Laurie Bouck

November 03, 2008

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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