Initial MELD Score Research Articles

S2625 Sickle Cell Intrahepatic Cholestasis

INTRODUCTION: Sickle Cell Disease (SCD) is a common autosomal recessive disorder among the African American community. While the most severe complications typically include pneumonia, stroke, and acute chest syndrome, in very rare cases it leads to Sickle Cell Intrahepatic Cholestasis (SCIC). This is an unusual case presentation which discusses the importance of early recognition of acute liver failure in a patient with suspected SCIC and the need to have a wide differential for elevated liver function tests. CASE DESCRIPTION/METHODS: A 24-year-old female with a past medical history of sickle cell disease presented from her hepatologist's office with jaundice, scleral icterus, and malaise. Two months prior, the patient had been discharged for a sickle cell crisis that required an exchange transfusion. Her initial lab work revealed profound hyperbilirubinemia of 43.4 mg/dL (cutoff 0.8 mg/dL), 29.9 direct (cutoff 0.4 mg/dL), and a reticulocyte count of 7.3% (cutoff 1.5%). Her initial MELD score was 38 and she was admitted to the ICU. A CT of the abdomen was remarkable for hepatomegaly and abdominal ascites. She was given lactulose along with supportive care and plasmapheresis. The patient gradually improved with exchange transfusions and by day 4, her total bilirubin had declined to 18 mg/dL. Unfortunately, despite acknowledging the severity of her illness, the patient has a long history of non-compliance and she was subsequently lost to follow up. DISCUSSION: SCIC is a rare disease process with an extensive literature review finding less than 10 prior cases. While the pathophysiology is not well understood, it is believed to be related to ischemic injury as a result of recurrent vascular obstruction and repair arising as a component of sickle cell disease. A potentially fatal sequela of this is cholestatic liver failure. While case reports are limited, they have all shown the benefit of treatment with early plasmapheresis. Only two cases of liver transplantation from SCIC exist in literature, and both ended in patient fatality. The thought process is transplantation for sickle cell disease involving the liver may carry a high risk of graft loss and death due to vascular problems. There has been a case report of a 15-year-old with SCIC who underwent chronic transfusions to halt his liver disease from progressing. When he stopped transfusions after a year, he went into acute liver failure. While only one case report, it serves to question whether these patients should be placed on chronic exchange therapy.

Efficacy and Safety of Ledispavir/Sofosbuvir with or without Ribavirin in patients with Decompensated Liver Cirrhosis and Hepatitis C Infection: a Cohort Study.

Ledipasvir/Sofosbuvir (LDV/SOF) with or without Ribavirin (RBV) has shown good results in terms of efficacy and safety in clinical trials in advanced liver cirrhosis, but real-life data are still needed in order to confirm this profile. We investigated the efficacy and safety of LDV/SOF in a large Romanian population with liver cirrhosis and genotype 1b hepatitis C virus (HCV). We analyzed a multicentric retrospective cohort enrolling 349 patients with decompensated liver cirrhosis due to HCV who received LDV/SOF±RBV 12/24 weeks (301/48). Patients were included between 2017-2018, all with genotype 1b. Main inclusion criteria were liver cirrhosis and detectable HCV RNA. The cases were followed-up monthly during therapy and 12 weeks after the end of therapy. The cohort included 60% females with a median age of 61, 16% interferon (IFN) pre-treated, 53% with comorbidities, 40/53/7 % with Child Pugh A/B/C, 4% with virus B co-infection and 8% with previously treated hepatocellular carcinoma. Mean initial MELD score was 11.92 (6.82÷ 24.5). Six patients were lost during follow-up. Sustained virologic response (SVR) in intention-to-treat was reported in 85.1%. Predictive factors of SVR in decompensated cirrhosis were female gender (p=0.01), advanced age (p<0.001), lower bilirubin levels (p=0.002) and lower CTP score (p=0.02). In patients with CTP score B or C low bilirubin levels (p=0.003), low INR (p<0.001), increased platelet count (p=0.04), low CTP score (p<0.001), lack of encephalopathy (p=0.02), serum albumin >3.5g/dl (p=0.002) predicted improvement of liver function. Serious adverse events were reported in 16/349 (4.6%), most of them due to severe liver decompensation (9/16). LDV/SOF±RBV proved to be highly efficient in our difficult to treat population with 85.1% SVR.

Abstract No. 528 Bland embolization versus radioembolization for the treatment of HCC in cirrhotic patients: propensity score analysis of the impact on hepatic function

Both bland transarterial embolization (TAE) and radioembolization (Y90) for the treatment of HCC have shown similar tumor responses and survival (excluding the radiation segmentectomy approach). While tumor control is a vital outcome, the degree of resulting hepatic impairment is important in this population who often have cirrhosis. The purpose of this study was to analyze the impact of TAE and Y90 on hepatic function based on the MELD score, with propensity score matching to optimally control potential confounders. Analysis was performed on 256 patients undergoing treatment of HCC in a lobar or bilobar fashion with Y90 (n= 100) or TAE (n=156) over a 10-year period. The total bilirubin, creatinine, and INR levels were ascertained immediately pre-procedure and at 1, 6, and 12 months after treatment to calculate MELD scores. Differences in MELD scores were compared using the paired or unpaired t-test and multivariate linear regression. Because confounders may result from selection bias, propensity score matching was performed with the following variables: treatment type, gender, age, unilobar versus bilobar, ECOG, AFP, maximum tumor diameter, viral hepatitis, presence of portal vein invasion, and initial MELD score. The mean baseline pretreatment MELD scores for patients undergoing TAE versus Y90 were 10.7 and 8.9, respectively (p<0.001). After TAE, the MELD score change at 1, 6, and 12 months were 0.8, 1.8, and 2.5 (p=0.036, 0.029, and 0.004), respectively. After Y90, the MELD score change was 2.6, 5.1, and 6.6 (p<0.001 for each). Using the propensity matched cohort, Y90 was associated with a higher change in MELD score at 1, 6, and 12 months (p=0.009, <0.001, and 0.001, respectively). Portal vein invasion was also associated with a higher change in MELD score at 6 months (p=0.004) and 12 months (p=0.04). In a propensity matched cohort of patients treated with lobar or bilobar TAE or Y90, Y90 was associated with significantly higher MELD score changes compared to TAE, and were most pronounced at 12 months. These findings may be important for patient selection and treatment planning, as well as understanding potential impact on liver transplant list status.

Long Term Mortality in Young Patients (&lt;40 y/o) With Alcoholic Liver Cirrhosis After First Hospitalization: Carilion Clinic Experience

Introduction: Long term mortality in young patients after their first hospitalization for alcoholic liver disease (ALC) is not well established. We aimed to evaluate the long term outcomes among young subjects with ALC after their first related hospitalization in a tertiary referral academic center. Methods: We searched the EPIC EMR and identified all patients hospitalized for ALC at Carilion Clinic, Roanoke from 2008-2016, and review outcomes through 6/2018. Information on demographics, comorbidities, lab values, procedures, and mortality were extracted. Cumulative risks of long-term mortality after the first hospitalization were estimated using Kaplan-Meier curves and compared between two groups; those 40 years of age. Demographic data, lab values, and comorbidities associated with cirrhosis were assessed using multivariate Cox proportional hazard analysis to determine risk factors associated with long-term mortality. Results: We identified Sixty-five young patients out of a total of 325 patients admitted for the first time for ALC (mean age, 34.6±4.7 years; 72.3% males, 48.4% current alcohol use, 67.2% current smokers, 15.8% current illicit drugs use). Seven (10.8%) had biopsy-proven ALC, others were diagnosed clinically. Over a mean follow-up of 1.3±2.0 years, twenty patients (30.8%) died. The mean number of hospitalizations was 2.3±2.2. The 1-, 3- and 5-years cumulative mortality was 21.1 %, 31.1% and 49.7% respectively. The median survival for young patients was longer as compared old patients (p<0.001); this was likely related to extra hepatic comorbidities. Mortality in those younger than 40 was lower than in older patients (P less than 0.001). On multivariate Cox proportional hazard analysis (HR), increased age (HR 1.04; 95% CI, 1.02-1.06), neutrophils-to-lymphocytes ratio (NLR) (HR 1.02; 95% CI, 1.001-1.038), and initial MELD score (HR 1.14; 95% CI, 1.08-1.21) were found to be associated with long-term mortality. Current tobacco (HR 1.07, p=0.08) and alcohol use (HR 1.23, p=0.09) were not found to be risk factors for long-term mortality. Conclusion: 5-year cumulative mortality for patients younger than 40 years of age with ALC after their first hospitalization is 49.7% despite quitting drinking in about 50% of the patients. Old age, most recent NLR, and initial MELD score were associated with increased risk for late mortality.

Liver maximum capacity (LiMAx) test as a helpful prognostic tool in acute liver failure with sepsis: a case report

BackgroundAcute liver failure (ALF) is a life-threatening entity particularly when infectious complications worsen the clinical course. Urgent liver transplantation (LT) is frequently the only curative treatment. However, in some cases, recovery is observed under conservative treatment. Therefore, prognostic tools for estimating course of the disease are of great clinical interest. Since laboratory parameters sometimes lack sensitivity and specificity, enzymatic liver function measured by liver maximum capacity (LiMAx) test may offer novel and valuable additional information in this setting.Case presentationWe here report the case of a formerly healthy 20-year old male caucasian patient who was admitted to our clinic for ALF of unknown origin in December 2017. Laboratory parameters confirmed the diagnosis with an initial MELD score of 28 points. Likewise, enzymatic liver function was significantly impaired with a value of 147 [> 315] μg/h/kg. Clinical and biochemical analyses for viral-, autoimmune-, or drug-induced hepatitis were negative. Liver synthesis parameters further deteriorated reaching a MELD score of 40 points whilst clinical course was complicated by septic pneumonia leading to severe hepatic encephalopathy grade III-IV, finally resulting in mechanical ventilation of the patient. Interestingly, although clinical course and laboratory data suggested poor outcome, serial LiMAx test revealed improvement of the enzymatic liver function at this time point increasing to 169 μg/h/kg. Clinical condition and laboratory data slowly improved likewise, however with significant time delay of 11 days. Finally, the patient could be dismissed from our clinic after 37 days.ConclusionEstimating prognosis in patients with ALF is challenging by use of the established scores. In our case, improvement of enzymatic liver function measured by the LiMAx test was the first parameter predicting beneficial outcome in a patient with ALF complicated by sepsis.

Dry Beriberi Manifesting as Acute Inflammatory Demyelinating Polyneuropathy in a Patient With Decompensated Laennecʼs Cirrhosis

Vitamin B1 (thiamine) deficiency is uncommon in developed countries and is most often seen in chronic alcoholism, poor dietary intake, malabsorption syndromes, and total parenteral nutrition. The incidence of alcohol abuse is increasing and thus thiamine deficiency is likely an under-recognized and potentially reversible cause of neurologic dysfunction. We describe a case of dry beriberi manifesting as acute inflammatory demyelinating polyneuropathy in a patient with decompensated Laennec's cirrhosis. 28-year-old Nepalese female who recently immigrated to the United States was admitted with decompensated Laennec's cirrhosis with ascites, hepatic encephalopathy, and esophageal varices. She was severely malnourished with a BMI of 14. Her initial MELD score was 26 and she was evaluated by the liver transplant team and listed contingent on improvement in nutritional status. Patient developed profound bilateral lower extremity weakness, complete loss of sensation, and areflexia. She was unable to stand unassisted and was changed to transplant status 7. An electromyogram was consistent with severe sensorimotor axonal polyneuropathy with active denervation. Extensive evaluation including cerebrospinal fluid analysis ruled out vasculitis and Guillain-Barre Syndrome (GBS). Nutritional evaluation revealed a low serum vitamin B1 level and patient was started on thiamine replacement therapy. She dramatically improved as had been able to navigate greater than 100 feet with a walker within six months. Her transplant evaluation remains in process. Vitamin B1 (thiamine) deficiency is uncommon in developed countries and can manifest with neurologic symptoms (dry beriberi). It is critical to accurately differentiate dry beriberi from chronic alcoholic neuropathy and other causes of acute inflammatory demyelinating polyneuropathy, as it is reversible with thiamine supplementation. Our patient developed profound lower extremity neurologic symptoms causing her to be changed to liver transplant status 7. This case demonstrates the importance of diagnosing neurological manifestations of thiamine deficiency in the setting of Laennec's cirrhosis as these are reversible and can increase the potential for a successful liver transplantation outcome in these high-risk patients.

Hepatorenal syndrome: outcome of response to therapy and predictors of survival.

Aim. Treatment of hepatorenal syndrome (HRS) in patients with liver cirrhosis is still challenging and characterized by a very high mortality. This study aimed to delineate treatment patterns and clinical outcomes of patients with HRS intravenously treated with terlipressin. Methods. In this retrospective single-center cohort study, 119 patients (median [IQR]; 56.50 [50.75–63.00] years of age) with HRS were included. All patients were treated with terlipressin and human albumin intravenously. Those with response to treatment (n = 65) were compared to the patient cohort without improvement (n = 54). Patient characteristics and clinical parameters (Child stage, ascites, hepatic encephalopathy, HRS type I/II, and initial MELD score) were retrieved. Univariate analysis of factors influencing the success of terlipressin therapy and Cox regression analysis of factors influencing survival was carried out. Results. One-month survival was significantly longer in the group of responders (p = 0.048). Cox regression analysis identified age [Hazard ratio, 95% confidence interval (CI); 1.05, 1.01–1.09, resp.], alcohol abuse [HR 3.05, 95% CI 1.11–8.38], duration of treatment [HR 0.92, 95% CI 0.88–0.96], and MELD score [HR 1.08, 95% CI 1.02–1.14] to be independent predictors of survival. Conclusions. Survival of HRS patients after treatment depends on age, etiology of liver disease, and the duration of treatment.

Higher Income Associated With Lower Risk of Liver Disease But Higher Likelihood of Listing for Liver Transplantation.

Access to solid organ transplantation varies by gender, race, place of residence, and insurance status. The factors influencing liver transplantation wait list rates are not well understood because there is no registry of patients with end-stage liver disease (ESLD). We therefore assessed the number of patients listed for liver transplantation compared with the incidence of fatal liver disease in 3,220 US counties. County demographic characteristics over 8 years were determined from US Census data. Deaths due to liver disease were defined as death certificates containing an ICD-10 code indicating a liver diagnosis as a cause of death. Wait list data was obtained from the Scientific Registry of Transplant Recipients. 17 covariates, including geographic, demographic, and socioeconomic characteristics, were analyzed for their effect on death and wait list rates. Deaths due to liver disease vary from 0 to 17.7 deaths per 10,000 county population per year (mean 3.0 ± 1.2). Liver death rate increases with age, percent Hispanic and Native American population, and age adjusted death rate, but decrease with increasing income (p<10-16 for all). Although annual wait list registrations vary from 0 to 8 per 10,000 county population (mean 0.3 ± 0.2), wait list rates per liver death fall into a narrower range from 0 to 3 per death (mean 0.1 ± 0.1). Considering only those candidates with listing MELD>15, registrations per liver death range from 0 to 1.5 (mean 0.05 ± 0.06). Wait list rates per liver disease death increase with income and decrease with larger distance to the nearest transplant center (p<10-16 for both), with those two factors accounting for 24% of the observed variability. Much of the county variation in wait list rates per capita is attributable to variation in the incidence of liver disease. Higher income is associated with decreased risk of death from liver disease, as well as with increased chance of being listed for transplantation. Increasing distance to the nearest transplant center also decreases the likelihood of being listed. Listing at any initial MELD score probably reflects access to specialized liver care at transplant centers. Thus, patients in counties with higher listing rates may have better access to such care earlier in their disease course. Counties listing more patients than die of liver disease may achieve this by treating ESLD patients with transplantation.

Abstract No. 351 - Efficacy of combined transarterial chemoembolization and radiofrequency ablation for treatment of single primary hepatocellular carcinomas (HCC) less than 3 cm: a single center experience

Purpose To assess overall survival at 6- and 12-months, 30-day adverse event rate, and recurrence rate within 1 year in patients treated with combination arterial chemoembolization and CT-guided radiofrequency ablation on initial presentation of small HCC Materials and Methods At our institution, 66 consecutive patients with newly diagnosed early HCC were evaluated retrospectively from Jan. 2008 - Aug. 2011 with respect to overall survival at 6- and 12-months, 30-day adverse event rate, and recurrence rate within 1 year. Patients not deemed to be surgical resection candidates as well as those awaiting liver transplant were included. Patients that had undergone prior treatment for HCC (including surgical resection) were excluded. Follow-up imaging (contrast-enhanced CT and MRI) was assessed per mRECIST criteria by a single board-certified reader. Results The 66 patients evaluated included 40 males and 26 females, varying etiologies of liver disease (39 hepatitis C, 10 hepatitis B, 8 alcoholic, 7 nonalcoholic steatohepatitis, and 2 cryptogenic), average age of presentation of 62.3 years, mean initial MELD score of 9.3, and mean index lesion size of 2.0 cm. Ten patients (15.2%) were lost to follow-up by 1 year. Of the remaining 56 patients evaluated, survival was 96.4% at 6 months and 87.5% at 12 months, including 4 out of 7 mortalities (57.1%) directly related to complications from liver transplant. Overall 30 day adverse event rate was 10.6%, including mostly minor complications: 3 subcapsular hematomas (not requiring transfusion), 3 pneumothoraces (2 requiring chest tube placement), and 1 small groin hematoma. No mortalities were seen related to combined treatment. Two patients required re-treatment due to stable disease on 1 month follow-up imaging, as determined by mRECIST criteria. Overall disease recurrence, including adjacent to and distant from the treated lesion, was seen in 15 patients (26.8%) by 1 year. Conclusion The analysis suggests that combination therapy with transarterial chemoembolization and radiofrequency ablation is efficacious for the treatment of small HCCs

Clinical outcome and predictors of survival after TIPS insertion in patients with liver cirrhosis.

To determine the clinical outcome and predictors of survival after transjugular intrahepatic portosystemic stent shunt (TIPS) implantation in cirrhotic patients. Eighty-one patients with liver cirrhosis and consequential portal hypertension had TIPS implantation (bare metal) for either refractory ascites (RA) (n = 27) or variceal bleeding (VB) (n = 54). Endpoints for the study were: technical success, stent occlusion and stent stenosis, rebleeding, RA and mortality. Clinical records of patients were collected and analysed. Baseline characteristics [e.g., age, sex, CHILD score and the model for end-stage liver disease score (MELD score), underlying disease] were retrieved. The Kaplan-Meier method was employed to calculate survival from the time of TIPS implantation and comparisons were made by log rank test. A multivariate analysis of factors influencing survival was carried out using the Cox proportional hazards regression model. Results were expressed as medians and ranges. Comparisons between groups were performed by using the Mann-Whitney U-test and the χ2 test as appropriate. No difference could be seen in terms of age, sex, underlying disease or degree of portal pressure gradient (PPG) reduction between the ascites and the bleeding group. The PPG significantly decreased from 23.4 ± 5.3 mmHg (VB) vs. 22.1 ± 5.5 mmHg (RA) before TIPS to 11.8 ± 4.0 vs. 11.7 ± 4.2 after TIPS implantation (P = 0.001 within each group). There was a tendency towards more patients with stage CHILD A in the bleeding group compared to the ascites group (24 vs 6, P = 0.052). The median survival for the ascites group was 29 mo compared to > 60 mo for the bleeding group (P = 0.009). The number of radiological controls for stent patency was 6.3 for bleeders and 3.8 for ascites patients (P = 0.029). Kaplan-Meier calculation indicated that stent occlusion at first control (P = 0.027), ascites prior to TIPS implantation (P = 0.009), CHILD stage (P = 0.013), MELD score (P = 0.001) and those patients not having undergone liver transplantation (P = 0.024) were significant predictors of survival. In the Cox regression model, stent occlusion (P = 0.022), RA (P = 0.043), CHILD stage (P = 0.015) and MELD score (P = 0.004) turned out to be independent prognostic factors of survival. The anticoagulation management (P = 0.097), the porto-systemic pressure gradient (P = 0.460) and rebleeding episodes (P = 0.765) had no significant effect on the overall survival. RA, stent occlusion, initial CHILD stage and MELD score are independent predictors of survival in patients with TIPS, speaking for a close follow-up in these circumstances.

Primary biliary cirrhosis in Southern Israel: A 20 year follow up study

BackgroundThe epidemiology of primary biliary cirrhosis (PBC) in Israel is unknown. We aimed to determine the epidemiology, long-term survival and outcomes of PBC in Southern Israel from 1990 to 2010. MethodsCase-finding methods and population-based administrative data were used to estimate and evaluate the incidence, prevalence and prognostic factors of outcome in our PBC cohort. Results138 cases of PBC were identified. The average annual prevalence of PBC was 255 cases per million. The overall age/sex-adjusted annual incidence of PBC was 10 cases per million from 1990 through 1999 and 20 cases per million from 2000 to 2010.Among 138 incident cases with a total follow-up of 960 persons-years from diagnosis, 30 patients (21.7%) died. Survival in PBC patients was significantly lower than that of the age/sex-matched Israeli population. Mortality was significantly increased in patients with an initial MELD score greater than 8 (P<0.001), with portal hypertension (P<0.001), and in non-responders to ursodeoxycholic acid (UDCA) therapy according to Barcelona criteria (P=0.005).Out of 138 patients, 95 patients (68.0%) responded to UDCA therapy according to Barcelona and Paris criteria. None of the responders died during the follow-up period as opposed to 30 out of 43 (69.8%) of non-responders. In multivariate analysis the factors associated with response to UDCA were: albumin levels above 3.5g/dL (P<0.001) and lower degree of fibrosis per liver biopsy (P=0.003). ConclusionsThis study addresses the increasing burden of PBC in Israel and confirms the importance of some clinical and therapeutic factors as predictors of long-term prognosis.

582 MELD-SCORE PREDICTS OUTCOME OF LUNG TRANSPLANTATION IN CYSTIC FIBROSIS PATIENTS

study is to create a model able to calculate the life months gained for each organ according to the particular value of MELD score. Methods: Period: 2003–2010. Study groups: (a) pre-LT = 732 consecutive adult patients with chronic end stage liver disease (ESLD) enlisted for first LT; (b) post-TF = 400 consecutive adult patients undergone to first LT for ESLD. Two independent Cox’s regressions adjusted for age, sex, ESLD etiology, and presence of hepatocellular carcinoma were used for the 2 groups, both aimed to measure the MELD predictive value (pre and post LT respectively). In the post-LT model the selected end-point was the patient survival with the first graft. The MELD related coefficients were then used to create a global predictive model able to calculate the life months gained for each used graft according to MELD score. Results: In the pre-LT group the initial MELD score (at the moment of listing) showed a significant ability to predict patient survival: hazard ratio = 1.21; 95% confidence interval = 1.14–1.28 (p =0.0000). In the post-LT group, conversely, MELD score at transplant did not show a significant prognostic value: hazard ratio = 0.99; 95% confidence interval = 0.94–1.03 (p =0.5428). The global model showed that the 5-year graft survival benefit increased as MELD score increased (MELD 6 = −5.4 months; MELD 40 = + 51.2 months). MELD 13 was selected as the threshold value below which there is not graft survival benefit after LT. Conclusion: A MELD score below 13 represents the minimal cut-off justifying LT in terms of gain in life months at 5-year for each used graft.

Renal Dysfunction Induced by Bacterial Infection other than Spontaneous Bacterial Peritonitis in Patients with Cirrhosis: Incidence and Risk Factor

Background/AimsDeterioration of renal function in cirrhotic patients with spontaneous bacterial peritonitis (SBP) is a predictor for in-hospital mortality; however, the clinical significance of renal dysfunction during bacterial infection other than SBP is unknown. The aim of this study was to investigate the prevalence and clinical significance of renal dysfunction due to bacterial infections other than SBP in patients with liver cirrhosis.MethodsRetrospective data from inpatients with bacterial infections other than SBP were analyzed.ResultsEighty patients were recruited for the analysis. The types of infections included that of urinary tract (37.5%), pneumonia (23.8%), biliary tract (20%), cellulitis (12.5%), and bacteremia of unknown origin (6.3%). Renal dysfunction developed in 29 patients (36.3%), of which 11 patients had irreversible renal dysfunction. The initial MELD score, neutrophil count, albumin, and blood pressure were significant risk factors in the univariate analysis, whereas only the MELD score was an independent risk factor for the development of renal dysfunction (p<0.001) after multivariate analysis.ConclusionsThe prevalence of renal dysfunction during bacterial infection other than SBP in patients with liver cirrhosis was 36.3%, and its development was related to the severity of the liver disease. Occurrence of irreversible renal dysfunction seemed to affect the prognosis of these patients.

Pretransplant survival is shorter in HIV-positive than HIV-negative subjects with end-stage liver disease

Despite improved survival after liver transplantation (OLTX) in HIV-positive individuals treated with highly active antiretroviral therapy (HAART), some transplant candidates do not survive to OLTX. To determine if pretransplant outcome is related to severity of liver disease and/or HIV infection, we prospectively evaluated 58 consecutive HIV-positive candidates seen at a single center from 1997-2002. Of the 58, 15 (25.9%) were transplanted, whereas 21 (36.2%) died before OLTX, a median one month of evaluation, with more than half of those (12 of 21, 57.1%) dying from infection. By contrast, of 1,359 HIV-negative candidates, 860 (63.3%) were transplanted, whereas 211 (15.5%) died before OLTX (P < 0.001). The cumulative survival following initial evaluation was significantly shorter among HIV-positive than HIV-negative candidates (880 vs. 1,427 days, P = 0.035, Breslow) but was not related to the initial pretransplant MELD score (16 vs. 15), INR (1.5 vs. 1.5), creatinine (1.3 vs. 1.3 mg/dL), or total bilirubin (6.6 vs. 5.7 mg/dL), respectively, all P > 0.05. Among untransplanted HIV-positive candidates, the 21 who died did not differ from the 22 surviving in initial MELD (15 vs. 13), CD4 (230 vs. 327/microL), HIV load (both < 400 copies/mL), HAART intolerance (10/21, 47.6% vs. 10/22, 45.4%), or HCV infection (16/21, 76.2% vs. 16/22, 72.3%), all P > 0.05. Further, the 21 did not differ from the 15 transplanted in pre-OLTX CD4, HIV load, or MELD score, all P > 0.05. In conclusion, pretransplant survival appears shorter in HIV-positive OLTX candidates and is unrelated to severity of liver or HIV disease. Further study is warranted to determine risk factors for poorer pretransplant outcomes.