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

Abstract

PurposeSurvival 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.MethodsThis 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.ResultsTransplant recipients suffering from PSC are significantly younger (p < 0.001), can be discharged earlier (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 < 0.001), and there is a trend toward lower match 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).ConclusionsProgress is stagnating in LTX for PSC. Current liver allocation for PSC patients should be reconsidered.

Primary sclerosing cholangitis – a comprehensive review

“…Conversely, it has been argued that whilst MELD predicts waitlist mortality, the actual need for liver transplantation is poorly reflected for some patient groups (PSC included) for which MELD introduces a systematic disadvantage. [228][229][230] PSC patients frequently experience a poor quality of life and increased risk of disease-specific adverse outcomes, including recurrent or intractable cholangitis and the development of biliary malignancies, all poorly reflected by MELD-score based risk prediction. 228 Overall <5% of transplants in the US are done on the basis of PSC while about 15% of those in Scandinavia are undertaken for PSC, reflecting both differences in practice and prevalence.…”

Liver transplantation for critically Ill patients with secondary sclerosing cholangitis: Outcome and complications

“…Comparable to patients with SSC‐CIP, patients with PSC show biliary alterations that may lead to LT . PSC is an excellent indication for LT as the long‐term survival rates are favorable . However, our findings add further evidence that even in critically ill patients with cholangiopathy, promising long‐term results after LT are achievable.…”

“…Comparable to patients with SSC‐CIP, patients with PSC show biliary alterations that may lead to LT . PSC is an excellent indication for LT as the long‐term survival rates are favorable .…”

“…This may lead to lower MELD scores in the initial phase of ICU treatment and higher scores in the late phase of multiple organ dysfunction, which may hamper LT. 1,14 Comparable to patients with SSC-CIP, patients with PSC show biliary alterations that may lead to LT. 15 PSC is an excellent indication for LT as the long-term survival rates are favorable. 15 However, our findings add further evidence that even in critically ill patients with cholangiopathy, promising long-term results after LT are achievable. The QoL and the healthrelated parameters were assessed retrospectively in a telephone interview.…”

Prognosis of primary sclerosing cholangitis - time to look at the population as a whole, not only from the center's or waiting list perspective

“… could show some years ago in a population‐based cohort of 599 patients in NL that included also patients from three Dutch transplant centers that the median (transplant‐free) survival after diagnosis was 21.3 years in the entire cohort compared to 13.2 years in the cohort seen at transplant centers. Thus, if viewed from a transplant center's or waiting list perspective alone, there is a risk of bias, be it referral bias or time‐lead bias, as exemplified in a recent study from Hannover, Germany .…”