Futility and rationing in liver retransplantation: When and how can we say no?

Biggins, Scott W.

doi:10.1016/j.jhep.2011.11.027

Cited by 76 publications

(75 citation statements)

References 28 publications

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“…Our retransplantation rate for treatment of biliary complications was 62.5%, higher than most reports 3,4,16,17 . This is possibly due to limitations of our public hospital, as mentioned earlier.…”

Section: Discussioncontrasting

confidence: 56%

Biliary Complications after Liver Transplantation

Facciuto

2014

Mount Sinai Expert Guides: Hepatology

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Section: Discussioncontrasting

confidence: 56%

Biliary Complications after Liver Transplantation

Facciuto

2014

Mount Sinai Expert Guides: Hepatology

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“…The optimal use of scarce liver grafts is dependent on appropriate candidate and donor liver selection: this is particularly true for candidates for ReLT 14, 15 . In this study, we found that the MELD threshold for survival benefit from ReLT is 21 which is higher than the MELD threshold of 15 for first LT reported previously 10 .…”

Section: Discussionmentioning

confidence: 99%

Survival Benefit of Repeat Liver Transplantation in the United States: A Serial MELD Analysis by Hepatitis C Status and Donor Risk Index

Biggins

Gralla

Dodge

et al. 2014

American Journal of Transplantation

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Survival benefit (SB) for first LT is favorable at MELD ≥ 15. Herein, we identify the MELD threshold for SB from repeat liver transplant (ReLT) by recipient HCV status and donor risk index (DRI). We analyzed lab MELD scores in new UNOS registrants for ReLT from 3/2002–1/2010. 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% 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 a survival benefit resulting in a narrower therapeutic window to optimize the utility of scarce liver grafts.

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“…Even though consensus is yet to be reached regarding this matter, an expected graft survival >50% 1-year after transplant has been proposed as a starting point. 6 The optimal use of scarce liver grafts depends on strategic matching of donor and recipient. Our NOTE: These numbers display the highest MELD score at which the 1-year expected survival after re-LT exceeded 50% (ie, the 95% CI for the 1-year expected survival did not include 50%).…”

Section: Discussionmentioning

confidence: 99%

“…Although there is no consensus on a definition of a futile LT, a minimum 1-year expected survival after re-LT of 50% has been proposed as the minimum survival threshold. 6 The Model for End-Stage Liver Disease (MELD) remains the primary method of allocating liver grafts in the United States and many areas of the world. 7 However, the current MELD-based system of liver graft allocation does not take into account several readily available donor and recipient risk factors known to affect graft survival.…”

mentioning

confidence: 99%

Optimizing repeat liver transplant graft utility through strategic matching of donor and recipient characteristics

Hung

Gralla²,

Dodge³

et al. 2015

Liver Transpl

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Repeat liver transplantation (LT) is controversial because of inferior outcomes versus primary LT. A minimum 1-year expected post-re-LT survival of 50% has been proposed. We aimed to identify combinations of Model for End-Stage Liver Disease (MELD), donor risk index (DRI), and recipient characteristics achieving this graft survival threshold. We identified re-LT recipients listed in the United States from March 2002 to January 2010 with > 90 days between primary LT and listing for re-LT. Using Cox regression, we estimated the expected probability of 1-year graft survival and identified combinations of MELD, DRI, and recipient characteristics attaining >50% expected 1-year graft survival. Re-LT recipients (n 5 1418) had a median MELD of 26 and median age of 52 years. Expected 1-year graft survival exceeded 50% regardless of MELD or DRI in Caucasian recipients who were not infected with hepatitis C virus (HCV) of all ages and Caucasian HCV-infected recipients <50 years old. As age increased in HCV-infected Caucasian and non-HCV-infected African American recipients, lower MELD scores or lower DRI grafts were needed to attain the graft survival threshold. As MELD scores increased in HCV-infected African American recipients, lower-DRI livers were required to achieve the graft survival threshold. Use of high-DRI livers (>1.44) in HCVinfected recipients with a MELD score > 26 at re-LT failed to achieve the graft survival threshold with recipient age 60 years (any race), as well as at age 50 years for Caucasians and at age < 50 years for African Americans. Strategic donor selection can achieve >50% expected 1-year graft survival even in high-risk re-LT recipients (HCV infected, older age, African American race, high MELD scores). Low-risk transplant recipients (age < 50 years, non-HCV-infected) can achieve the survival threshold with varying DRI and MELD scores.

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Futility and rationing in liver retransplantation: When and how can we say no?

Cited by 76 publications

References 28 publications

Biliary Complications after Liver Transplantation

Biliary Complications after Liver Transplantation

Survival Benefit of Repeat Liver Transplantation in the United States: A Serial MELD Analysis by Hepatitis C Status and Donor Risk Index

Optimizing repeat liver transplant graft utility through strategic matching of donor and recipient characteristics

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