Liver Transplant Waiting Time Does Not Correlate With Waiting List Mortality: Implications for Liver Allocation Policy

Abstract

Factors associated with the risk for mortality once placed on the liver transplant waiting list and how this risk relates to center-specific waiting time and transplant activity have not been adequately evaluated. We performed this study to determine the association between center-specific waiting time and waiting list mortality among liver transplant candidates stratified by medical urgency at the time of registration. A Cox proportional hazards model was used to calculate 2-year mortality risk for a cohort of 16,414 registrants added to the United Network for Organ Sharing liver transplant waiting list between January 1, 1997, and December 31, 1997. After controlling for confounding variables, we calculated the mortality risk for centers, organ procurement organizations (OPOs), and states. The relation between center-specific waiting list mortality risk and median waiting time or transplant activity was determined by linear regression. In multivariate analyses, higher initial medical urgency status (relative risk [RR] ‫؍‬ 12.8; P < .001), increasing age (P < .001), black ethnicity (RR ‫؍‬ 1.29; P < .001), history of previous transplant (RR ‫؍‬ 1.2; P ‫؍‬ .009), certain liver diagnoses, and smaller center size (RR ‫؍‬ 1.39; P ‫؍‬ .008) were associated with significantly increased waiting list mortality. Candidates with blood type A (RR ‫؍‬ 0.87; P < .001) and those with cholestatic cirrhosis as the primary diagnosis (RR ‫؍‬ 0.73; P < 0.001) had a reduced risk for dying. There were significant variations in 2-year waiting list mortality risk among centers, OPOs, and states. However, when stratified by medical urgency status at waiting list entry, center-specific waiting time and transplantation rates accounted for almost none of the center-specific waiting list mortality. Although there are variations in waiting list mortality risk among centers, OPOs, and states, there is very little relation between center-specific waiting list mortality and center-specific median waiting time or center-specific transplantation rates when stratified by medical urgency. Waiting time and center transplant rates should not influence liver allocation policy. (Liver Transpl 2000;6:543-552.)

Aplicação do escore MELD em pacientes submetidos a transplante de fígado: análise retrospectiva da sobrevida e dos fatores preditivos a curto e longo prazo

“…O escore delta-MELD (17,21) foi definido como sendo o valor do MELD calculado na data da cirurgia do transplante de fígado subtraído do valor do MELD na época da inscrição do paciente na Central de Transplante da Secretaria do Estado da Saúde de São Paulo.…”

“…FREEMAN e EDWARDS (21) conduziram um estudo e reportaram que o tempo em lista de espera não deveria ser o único critério utilizado para alocação de órgãos, pois não estaria relacionado com a mortalidade observada em lista; também referiram que já havia evidência de que a sobrevida após transplante era menor em pacientes mais graves.…”

“…FREEMAN (22) e FREEMAN et al (21,23,24) reportaram que houve na era pós-MELD 12% menos inscrições de pacientes com MELD menores do que 10. Houve aumento de 10,2% no número de transplantes realizados e diminuição de 3,5% de óbito em lista de espera.…”

“…Verificaram também que não houve diferenças estatísticas significantes quando se analisou a sobrevida pós-transplante de fígado, embora o paciente mais grave (conceito de "sickest first" (em pior estado clínico)), tivesse sido transplantado e o tempo de lista tenha sido reduzido de 656 para 416 dias (2,3,20,21,31) .…”

“…Em 2006, o consenso nacional (MESSAGE) para estudos do escore MELD (4,5,6,7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,23,25) não incorporou o sódio sérico ou a presença de ascite ao escore MELD.…”