Survival Benefit-Based Deceased-Donor Liver Allocation

Abstract

Currently, patients awaiting deceased-donor liver transplantation are prioritized by medical urgency. Specifically, wait-listed chronic liver failure patients are sequenced in decreasing order of Model for Endstage Liver Disease (MELD) score. To maximize lifetime gained through liver transplantation, posttransplant survival should be considered in prioritizing liver waiting list candidates. We evaluate a survival benefit based system for allocating deceased-donor livers to chronic liver failure patients. Under the proposed system, at the time of offer, the transplant survival benefit score would be computed for each patient active on the waiting list. The proposed score is based on the difference in 5-year mean lifetime (with vs. without a liver transplant) and accounts for patient and donor characteristics. The rank correlation between benefit score and MELD score is 0.67. There is great overlap in the distribution of benefit scores across MELD categories, since waiting list mortality is significantly affected by several factors. Simulation results indicate that over 2000 life-years would be saved per year if benefit-based allocation was implemented. The shortage of donor livers increases the need to maximize the life-saving capacity of procured livers. Allocation of deceased-donor livers to chronic liver failure patients would be improved by prioritizing patients by transplant survival benefit.

Severe muscle depletion predicts postoperative length of stay but is not associated with survival after liver transplantation

“…Clinicians are often challenged when they are determining the cost/efficiency of liver transplantation for very frail and deconditioned patients with cirrhosis, and in order to avoid futile liver transplants, some validated but subjective measures of post-liver transplant survival, such as admission to the intensive care unit, the use of mechanical ventilation or renal replacement therapy, multiorgan failure, advanced age, and hepatitis C virus (HCV) infection and comorbidities, are being used to screen patients who may present with poor outcomes after transplantation. [7][8][9] Currently, cross-sectional imaging studies such as computed tomography (CT) scans are the gold standard for quantifying skeletal muscle mass 10 and hence constitute good resources for objective and detailed nutritional/metabolic assessments of patients and for the identification of sarcopenia. Moreover, the measurement of a single abdominal image of the third lumbar vertebra (L3) provides an excellent estimation of the total body skeletal muscle.…”

Association of preoperative parameters with postoperative mortality and long-term survival after liver transplantation

“…1 However, implementation of the MELD score has raised the issue of utility of the donated liver grafts. 2 According to the "utility" concept (i.e., organs are allocated preferentially to the lowest-risk candidates), an ideal liver allocation model should not only identify the patient with the highest probability of dying on the waiting list, but also predict early postoperative mortality and longterm survival. Early postoperative mortality usually is associated with technical failures, high-risk recipients and poor-quality grafts.…”

Outcomes matter: estimating pre-transplant survival rates of kidney-transplant patients using simulator-based propensity scores

“…Hence, the CCA approach treats recipients' PTLY values as missing values and drops all kidney recipients from the modeling. CCA is based on the assumption that excluded and included observations are statistically equivalent in terms of mortality-rate-related characteristics (SRTR, 2007a,b;Wolfe et al, 2008;Schaubel et al, 2009). The main limitation of the CCA approach in our context is that in practice the underlying assumption is violated: recipients and candidates differ statistically in terms of their medical conditions which are related to their mortality rate.…”