Potentially inappropriate liver transplantation in the era of the “sickest first” policy – A search for the upper limits

Linecker, Michael; Krones, Tanja; Berg, Thomas; Niemann, Claus U.; Steadman, Randolph H.; Dutkowski, Philipp; Clavien, Pierre Alain; Busuttil, Ronald W.; Truog, Robert D.; Petrowsky, Henrik

doi:10.1016/j.jhep.2017.11.008

Cited by 88 publications

(88 citation statements)

References 147 publications

(201 reference statements)

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“…This finding quantifies an observation that has been previously made by experts in the field that patients are growing sicker at listing. 38 Not only is the population being listed for transplant sicker (at least in terms of bilirubin, creatinine, and international normalized ratio), it is also increasing in mean age, having increased from 50.1 years old at listing in 2002 to 53.9 years in 2016. With an older, sicker population being listed for transplant, the question of when and for whom liver transplant would be an inappropriate therapy is increasingly vital.…”

Section: Discussionmentioning

confidence: 99%

The decreasing predictive power of MELD in an era of changing etiology of liver disease

Godfrey

Malik

Lai

et al. 2019

American Journal of Transplantation

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The field of liver transplantation has shifted considerably in the MELD era, including changing allocation, immunosuppression, and liver failure etiologies, as well as better supportive therapies. Our aim was to evaluate the predictive accuracy of the MELD score over time. The United Network for Organ Sharing provided de‐identified data on 120 156 patients listed for liver transplant from 2002‐2016. The ability of the MELD score to predict 90‐day mortality was evaluated by a concordance (C‐) statistic and corroborated with competing risk analysis. The MELD score's concordance with 90‐day mortality has downtrended from 0.80 in 2003 to 0.70 in 2015. While lab MELD scores at listing and transplant climbed in that interval, score at waitlist death remained steady near 35. Listing age increased from 50 to 54 years. HCV‐positive status at listing dropped from 33 to 17%. The concordance of MELD and mortality does not differ with age (>60 = 0.73, <60 = 0.74), but is lower in diseases that are increasing most rapidly—alcoholic liver disease and non‐alcoholic fatty liver disease—and higher in those that are declining, particularly in HCV‐positive patients (HCV positive = 0.77; negative = 0.73). While MELD still predicts mortality, its accuracy has decreased; changing etiology of disease may contribute.

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Section: Discussionmentioning

confidence: 99%

The decreasing predictive power of MELD in an era of changing etiology of liver disease

Godfrey

Malik

Lai

et al. 2019

American Journal of Transplantation

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“…78,79 In the context of a global organ shortage in LT, the concept of utility has therefore been opposed to the one of equity. 80 This raises several unsolved issues linked to the question of results of LT in patients with very high MELD scores, identification of "too sick to transplant" patients and the associated upper limits of the "sickest first" policy.…”

Section: Therapiesmentioning

confidence: 99%

“…In recent years, the notion of "futility" of LT has been used if post-transplant mortality was higher than waiting list mortality 81,82 or in case of 3month or in-hospital mortality after LT. 76,83 However, authors of a recent review preferred to correct "futile" LT to "potentially inappropriate" LT, thus reducing the value judgment inherent to the term "futile". 80 This semantic change follows the adoption of these new terms by a multisociety statement that provided guidance for clinicians to prevent and manage disputes regarding patients with advanced critical illnesses. 84 This change introduces an element of uncertainty in this area (i.e.…”

Section: Therapiesmentioning

confidence: 99%

Approaches for patients with very high MELD scores

Artru

Samuel

2019

JHEP Reports

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In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.

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“…The predictive factors for a futile or inappropriate LT in the setting of ACLF have not been clearly determined . On the basis of past experience, we believe that patients with advanced circulatory, renal, and respiratory failure may end up having an inappropriate transplant.…”

Section: Discussionmentioning

confidence: 99%

Living Donor Liver Transplantation for Acute‐on‐Chronic Liver Failure

et al. 2019

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Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of previously diagnosed or undiagnosed liver disease with organ failure(s) with high short-term mortality. This study was conducted to report the outcomes of living donor liver transplantation (LDLT) in ACLF and assess the survival benefit of liver transplantation (LT) in these patients. It was a retrospective study of 218 ACLF patients on the basis of European Association for the Study of the Liver (EASL)-chronic liver failure criteria from January 2014 through November 2017. Patients were considered for LDLT if there was no improvement on standard medical therapy for 5-10 days. Prior to LDLT, active sepsis was excluded/treated, and renal, circulatory, and respiratory failures were improved to the greatest extent possible. The mean age was 42.9 years, and 181 patients were male. Sepsis was the most common acute precipitating event followed by alcohol. Of the patients, 35 (16.1%), 66 (30.3%), and 117 (53.7%) were classified into ACLF grades 1, 2, and 3, respectively. Although 80% of the ACLF 1 group and 72.7% of the ACLF 2 group underwent LDLT, only 35% of the ACLF 3 group could undergo LDLT. The circulatory and respiratory failures at admission were significantly higher in the nontransplant group with poor subsequent response to standard medical therapy, exclusion from LDLT, and poor outcomes. None of the patients on high support for circulatory and respiratory failure underwent LDLT. Posttransplant survival at 1 year was comparable among different grades of ACLF (92.9%, 85.4%, and 75.6%; P = 0.15). Among patients in the ACLF 3 group, survival at 90 days was extremely poor in those who could not undergo LDLT (5.9% versus 78%; P < 0.001). In conclusion, LDLT results in good survival with acceptable post-LT morbidity in patients with ACLF. YaDav et aL.Renal 63 (28.9) Brain 39 (17.9) Circulation 48 (22.0) Respiration 39 (17.9) Organ failure at 7 days after admission Liver 177 (81.2) Coagulation 112 (51.4) Renal 50 (22.9) Brain 37 (17.0) Circulation 71 (32.6) Respiration 72 (33.0) NOTE: Data are given as n (%) and mean ± SD. Liver transpLantation, vol. 25, no. 3, 2019 YaDav et aL.

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Potentially inappropriate liver transplantation in the era of the “sickest first” policy – A search for the upper limits

Cited by 88 publications

References 147 publications

The decreasing predictive power of MELD in an era of changing etiology of liver disease

The decreasing predictive power of MELD in an era of changing etiology of liver disease

Approaches for patients with very high MELD scores

Living Donor Liver Transplantation for Acute‐on‐Chronic Liver Failure

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