AASLD 2008: Mortality Lower for Early Liver Transplant in Healthier Patients

Laurie Bouck
Medscape Medical News 2008. © 2008 Medscape




November 3, 2008 (San Francisco, California) — Patients with low to mid Model
for End-Stage Liver Disease (MELD) scores benefit more from early liver
transplantation than sicker patients, said Michael Goldstein, MD, from Columbia
University, in New York City, here at The Liver Meeting 2008, the 59th Annual
Meeting of the American Association for the Study of Liver Diseases.
Dr. Goldstein and his colleagues looked at the 5-year survival rate from the
time patients were put on the waitlist, analyzing United Network for Organ
Sharing (UNOS) data from a 2002 to 2006 study of 22,863 liver-only adult
transplant recipients and 43,497 liver transplant waitlist patients. They looked
at both waitlist and posttransplant mortality. The organ transplants studied
included both living-donor organs and deceased donor high-donor-risk index
organs (DRI >2.0) and low-donor-risk index organs (DRI <1.5). Study methods
included a Cox proportional hazards regression and a Kaplan–Meier analysis.
Early timing of liver transplants was key to the analysis. Dr. Goldstein
calculated a "break even" 5-year mortality rate for high- and low-risk organs to
find the best timing for high DRI organ transplantation. For example, for
patients with a MELD score of 11 to 14, survival improved with transplantation
at 15 months instead of a projected 21 months, he stated in his presentation.
He also said during his presentation that living-donor allografts worked well
for patients with MELD scores lower than 15. Dr. Goldstein said that "living
donor allografts actually outperformed all deceased-donor allografts," in the
UNOS data.
In his presentation, Dr. Goldstein said that the 5-year mortality rate for those
on the transplant waitlist is probably higher than it appears. "No one knows
really how to predict 5-year mortality [from] MELD," he said, and a lack of
follow-up on transplant patients probably skews the data as well.
In the 4 MELD-score cohorts (<10, 11–18, 19–24, and >25), those with the lowest
and highest MELD scores who received an early living-donor transplant had 5-year
mortality rates higher than the national average: those with a MELD score lower
than 10 had a 3.5% increased mortality rate, and those with a MELD score higher
than 25 had a 7.6% increased mortality rate. However, 5-year mortality decreased
for early living-donor transplants given to patients with MELD scores of 11 to
18 (a 13.4% decrease) and of 19 to 24 (a 14.8% decrease).
Patients who received a high DRI organ followed a similar pattern. Those with a
MELD score higher than 25 had a slight improvement in 5-year mortality rates,
but those with MELD scores in the middle 2 cohorts (11 to 18 and 19 to 24)
benefited most.
"The small differences in posttransplant mortality by donor type are offset by
the greater benefit in early access to transplantation, regardless of donor
type," Dr. Goldstein stated in his abstract. "Living-donor and high DRI
allografts are best utilized in mid-MELD recipients and offer the most benefit
when utilized early to balance waitlist mortality."
Clinicians who want to apply these data need to look at the average wait time
for their patients and the number of patients who would benefit from early
transplantation, Dr. Goldstein told Medscape Gastroenterology.
Dr. Goldstein admitted that his conclusions are "somewhat contradictory to the
general MELD principles" of treating the sickest patients first, since the
patients he recommends for early transplant are "exactly those patients who no
one transplants early," he told Medscape Gastroenterology. However, he said that
patients with lower MELD scores "have the most to gain" because they have a
better quality of life before and after transplantation and live longer
posttransplant than the sicker patients. When making transplantation decisions
with limited organs, "we should look at the total benefit for society as a
whole," he said.
Session moderator Sandy Feng, MD, PhD, from the Department of Surgery,
University of California, San Francisco, who was not involved with the study,
told Medscape Gastroenterology that each patient must be viewed as an
individual. "I think it's always dangerous to make individual decisions based on
modeling data," she said. "I think the weakest argument is really in the
low-MELD group.... We don't really know that people with MELD scores of 11 to 14
have that waitlist mortality curve all the way out to 20 months," she said. "So
I still am nervous in particular about his conclusions regarding the very low
MELD-score patients and that they should proceed to living-donor
transplantation."
Dr. Feng added that transplant outcomes vary by transplant center. "I don't
think you should undergo those transplants at low MELD scores unless you're at a
very, very experienced center with the best outcomes," she said.
Dr. Goldstein received no commercial support for his analysis. Neither Dr.
Goldstein nor Dr. Feng have disclosed any relevant financial relationships.
The Liver Meeting 2008: 59th Annual Meeting of the American Association for the
Study of Liver Diseases (AASLD): Abstract 22. Presented November 2, 2008.

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