and MELD >29 showed that downgrading MELD score using anti-HBV drugs improved outcomes of LT compared to emergency LT. 42 In this respect, product of age and delta-MELD less than 1600 may be required for optimal post-transplant outcomes. 43 …”

Liver transplantation in acute-on-chronic liver failure

“…Replacement of the patients' plasma with its wide range of toxins and mediators by fresh frozen plasma is thought to facilitate liver regeneration and recovery. In each of the three studies summarised [ Table 1], [8][9][10] there was a statistically significant improvement either in survival or in the obtaining of a reduced MELD score prior to LT. I would ask you also to take note of the very recently published study of high volume plasma exchange in acute liver failure (ALF) showing in those not transplanted, significant survival improvement.…”