Aminopyrine breath test in cirrhotic patients awaiting liver transplantation: do we really need it ?

Abstract

Received: 20 April 2004 Accepted: 8 June 2004 Published online: 27 October 2004 Springer-Verlag 2004 Dear Editors: We read with interest the article by Degre and colleagues on the use of the aminopyrine breath test (ABT) to predict mortality among cirrhotic patients waitlisted for liver transplantation (LT) [1]. However, their well-designed study raises questions as to the real impact of such a test in the management of LT waiting lists. Patient stratification—which is often referred to as the sickest first principle—is crucial to any resource allocation, but prediction of post-transplant survival, i.e. utility, is mandatory if an LT programme is to be cost effective. The abysmal gap between organ demand and supply and the everincreasing use of suboptimal donors mandate a policy of effective graft allocation, which is often opposite to the principle of equity. Over the recent years several quantitative tests of liver function (QTLF) have been suggested to assess the hepatic functional reserve in patients with chronic liver disease [2]. These tests include the ABT, the methionine breath test, the galactose clearance capacity, the sorbitol and the indocyanine-green clearance [2, 3]. However, none has proved superior to the traditional Child–Pugh (CP) classification, which is based on clinical and laboratory parameters. Furthermore, QTLF may vary significantly within and across CP classes as a result of enzyme-inducing agents [4] and of causes of disease [5]. To date, it is unclear whether QTLF may provide relevant prognostic information in cirrhotic patients that is superior to that of conventional prognostic parameters or risk scores [2]. The recent introduction of the model for end-stage liver disease (MELD) scoring system for patient prioritisation is based on the assumption that graft allocation should favour the most urgent patients and that the CP-driven allocation system fails to identify seriously ill patients in a timely fashion [6]. However, even though the MELD system is a reliable indicator of patients’ urgency within populations, there are differences in actual calculated risks for a given MELD score between populations [7]. Furthermore, the MELD score has been found to be poorly correlated with post-transplantation outcome, and surrogate prognostic models have been suggested [8]. The assumption that the pretransplantation patient risk is paramount and that every patient has the same right to be offered LT is not the case in most European centres, where a National Health System run programme must comply with economic and ethic issues and face shortage of available resources. Moreover, the impact of marginal donor grafts on post-transplantation outcome is to be taken into account Transpl Int (2004) 17: 651–652 DOI 10.1007/s00147-004-0772-x LETTER TO THE EDITORS