high-MELD Patients Research Articles

Waiting Time, not Donor-Risk-Index, Is a Major Determinant for Beneficial Outcome after Liver Transplantation in High-MELD Patients

Introduction: Due to the increasing donor shortage in Western Europe, patients undergo liver transplantation actually only with high MELD-scores. Furthermore, the waiting times are more and more prolonged. In this study, we analyze high-MELD patients who underwent liver transplantation at our center. Methods: Since the implementation of the MELD-score within the Eurotransplant region (December 2006), 45 patients with a lab-MELD-score ≥ 36 underwent liver transplantation at our center. We correlated the 6-months-survival with donor data (especially the donor risk index), the waiting time from reaching a lab-MELD-score ≥ 36 up to the liver transplantation and the recipient's state prior transplantation. Results: The 6-months-survival in our cohort is 68,8 %. The waiting time of the survivors was significantly shorter compared to the patients who died within the first six months after the liver transplantation (median survivors: 2 ± 1,88 days; median dead: 4 ± 2,42 days; p = 0,049). The donor risk index showed no significant differences between both groups (median survivors: 1,72 ± 0,4; median dead: 1,89 ± 0,33; p = not significant). Furthermore, the recipient's state prior transplantation (dialysis, mechanical ventilation, catecholamine administration) showed no significant association with the outcome. In a multivariate analysis, the waiting time was also the only independent risk factor associated with a inferior outcome. Conclusion: The outcome after liver transplantation in high-MELD patients is worse compared to the long-term survival of transplanted patients with a marked lower MELD-score. Especially the time interval between reaching a lab-MELD score ≥36 to the liver transplantation is a major determinant for survival. Since the donor risk index is not associated with a worsened outcome, transplantation centers should accept even marginal organs for high-MELD patients to keep the waiting time as short as possible.

Conversion from CNI Based Immunosuppression to Everolimus in High MELD Patients (> 30)

The number of critically ill patients undergoing orthotopic liver transplantation (OLT) has constantly increased since the introduction of the MELD system in 2006. In many cases patients with a high MELD score (> 30 MELD points) show an impaired renal function reflected by an increase in serum creatinine levels or a decrease of the glomerular filtration rate (GFR). It has been suggested that immunsuppression with mTor-inhibitors might improve renal function in patients after OLT. In 84 patients with a lab MELD score > 30 OLT was performed after MELD based allocation was introduced. In 15 patients (18%) immunosuppression was converted from calcineurin inhibitor based immunosuppression to Everolimus. Initial analysis of these 15 patients showed no significant differences in serum creatinine levels or MDRD (Modifikation of Diet in Renal Disease)-GFR within 270 days after conversion of the immunosuppressive protocol compared to values before conversion. Ten out of these 15 patients (66%) showed a creatinine greater 100 umol/l at the day of conversion (mean 201.2 ± 72.3 umol/l). Renal function improved significantly with creatinine 201.2 ± 72.3 umol/l before vs. 138 ± 32.7 (p=0.03) at day 90 (± 45, n=9) after conversion in this group. Regarding GFR an increase could also be shown with mean GFR of 37.1 ml/min/1.73m2 at day of conversion vs. 53.4 ± 19.3 ml/min/1.73m2 (p=0.02) at day 90. This effect remained significant for creatinine levels over the analyzed period of 270 days. Our data support the previously published positive effect of everolimus on renal function post transplantation. This effect could only be shown in patients with an already impaired renal function (creatinine >100 umol/l, GFR < 100 ml/min/1.73m2) at day of conversion. For high MELD patients with an impaired renal function in conversion from CNI to everolimus based immunosuppressive protocols seems to be justified, however further studies including more patients and longer follow up periods are necessary.

Lessons from liver transplantation

Lessons from liver transplantation

PTU-045 Proton nuclear magnetic resonance spectroscopy of plasma in patients with cirrhosis correlates with arterial ammonia but not grade of hepatic encephalopathy

IntroductionDiagnosis of overt hepatic encephalopathy (HE) in patients with cirrhosis often relies on subjective clinical examination. Arterial ammonia correlates poorly with HE grades and a blood marker for diagnosis and...

Liver transplantation cost in the model for end-stage liver disease era: Looking beyond the transplant admission

We examined the relationship between the total cost incurred by liver transplantation (LT) recipients and their Model for End-Stage Liver Disease (MELD) score at the time of transplant. We used a novel database linking billing claims from a large private payer with the Organ Procurement and Transplantation Network registry. Included were adults who underwent LT from March 2002 through August 2007 (n = 990). Claims within the year preceding and following transplantation were analyzed according to the recipient's calculated MELD score. Cost was the primary endpoint and was assessed by the length of stay and charges. Transplant admission charges represented approximately 50% of the total cost of LT. MELD was a significant cost driver for pretransplant, transplant, and total charges. A MELD score of 28 to 40 was associated with additional charges of $349,213 (P < 0.05) in comparison with a score of 15 to 20. Pretransplant and transplant admission charges were higher by $152,819 (P < 0.05) and $64,286 (P < 0.05), respectively, in this higher MELD group. No differences by MELD score were found for posttransplant charges. Those in the highest MELD group also experienced longer hospital stays both in the pretransplant period and at the time of LT but did not have higher rates of re-admissions. In conclusion, high-MELD patients incur significantly higher costs prior to and at the time of LT. Following LT, the MELD score is not a significant predictor of cost or re-admission.

Split-liver transplantation in the high-MELD adult patient: are we being too cautious?

The fear that patients with high-mathematical model for end stage liver disease (MELD) score may not be suitable candidates for segmental grafts because of their need for greater liver mass has continued to push the transplant community toward the use of whole LT (WLT) in preference to split LT (SLT). In order to define the outcome of segmental liver transplantation in a better manner in high-MELD patients (score > or =26), we queried the UNOS registry for graft and patient survival results according to MELD score in adult patients receiving WLT and SLT in the United States from the inception of MELD allocation (February 27, 2002) through March 9, 2007. A total of 316 adult patients received a SLT as compared with 20 778 WLTs. Patient and graft survival rates at 6 and 12 months were comparable for all MELD ranges, including the 'high-MELD' recipients (e.g. at MELD score 31-35, patients' and grafts' survival rates at 12 months was 87.5% in SLT group vs. 84.4% and 76.7% in WLT group respectively). The results even at higher MELD scores (i.e. >35) were more than acceptable. In conclusion, patient and graft survival rates for SLT in high-MELD adult patients are comparable to the same for WLT.

The Economic Impact of MELD on Liver Transplant Centers

Adoption of the model for end stage liver disease (MELD) system prioritized patients awaiting liver transplant (LT) by severity of illness including progressive renal dysfunction. Unfortunately, current reimbursement for LT is not adjusted by severity of illness or need for simultaneous liver-kidney transplantation (LKT). This study examines hospital cost and reimbursement for LT and LKT to determine the effect of MELD on transplant center (TC) financial outcomes given current reimbursement practices as well as DRG outlier threshold limits. LT was performed for 86 adults prior to and 127 following the implementation of MELD. Between the eras, there was a substantial increase in the average laboratory MELD score (17.1 to 20.7 p=0.004) and percentage of LKTs performed (5.8% to 17.3% p=0.01). Increasing MELD score was associated with higher costs ($4309 per MELD point p<0.001) and decreasing TC net income ($1512 per MELD point p<0.001). In patients not achieving the Medicare outlier status, predicted net loss was $17,700 for high-MELD patients and $19,133 for those needing LKT. In conclusion, contractual reimbursement agreements that are not indexed by severity of disease may not reflect the increased costs resulting from the MELD system. Even with outlier thresholds, Medicare reimbursement is inadequate resulting in a net loss for the TC.