Higher MELD Research Articles

MELD Score: A Predictor of Mortality for Patients Receiving RVAD after LVAD Implantation

Purpose Right ventricular failure (RVF) after LVAD implantation leads to poor prognosis. Use of Right ventricular assist device (RVAD) has become a standard practice for RVF. Even with RV support mortality up to 40% is observed. Aim of this study is to identify predictors of mortality in patients supported with an RVAD. Methods Retrospective analysis of 16 patients who received an RVAD after an LVAD implantation were carried out. Primary end point was death. Patient's demographic, pre-op labs, echo findings, indications and INTERMACS profile were assessed for mortality association. For normally distributed variables student's t-test was used, and non-parametric variables had Wilcoxon-Mann-Whitney test applied. Results 10 (62.5%) were male and 10 (62.5%) were African Americans. 6 (40%) died within 30 days of RVAD support. At time of hospital admission, variables among the “Survivor” vs. “Non-Survivor” were similar including the MELD score (30.4 ± 6.52 vs. 22.44 ± 9.37, p-value 0.0859). During admission patients were optimized for heart failure with inotropes and IABP. Prior to going for surgical implant majority showed an improvement of MELD score when compared to admission MELD. LVAD implantation was performed utilizing standard techniques. All RVAD implants (Protek-Duo, Tandem Life, Pittsburgh.PA) performed within first 48 hrs of LVAD implant. Poor survival was observed in patients who did not show an improvement in MELD score since admission “Non-Survivor” [Median 30(22-32)], vs. “Survivor” [Median 11(10-13)], p-value 0.0029. Mortality was 100% in patients; with MELD >30, 66.67% with MELD 20-29, 50% with MELD 15-19 and 0% in-group with MELD ≤14. Conclusion Increased mortality is observed among patients who failed to show any significant improvement in MELD score with interventions prior to LVAD implantation. Our data suggests higher MELD score can predict mortality in patients supported with an RVAD after LVAD implantation. Large multi-institutional studies are needed to support these initial findings.

Pre-S/Surface and Core Promoter/Precore Mutations in Chronic Hepatitis B Patients with Severe Acute Exacerbation.

The role of pre-S/surface and basal core promoter/precore (BCP/PC) mutations in chronic hepatitis B (CHB) patients with severe acute exacerbation (SAE) remains unclear. To investigate the role of pre-S/surface and BCP/PC mutations in CHB patients with SAE and mortality. A total of 114 CHB patients with spontaneous SAE [alanine aminotransferase (ALT) ≥ 400U/L] and hepatic decompensation were analyzed along with 114 patients with moderate liver inflammation (ALT: 80-400U/L without hepatic decompensation) who were matched with the SAE patients in regard to age, sex, HBeAg, and cirrhosis. Compared with patients with moderate liver inflammation, those with SAE had a higher rate of genotype B. Multivariate analysis showed that the independent factors for SAE were V14G/A and L21S in surface genes, codons 109-119 deletions in pre-S1 genes, M1V/T/I in pre-S2 genes, and C1766T/T1768A and C1913A/G mutations in BCP/PC genes. However, these gene variants or mutations were not significant predictors of mortality in patients with SAE. Of the 114 SAE patients, 17 died at week 24 of nucleoside analog treatment. Cox regression analysis showed that independent predictors for mortality at week 24 of treatment in SAE patients were higherinternational normalized ratio, the presence of ascites, and T1753C/A/G mutations. The SAE patients with T1753C/A/G mutations had a higher rate of acute-on-chronic liver failure (P = 0.006) and higher MELD score (P = 0.018) than those without T1753C/A/G mutations. The variants or mutations in pre-S/surface and BCP/PC regions might play important roles and could predict mortality in SAE patients.

Persistent acidosis after reperfusion-A prognostic indicator of increased 30-day and in-hospital postoperative mortality in liver transplant recipients.

During liver transplantation, the patient is at risk of developing progressive lactic acidosis. Following reperfusion, correction of acidosis may occur. In some patients, acidosis will worsen, a phenomenon referred to as persistent acidosis after reperfusion (PAAR). We compared postoperative outcomes in patients who manifested PAAR vs those that did not. All adult patients undergoing liver transplantation from 2002 to 2015 were included. PAAR is defined by the presence of a significant negative slope coefficient for base excess values measured after hepatic artery anastomosis through 72hours postoperatively. Primary outcome was a composite of 30-day and in-hospital mortality. Secondary outcomes included: ICU LOS, total hospital LOS, and re-transplantation rate within 7days. PAAR occurred in 10% of the transplant recipients. Patients with PAAR had higher MELD, BMI, and eGFR and demonstrated a longer median ICU LOS and hospital median LOS with a trend toward mortality difference. But, after propensity matching, the mortality rate difference became significantly higher in patients with PAAR compared with matched controls while the ICU LOS differences disappeared. The re-transplantation rates were similar also between the PAAR and no PAAR groups. The cohort with PAAR had a significant 30-day and in-hospital increase in mortality after propensity score matching.

Impact of the baseline anti-A/B IgG titer on the clinical outcome in ABO-incompatible liver transplantation

Introduction: The use of ABO incompatible (ABOi) living donors is an attractive solution for expanding the liver donor pool. We investigated the impact of the baseline anti-A/B IgG titer on the transplant outcomes in ABOi liver transplantation (LT). Method: We analyzed 394 adult patients who underwent living donor LT (303 ABO compatible LT and 91 ABOi LT) between 2012 and 2018. ABOi LT patients were categorized by baseline IgG titer: low IgG titer (≤ 1:64, n=51) versus high IgG titer (≥ 1:128, n=40). All ABOi LT patients received desensitization therapy including rituximab and plasmapheresis. Result: Patients with high IgG titer experienced antibody rebound (≥ 1:64) more frequently than those with low IgG titer during the first month after LT (35.0% vs. 15.7%, P=0.033). Patient survival rates for ABO compatible, low IgG titer, and high IgG titer were 85.0%, 91.5%, and 74.4%, respectively, at 3 years post-transplantation (P=0.006). High IgG titer (HR, 2.76; 95% CI, 1.39-5.48; P=0.004) and MELD score of >20 (HR, 2.32; 95% CI, 1.22-4.41; P=0.010) were independent risk factors for mortality. Infection was the leading causes of death in all groups, but the proportion was significantly higher in high IgG titer group than in other groups (81.8% vs. 30.8% vs. 33.3%). Conclusion: Patients with high IgG titer (≥ 1:128) are associated with a higher risk of death after ABOi LT than those with low IgG titer (≤ 1:64). Thus, ABOi LT patients with high IgG titer should be managed with great care.

Cephalosporin resistance in community acquired spontaneous bacterial peritonitis.

Objective:To determine 3rd generation cephalosporin resistance in patients with community-acquired spontaneous bacterial peritonitis (SBP) using early response assessment.Methods:This prospective quasi-experimental study was carried out at Doctors Hospital & Medical Center from January 2016 to September 2018. Patients with cirrhosis and SBP were included. Third generation cephalosporins i.e. cefotaxime/ceftriaxone were used for treatment of SBP. Response after 48 hours was assessed and decline in ascitic fluid neutrophil count of < 25% of baseline was labelled as cephalosporin resistant. Carbapenem were used as second line treatment. Recovery and discharge or death of patients were primary end points.Results:Male to female ratio in 31 patients of SBP was 1.2/1 (17/14). Hepato-renal syndrome was diagnosed in 11(37.9%) patients. Cefotaxime was used for 16(51.6%) patients whereas ceftriaxone for 15(48.3%) patients. Early response of SBP was noted in 26(83.8%) patients while 5 (16.2%) were non-responders to cephalosporins. SBP resolved in all non-responding patients with i/v carbapenem. In-hospital mortality was 12.9% and had no association with cephalosporin resistance. High bilirubin (p 0.04), deranged INR (p 0.008), low albumin (p 0.04), high Child Pugh (CTP) score (p 0.03) and MELD scores (p 0.009) were associated with in-hospital mortality.Conclusion:Cephalosporin resistance was present in 16.2% of study patients with community-acquired SBP. Mortality in SBP patients is associated with advanced stage of liver disease.

Primary prophylaxis of hepatic encephalopathy in decompensated cirrhosis: Low dose vs. full dose rifaximin

Objective:To compare efficacy of high vs low dose rifaximin for primary prophylaxis of portosystemic encephalopathy (PSE) in decompensated liver cirrhosis.Methods:In a quasi-experimental double blind randomized study at Services Institute of Medical Sciences (SIMS), Lahore from August 2017 to August 2018, patients of decompensated cirrhosis with no previous PSE were randomized to receive twice daily rifaximin 200mg in Group-A and 550mg in Group-B. Patients were followed for 6 months for development of PSE.Results:In 75 included patients, mean age was 53.8(±10.7) years and male/female ratio was 0.97/1(37/38). After randomization, 34 (45.3%) patients were included in Group-A and 41 (54.7%) patients in Group-B. During 6 month follow up 24 (32%) patients developed PSE, 12 (35.2%) in Group-A and 12 (29.2%) in Group-B, difference was not significant (p value 0.57). In 6 months, 13 (17.3%) patient died, 6 (17.6%) in Group-A and 7 (17.07%) patients in Group-B, difference not significant (p value 0.94). Patients who died had higher bilirubin (p < 0.00), higher serum creatinine (p 0.05), high CTP score (p 0.04) and worse MELD score (p 0.004).Conclusion:Rifaximin is not effective for primary prophylaxis of overt hepatic encephalopathy in decompensated cirrhosis patients.

Myocardial contractile dispersion: A new marker for the severity of cirrhosis?

Introduction: Cirrhotic cardiomyopathy (CCM) develops in about half of all cirrhotic patients, affecting the long-term morbidity and mortality. Although some studies have shown an increased QT-interval in cirrhotic patients, no evidences of myocardial contractile and QT dispersion (QTd) changes are available. This study aimed to compare myocardial contractile dispersion (MCd), using tissue Doppler imaging (TDI), as well as QTd between cirrhotic patients and healthy individuals, investigating their associations with cirrhosis severity. Methods: This prospective cross-sectional study was conducted on patients with confirmed liver cirrhosis and healthy individuals. Participants with structural heart disease, heart ventricular pacing, electrolyte abnormalities, using drugs affecting QT interval were excluded. All individuals underwent 2D echocardiography, and TDI by vivid E9 echo machine. MCd and QTd were considered as main outcomes. Chi-square, independent-sample t test, and Pearson correlation test, were used for statistical analyses by SPPS version 17.0. P value <0:05 was considered statistically significant. Results: Sixty participants (40 male/20 female) with a mean age of 40.1 ± 7.1 years in two groups of cirrhotic patients (n=30) and healthy individuals (n=30) were studied. Both groups were statistically similar in terms of age (P = 0.31) and gender (P = 0.39). MCd and QTd of cirrhotic patients were significantly higher than healthy individuals (MCd: 41.0 ± 26.8 versus 27.6±18.1; P = 0.028; and QTd: 37.0 ± 22.1 versus 25.3 ± 8.9; P = 0.010). Cirrhotic patients with MELD score <15 had a lower MCd in comparison to score ≥15 (29.2 ± 13.8 versus 50.0 ± 31.1, P = 0.034). Conclusion: Cirrhosis was associated with increased MCd, assessed by TDI. Also, MCd and QTd were associated with a higher MELD score. According to the results, it seems that MCd and QTd might be useful predictor of ventricular arrhythmia and negative prognostic factor in cirrhotic patients.

Acute kidney injury network criteria as a prognostic factor in cirrhotic patients with spontaneous bacterial peritonitis

Background and aimOne of the most common complications of spontaneous bacterial peritonitis (SBP) is renal injury. The aim of the study was to detect the frequency of AKI as a problem in end stage liver disease patients with SBP, evaluate the role of acute kidney injury network criteria (AKIN) as a prognostic factor for kidney insult in cirrhotic patients complicated by SBP and lastly.Settings and designA single center, observational, prospective study.Patients and methodsThe study was conducted on 150 cirrhotic patients complicated by SBP who were admitted in hepatology unit, Mansoura Specialized Medical Hospital, Mansoura University. After that, all patients were followed up for three months duration.Statistical analysis usedData analysis was performed using SPSS version 16.0 (SPSS, Inc, USA). Chi-square test (crosstabs) was used to compare the distribution of different clinical finding according to AKI stage.ResultsThe obtained results were showed a significant change in the number of patients among the three groups at the end of the study versus at admission indicating progressive deterioration of kidney functions. Moreover, the mortality was high (70.42%), most of them were AKIN stage 2 and 3. There was a significant increase of hospital acquired complication especially (hepatic encephalopathy, ICU admission) more commonly in advanced AKIN stages (stage 3).ConclusionAKI, as defined by AKIN diagnostic criteria, is associated with a high mortality rate in cirrhotic patients presented with SBP, especially patients with advanced liver disease (Child B and C, high MELD score) in a stage-dependent pattern.

Healthcare Resource Utilization in Obese Patients With High MELD (≥ 35) Undergoing Liver Transplantation: Presidential Poster Award

Introduction: Obese patients have a higher rate of metabolic syndrome and medical comorbidities including renal disease and are likely to incur more cost in the post-transplant period. There is only limited data on transplant related cost and resource utilization in obese patients particularly in those with a high MELD score (≥ 35). Our aim was to analyze the healthcare resource utilization in liver transplant recipients with high BMI and high MELD scores. Methods: Single center retrospective chart review of 1,487 liver transplant recipients from Jan 2006 to Dec 2017 was conducted. We identified 92 patients with a MELD score ≥ 35. Patients were stratified in 3 BMI classes( <30, 30-35(Class I Obesity), and >35(Class II Obesity)). Healthcare resource utilization metrics such as: length of hospital stay (LOS), length of ICU stay, transfusion requirements, number of readmissions within one year of transplantation, use of intravenous antibiotics and need for renal replacement therapy were studied. In addition, we compared the actual costs assigned to the patients by the hospital billing department. The costs were divided into labor cost (direct “face to face time” with the patients and administrative cost related to patient care) and supply cost (drugs, environmental services and supplies for special procedures). Cost data was separated into transplant encounter costs and post-transplant care cost. Results: 40 of 92 (43%) patients were obese (BMI > 30) and among them 14 (35%) had class II obesity. NASH was the most common underlying condition for liver transplantation (p=0.03) in obese patients. Obese patients also tend to have significant medical comorbidities of Diabetes (p=0.03), Hypertension (p= 0.01). Class II obesity is associated with higher total transplant cost ($134K) compared to those with Class I obesity ($111K). The Class II obese patients tend to be readmitted sooner (54.5 days) than non-obese (233.4 days) and Class I patients (108.5 days) after liver transplantation and both the groups were comparable with regard to mortality, length of hospital stays, ICU stay and blood transfusion requirement. Conclusion: Class II obesity is associated with significantly higher transplant related costs in patients with a high (≥ 35) MELD score. Considering higher cost and increased readmission risk in class II obesity, third party reimbursement rate for these high risk patients should be renegotiated.1035 Figure 1 No Caption available.

Positive familial history for metabolic traits predisposes to early and more severe alcoholic cirrhosis: A cross-sectional study.

Familial aggregation of metabolic traits in NAFLD is well documented. However, relevance of these traits in alcoholic cirrhosis is not well studied. We aimed to explore the association of family history of metabolic traits with age at diagnosis, severity and complications of alcoholic cirrhosis. In a cross-sectional study, all consecutive patients with alcoholic cirrhosis presenting to our tertiary care centre were included. Family and personal history, demographic characteristics, medical history, anthropometric measurements and laboratory data were recorded. The amount and duration of alcohol consumption were also carefully recorded. Out of 1084 alcoholic cirrhotics (age 48.5±10.1years, all males), family history for metabolic traits was documented in 688 (63.5%) patients. These patients had younger age at diagnosis, increased incidence of jaundice, ascites, variceal bleed and hepatic encephalopathy with consequently higher MELD and CTP score. These patients developed cirrhosis despite shorter median duration (13years, IQR 7-20 vs 21, IQR 18-25) and lesser amount of alcohol consumption (74g/d, IQR 24-96 vs 144, IQR 100-148). Patients with both family and personal history of metabolic traits had a higher risk by 3.3 times (95% CI 2.2-4.8) of an early age at diagnosis, 13.2 times (95% CI 8.7-20.1) of progression to cirrhosis with lesser amount of alcohol consumption and 4.6 times (95% CI 3.1-6.9) with lesser duration of alcohol consumption. Positive family and personal history of metabolic traits predispose to alcoholic cirrhosis with an earlier age at onset and more severity despite lesser exposure to alcohol.

Impact of Sustained Viral Response in the Evolution of Minimal Hepatic Encephalopathy: a Prospective Pilot Study

Introduction and aims. To determine the prevalence of minimal hepatic encephalopathy (MHE) in patients with liver cirrosis (LC) due to hepatitis C virus (HCV) infection and to evaluate the impact of sustained viral response (SVR) on MHE. Material and methods. We performed a prospective study using MHE screening and follow-up on patients with HCV and LC. The patients were evaluated at the beginning of treatment and 24 weeks after treatment. Results. 64 patients were included. 51.6% were male, the median age was 62years, Child-Pugh classification A/B/C 93.8%/4.7%/1.6% and median MELD was 8.3. Prior hydropic decompensation was present in 11 patients. Median values of liver stiffness, as measured by transient elastography (TE) were 22.8 KPa. Indirect signs of portal hypertension (PH) were present in 53.1% of patients, with a mean of 11.9 mmHg among the ones with a measurement of the hepatic venous pressure gradient. The prevalence of MHE before treatment was 26.6%. After treatment, 98.4% of patients achieved SVR. The presence of MHE at 24weeks post-treatment had an statistically significant association with the presence of pre-treatment MHE (80% vs. 21.6%; p &lt; 0.01), higher MELD scores at 24-weeks post-treatment (9.8 vs. 8; p = 0.02), higher Child-Pugh scores at 24-weeks post-treatment (p = 0.04), higher baseline INR levels (1.4 vs. 1.1; p &lt; 0.001) and with the presence of indirect signs of PH (100% vs. 47.1%; p = 0.02). During follow-up, those patients without MHE at 24weeks post-treatment had a higher probability of experiencing an improvement in post-treatment TE (80.9% vs. 40%, p = 0.04). Conclusion. We found that SVR may lead to MHE resolution in a considerable proportion of patients, which has potential implications for disease prognosis.

Living donor liver transplantation for alcoholic liver disease; does abstinence correlate with recidivism?

Introduction: The traditional “6 months rule” for ALD is becoming debatable with recent evidences showing comparable outcomes without a pre-fixed abstinence period. Method: Abstinence of minimum 3 months being the standard, was made flexible in selected cases where patients' clinical condition with good social support merited early Liver Transplant. Outcomes of all spectrums of ALDs undergoing LT between “June 2011 to September 2017" were analyzed. Recidivism was defined as any alcohol intake after LT and was compared between three groups (A up to 3 months, B 4 to 6 months and C > 6 months). Results: Out of total 159 ALD patients, 148 underwent Living donor LT ad 11 had diseased donor LT. The mean MELD Na was 24 and 65 patients (40.8%) had score > 25. Amongst living donors, 97(65%) were female family members. The median abstinence period was 8 months (range 1 to 84) with 64(43.2%) patients had < 6 months and 23(15.5%) had < 3 months of sobriety. Out of 148 patients, 9 (6.08%) had recidivism, out of which 5(55.5%) died within 6 months. The recidivism rates were 2(8.7%) in Group A, 3(7.3%) in B and 4(4.8%) in C (p value 0.72).The overall survival was significantly lesser in the recidivism group compared to those who didn't resume to alcohol (44.5% vs 89.8%, p = 0.004). Conclusion: Abstinence didn't predict recidivism, provided a promising social support along with strong commitment from patient. Specifically in LDLT settings, abstinence can be made more flexible to benefit patients with high MELD.

Zero mortality using extreme small-for-size graft with graft-to-recipient weight ratio

Introduction: GRWR ≥0.8% is considered the threshold in LDLT. This study evaluated outcomes with GRWR <0.6%. Methods: This was a retrospective study with all adult LDLT from 2001 to 2016. We defined GRWR <0.6% as extreme small liver graft. Outcomes of GRWR <0.6% were compared to ≥0.6%. Results: There’re 531 LDLT during study period. 35 patients had GRWR <0.6% with median graft weight 435g and median GRWR of 0.55% (0.46–0.59). GRWR ≥0.6% patients had median graft weight 597.5 g and GRWR 0.90% (0.6–2.6), p < 0.001. Median recipient age (52 vs. 52, p = 0.48), male (85.7 vs. 72.8%, p=0.11), median MELD (16.5 vs. 21, p = 0.18), MELD > 25 (28.6 vs. 44.4%, p =0.08) and HCC (45.7 vs. 34.7%, p=0.20) were the same. Patients with GRWR < 0.6% had higher BMI (27.3 vs. 24.2, p < 0.001). GRWR < 0.6% had more left lobe LDLT (28.6 vs. 4.4%, p < 0.001). More patients in GRWR< 0.6% required portal flow modulation (20 vs. 3.6%, p < 0.001), mostly splenic artery ligation/embolization. Fig. 1 showed recipients' postoperative outcomes. No hospital mortality in GRWR < 0.6%. Donor age, sex, >10% steatosis graft, hospital stay and complication were the same. Donor BMI was lower in GRWR <0.6% (19.8 vs. 21.7, p < 0.001). Patient/graft survivals were equivalent (Fig. 2). Multivariate analyses, recipient sex, BMI and HCC predicted patient survival while recipient sex, BMI and high MELD predicted graft survival; graft size didn´t predict patient/graft survival. Conclusion: GRWR< 0.6% wasn't associated with higher mortality, complication, small for size syndrome and inferior long-term outcomes.

Hepatic encephalopathy impacts the predictive value of the Fried Frailty Index.

Frailty is increasingly recognized as a predictor of poor outcomes in solid organ transplantation. The most widely utilized frailty tool, the Fried Frailty Index (FFI), includes patient-reported exhaustion, weight loss, and physical activity as well as measured walk speed and handgrip. Although hepatic encephalopathy (HE) is common among liver transplant candidates, data are lacking regarding its impact on the interpretation of frailty. We prospectively enrolled 685 patients with cirrhosis during their transplant evaluation, following them until death or transplantation. Our cohort was aged 54.5±10.3years, 60% male, with an average MELD score of 14.7±6.3. A history of HE was present in 39%. Frailty was present in 41%, associated with higher MELD, low albumin, ascites, and HE. HE was associated with frail performance on three components of the FFI-grip (odds ratio 1.41 95% CI, 1.03-1.92), walk speed (1.56 95% CI, 1.14-2.15), and decreased energy (1.44 95% CI, 1.05-1.99). These three components were associated with transplant free survival in the whole cohort: energy (hazard ratio 1.67 95% CI, 1.25-2.28), grip (1.63 95% CI, 1.24-2.16), and walk speed (1.56 95% CI, 1.19-2.04). However, among patients with HE, the FFI was not associated with survival. HE plays a critical role in the frailty phenotype and the implications of frailty among patients with cirrhosis evaluated for liver transplantation.

2. Reversible non-ischemic cardiomyopathy after orthotopic liver transplantation: a report of case series from single-center experience

Background: Non-ischaemic cardiomyopathy (NIC) is an early complication of liver transplantation (LT). Patients undergoing LT at our institution from September 2014 to April 2018. Patients who developed NIC were identified. Data collected included demographic and clinical data. Case Summary: A total 31 transplants were performed in this period and three patients developed NIC. Pretransplant dobutamine stress echocardiography was negative and Ejection fraction showed good LV systolic function. 25 patients (82%) were severely malnourished and required nutritional support. Median time to onset was 2 days post-transplant (range, 0–20). Echocardiograms showed global left ventricular hypokinesis and a decrease in ejection fraction (EF) from a median of 74% (range, 66–78) pretransplant to a median of 30% (range, 30–35). There was no significant difference between recipients with NIC vs. recipients without cardiomyopathy regarding donor age, donor risk index, and cold and warm ischemia time. Recovery of cardiac function occurred in all 3 patients, with a median EF of 60% (range, 58–62%) at the time of discharge. One-year survival of NIC patients was 100%. Conclusion: patients who developed NIC were individuals who had advanced liver disease with a high MELD score. The etiology of NIC is unknown, but it is most likely multifactorial. Although NIC is a rare complication of LT, and in most cases it is reversible, it can also cause significant post-operative morbidity requiring significant physiological support, a prolonged hospital stay, or mortality. Conclusions: Recognition of individuals at risk of NIC in the pre- or immediately post-LT period may be beneficial in reducing cardiovascular complications and may improve outcomes. The authors have none to declare.

Introduction of Share 35 Interregional Allocation for High MELD Liver Transplant Waiting List Patients in Australia and New Zealand

Introduction of Share 35 Interregional Allocation for High MELD Liver Transplant Waiting List Patients in Australia and New Zealand

The effect of Share 35 on biliary complications: An interrupted time series analysis.

The purpose of the Share 35 allocation policy was to improve liver transplant waitlist mortality, targeting high MELD waitlisted patients. However, policy changes may also have unintended consequences that must be balanced with the primary desired outcome. We performed an interrupted time series assessing the impact of Share 35 on biliary complications in a select national liver transplant population using the Vizient CDB/RM database. Liver transplants that occurred between October 2012 and September 2015 were included. There was a significant change in the incident-rate of biliary complications between Pre-Share 35 (n=3018) and Post-Share 35 (n=9984) cohorts over time (P=.023, r2 =.44). As a control, a subanalysis was performed throughout the same time period in Region 9 transplant centers, where a broad sharing agreement had previously been implemented. In the subanalysis, there was no change in the incident-rate of biliary complications between the two time periods. Length of stay and mean direct cost demonstrated a change after implementation of Share 35, although they did not meet statistical difference. While the target of improved waitlist mortality is of utmost importance for the equitable allocation of organs, unintended consequences of policy changes should be studied for a full assessment of a policy's impact.

6 - While Alcoholic Liver Disease has Risen to become the Leading Indication for Liver Transplantation Waitlist Registration in the U.S., these Patients have more Severe Hepatic Decompansation at Time of Listing and Significantly higher Meld Scores

6 - While Alcoholic Liver Disease has Risen to become the Leading Indication for Liver Transplantation Waitlist Registration in the U.S., these Patients have more Severe Hepatic Decompansation at Time of Listing and Significantly higher Meld Scores

Simultaneous Heart-Liver Transplant is Associated with Excellent Outcomes Independent of MELD Score

High MELD is associated with increased mortality pre-transplant and there is a paucity of data regarding its association with post-transplant outcome. The aim of our study is to exam if the MELD score underlying different indications for heart and liver transplant is associated with adverse post-transplant outcome.

Internal biliary stenting in liver transplantation.

Internal biliary stenting (IBS) was reported to decrease biliary complications after liver transplantation (LT) but data in literature is scarce. The aim of the present study was to evaluate our experience with end-to-end choledoco-choledocostomy during liver transplantation with special focus on the influence of IBS on patient and biliary outcomes. Between 2009 and 2013, 175 patients underwent deceased donor LT with end-to-end choledoco-choledocostomy and were included in the study. Supra-papillary silastic stent was inserted in 67 patients (38%) with small-size (< 5mm) bile ducts (recipient or donor). Endoscopic retrograde cholangiopancreatography (ERCP) was scheduled for IBS removal, 6months after LT. Operative outcomes and survival of patients who received internal stenting (IBS group) were compared with those of patients who did not (no-IBS group). Risk factors for biliary anastomotic complications were identified. Ten patients died (6%) and 104 (59%) experienced postoperative complications. Five-year patient and graft survival rates were 77 and 74%, respectively. Biliary complications were recorded in 61 patients (35%) and were significantly decreased by IBS insertion (p = 0.0003). Anastomotic fistulas occurred in 23 patients (13%) and stenoses in 44 patients (25%). On multivariate analysis, high preoperative MELD scores (p = 0.02) and hepatic artery thrombosis (p < 0.0001) were predictors of fistula; absence of IBS was associated with both fistula (p = 0.014) and stricture (p = 0.003) formation. IBS insertion during LT decreases anastomotic complication.