Low Model For End-Stage Liver Disease Research Articles

Differential Effects of Ascites and Hepatic Encephalopathy on Waitlist Mortality in Liver Transplantation by MELD 3.0.

MELD 3.0 introduces changes to address waitlist disparities for liver transplant (LT) candidates. Ascites and hepatic encephalopathy (HE) are important milestones in the natural history of cirrhosis regardless of the Model for End-Stage Liver Disease (MELD) score. We aim to assess the impact of ascites and HE and its interaction with MELD 3.0 on waitlist mortality. This is a retrospective study of patients listed for LT in the Organ Procurement and Transplantation Network database from 2016 to 2021. The primary outcome was waitlist mortality (death/delisting for too sick to LT). Ascites/HE were classified as moderate ascites without moderate HE (mAscites), moderate HE without moderate ascites (mHE), both moderate ascites/HE (mBoth), and neither. MELD 3.0 scores were categorized as <20, 20-29, 30-39, and ≥40. Of 39 025 candidates, 29% had mAscites, 3% mHE, and 8% mBoth. One-year waitlist mortality was 30%, 38%, and 47%, respectively, compared with 17% (all P < 0.001) for those with neither. In multivariable Cox regression, the adjusted risk of waitlist mortality associated with mAscites (versus neither) was a hazard ratio (HR) of 1.76 (95% confidence interval [CI], 1.55-2.00) when the MELD 3.0 score was <20, significantly higher than when the MELD 3.0 score was 20-29 (HR 1.40; 95% CI, 1.27-1.54), 30-39 (HR 1.19; 95% CI, 1.04-1.35), and ≥40 (HR 1.14; 95% CI, 0.91-1.43, interaction P < 0.05 for all). A similar pattern was observed by MELD 3.0 for both moderate ascites/HE. The presence of moderate ascites alone, or combined with moderate HE, not only increases the risk of waitlist mortality but also has a differential effect by MELD 3.0, especially at lower MELD scores. Earlier strategies addressing this group and improving treatment plans or access to LT regardless of MELD remain needed.

Sexual Dimorphism in Decompensated Non Ethanol-related Chronic Liver Disease: A Retrospective Cohort Study

Introduction: Women exhibit a distinct natural history of chronic liver disease compared to men, particularly regarding progression and outcomes. Although liver disease prevalence is generally higher in men, the incidence of non ethanol-related liver disease is increasing among females. Metabolic syndromes and their consequences are less recognised in the female population until they develop end-stage cirrhosis. Limited studies have explored the differences between male and female cirrhosis. The present study aimed to address the knowledge gap in female Decompensated Chronic Liver Disease (DCLD). Aim: To identify the differences in presentation and outcomes between females and males with non ethanol-related cirrhosis. Materials and Methods: The present retrospective cohort study was conducted in the Department of Medical Gastroenterology and Hepatology,Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India, involving 27 males and 33 females with non ethanol-related decompensated cirrhosis. A comparison was made between the aetiologies, presenting symptoms, complications, laboratory values, Model for End-stage Liver Disease (MELD) score, and in-hospital mortality during the first decompensation. Data analysis was performed using Statistical Packages for Social Sciences (SPSS) version 24.0 Quantitative variables were expressed as mean and Standard Deviation, while qualitative variables were expressed as frequency and percentage. The association between categorical variables was analysed using the Chi-square test, and the comparison of continuous variables between the two groups was analysed using independent sample t-test. A p-value of &lt;0.05 was considered statistically significant. Results: The mean age of decompensation was 56.5 years for men and 50.9 years for women. The most common aetiology in men was Non Alcoholic Fatty Liver Disease (NAFLD) (63%), while in females, it was NAFLD (45%) and cryptogenic cirrhosis (45%) (p=0.020). Diabetes Mellitus (DM) was more prevalent in males (55.6% versus 33.3%). Variceal bleed was more common in females (66.7% versus 48.1%). Jaundice was more frequently observed in males (44.4% versus 21.2%) (p=0.05). Ascites was more prominent in males (70.4% versus 45.5%) (p=0.05). Hepatic Encephalopathy (HE) was more prevalent in males (22.2% versus 15.2%). Females had a lower MELD scores compared to males (12.4±6.1 versus 15.2±6.4). Mortality was higher in males (22.2% versus 12.1%). Conclusion: Women with Decompensated Chronic Liver Disease tend to decompensate at a younger age compared to males and have a higher risk of Upper Gastrointestinal (UGI) bleeding. NAFLD was the most common aetiology in both groups. Ascites and HE were more commonly observed in men. Females had lower MELD scores, resulting in a longer waiting period on the transplant list compared to males. Mortality was higher in males.

Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study).

Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications. Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients. Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Natural history of NASH cirrhosis in liver transplant waitlist registrants

Non-alcoholic steatohepatitis (NASH) cirrhosis is rapidly growing as an indication for liver transplant(ation) (LT). However, the natural history of NASH cirrhosis among LT waitlist registrants has not been established. The present study aimed to define the natural history of NASH cirrhosis using the Scientific Registry of Transplant Recipients database. The study cohort comprised patients registered on the LT waitlist between 1/1/2016 to 12/31/2021. The primary outcomes included probability of LT and waitlist mortality, comparing NASH (n= 8,120) vs. non-NASH (n= 21,409) cirrhosis. Patients with NASH cirrhosis were listed with lower model for end-stage liver disease (MELD) scores despite bearing a greater burden of portal hypertension, especially at lower MELD scores. The overall transplant probability in LT waitlist registrants with NASH [vs. non-NASH] cirrhosis was significantly lower at 90 days (HR 0.873, p <0.001) and 1 year (HR 0.867, p <0.001); this was even more pronounced in patients with MELD scores >30 (HR 0.705at 90 days and HR 0.672at 1 year, p <0.001 for both). Serum creatinine was the key contributor to MELD score increases leading to LT among LT waitlist registrants with NASH cirrhosis, while bilirubin was in patients with non-NASH cirrhosis. Finally, waitlist mortality at 90 days (HR 1.15, p <0.001) and 1 year (1.25, p <0.001) was significantly higher in patients with NASH cirrhosis compared to those with non-NASH cirrhosis. These differences were more pronounced in patients with lower MELD scores at the time of LT waitlist registration. LT waitlist registrants with NASH cirrhosis are less likely to receive a transplant compared to patients with non-NASH cirrhosis. Serum creatinine was the major contributor to MELD score increases leading to LT in patients with NASH cirrhosis. This study provides important insights into the distinct natural history of non-alcoholic steatohepatitis (NASH) cirrhosis among liver transplant (LT) waitlist registrants, revealing that patients with NASH cirrhosis face lower odds of transplantation and higher waitlist mortality than those with non-NASH cirrhosis. Our study underscores the significance of serum creatinine as a crucial contributor to model for end-stage liver disease (MELD) score in patients with NASH cirrhosis. These findings have substantial implications, emphasizing the need for ongoing evaluation and refinement of the MELD score to more accurately capture mortality risk in patients with NASH cirrhosis on the LT waitlist. Moreover, the study highlights the importance of further research investigating the impact of the implementation of MELD 3.0 across the US on the natural history of NASH cirrhosis.

Health-related Quality of Life After Liver Transplantation-An Important Goal, but One Definition (or Size) Does Not Fit All.

Health-related Quality of Life After Liver Transplantation-An Important Goal, but One Definition (or Size) Does Not Fit All.

Liver Transplantation in Rescue Allocation: Comparison of the Donor Risk Index, Balance of Risk Score and Graft Function After Liver Transplantation

Background: In the model for end-stage liver disease (MELD) system, the use of livers from rescue allocation (RA), those refused for the first five of the ranking, have conflicting results in the literature. Objective: Analysis of the characteristics of the different simulated patterns of allocation (pattern vs. rescue), using the donor risk index (DRI), the balance of risk score (BAR) and its impact on the graft function. Method: Cohort of 233 liver transplants in adults, performed between 2015 and 2022. Results: General characteristics, age 50.3 ± 11.8 years; 64.81% CHILD C; MELD in allocation 22.4 ± 7.6. Initial graft dysfunction in 12.45% and primary nonfunction (PNF) in 8.15%; with DRI 1.41 ± 0.32. Transplants in RA occurred in 18.03% (n = 42) of cases, in patients with significantly lower MELD (18.4 ± 4.8) and BAR (7.1 ± 3.2) compared to standard allocation (23.2 ± 7.9; 9.2 ± 4.2 respectively). The DRI was significantly higher (p = 0.001) in the RA (1.58 ± 0.37). Age (p = 0.23) and body mass index (p = 0.85) of the donor, cold ischemia time (CIT) (p = 0.10) showed no differences between the groups. RA organs came more often from out-of-state (50% vs. 2.62%) and less harvested by our surgical team (38.1% vs. 79.0%). Early graft dysfunction (EGD) in 16.67% (n = 7); 14.29% (n = 6) of primary nonfunctioning in the RA group, percentage higher than in the standard allocation group with 11.52% (n = 22) and 6.81% (n = 13) respectively; however, there was no difference with statistical significance (p = 0.052). There was no difference in survival (73.81% vs. 72.25%; p = 0.83). Conclusion: A strategy more frequently employed in patients with less severe conditions according to BAR score, liver grafts in a RA rescue allocation system had higher DRI scores and did not provide a difference in short-term survival.

Impact of high MELD scores on CMV viremia following liver transplantation.

Advanced liver disease or cirrhosis is associated with an increased risk of infections; however, the impact of high pretransplant model for end-stage liver disease (MELD) score on cytomegalovirus (CMV) viremia after liver transplantation is unknown. This single-center, retrospective, cohort study evaluated CMV high-risk (CMV immunoglobulin G D+/R-) liver transplant recipients who received valganciclovir prophylaxis for 3 months between 2009 and 2019. Patients were stratified by pretransplant MELD score of <35 (low MELD) and ≥35 (high MELD). The primary outcome was 12-month CMV viremia, and secondary outcomes included CMV resistance and tissue invasive disease, mortality, biopsy-proven acute rejection (BPAR), leukopenia, and thrombocytopenia. Multivariable Cox proportional-hazards modeling was used to assess the association of MELD score with the time to CMV viremia. There were 162 and 79 patients in the low and high MELD groups, respectively. Pretransplant MELD score ≥35 was associated with an increased risk of CMV viremia (hazard ratio [HR] 1.73; confidence interval 1.06-2.82, p=.03). CMV viremia occurred at 162±61 days in the low MELD group and 139±62 days in the high MELD group. Although BPAR occurred early at 30 days (13-59) in the low-MELD group and at 18 days (11-66) in the high-MELD group (p=.56), BPAR was not associated with an increased risk of CMV viremia (HR 1.55 [0.93-2.60], p=.1). MELD scores ≥35 were associated with an increased hazards of CMV viremia. In liver transplant recipients with MELD scores ≥35 who are CMV high-risk, additional CMV intervention may be warranted.

Factors predicting early re-bleeding and in-hospital mortality after acute variceal hemorrhage in patients with cirrhosis

Introduction: Risk factors for early re-bleeding and in-hospital mortality following acute variceal hemorrhage (AVH) are incompletely understood. The aim of this study was to find out the risk factors for early re-bleeding within 5 days and in-hospital mortality after AVH in patients with cirrhosis.&#x0D; Method: This was an analytical cross-sectional study conducted in Department of Medicine, Patan Hospital, Patan Academy of Health Sciences (PAHS), Nepal from July 2021 to June 2022. The ethical clearance was obtained from the Institutional Review Committee-PAHS. Informed consent was taken from the patients. Patients aged &gt;18 y with diagnosed case of liver cirrhosis and endoscopy confirmed variceal bleeding were enrolled. All cases of early re-bleeding within 5 days and in-hospital outcome were recorded.&#x0D; Result: In this study total 72 patients were enrolled. The mean age of our patients was 51.68 y. Sixty seven (93%) of the patients improved, 3(4.16%) had early re-bleeding and 5(6.9%) died during the same hospital admission. Univariate analysis showed that early re-bleeding was significantly associated with the high PT/INR (p&lt;0.001) and high Child-Turcotte Pugh (CTP) score (p=0.032), whereas in-hospital mortality of patients was significantly associated with low Protein (p=0.044), high CTP score (p=0.041), high Model for End stage Liver Disease (MELD) score (p=0.002) and presence of gastric varices (p=0.008).&#x0D; Conclusion: High PT/INR and high CTP score are the risk factors of early re-bleeding after AVH in cirrhotic patients. Low Protein, high CTP and MELD scores, and presence of gastric varices are the factors associated with in-hospital mortality in these patients.

MELD or MELD-Na as a Predictive Model for Mortality Following Transjugular Intrahepatic Portosystemic Shunt Placement.

The model for end-stage liver disease (MELD) was originally developed to predict survival after transjugular intrahepatic portosystemic shunt (TIPS). The MELD-sodium (MELD-Na) score has replaced MELD for organ allocation for liver transplantation. However, there are limited studies to compare the MELD with MELD-Na to predict mortality after TIPS. We performed a retrospective chart review of patients who underwent TIPS placement between 2006 and 2016 at our institution. The primary outcome was mortality, and the secondary outcomes sought to assess which variables could provide prognostic information for mortality after TIPS placement. We performed receiver operating characteristic (ROC) curve analysis to assess the performance of MELD and MELD-Na. There were 186 eligible patients in the analysis. The mean pre-TIPS MELD and MELD-Na were 13 and 15, respectively. Overall, mortality after TIPS was 15% at 30 days and 16.7% at 90 days. In a comparison of the areas under the ROCs for MELD and MELD-Na, MELD was superior to MELD-Na for 30-day (0.762 vs. 0.709) and 90-day (0.780 vs. 0.730) mortality after TIPS. The optimal cutoff score for 30-day mortality was 15 (0.676-0.848) for MELD and 17 (0.610-0.808) for MELD-Na, whereas the optimal cutoff score for 90-day mortality was 16 (95% CI: 0.705-0.855) for MELD and 17 (95% CI: 0.643-0.817) for MELD-Na. There were 24 patients with high MELD-Na ≥17, but with low MELD <15, and 90-day mortality in this group was 8.3%. Although MELD-Na is a superior prognostic tool to MELD for predicting overall mortality in cirrhotic patients, MELD tended to outperform MELD-Na to predict mortality after TIPS.

Outcomes of liver transplant recipients with high MELD scores: an experience from a Canadian centre.

Background:The frequency with which patients with high Model for End-Stage Liver Disease (MELD) scores undergo liver transplantation has been increasing. Canadian literature regarding the outcomes of liver transplantation in recipients with high MELD scores is limited. The primary objective of this study was to assess patient and graft survival among recipients with high (> 35) and low (≤ 35) MELD scores. Secondary objectives were to potentially identify independent predictors of graft failure and patient mortality.Methods:We conducted a retrospective chart review of patients undergoing liver transplantation at a single Canadian centre from 2012 to 2017.Results:A total of 332 patients were included in the study: 280 patients had a MELD score of 35 or lower, and 52 had a MELD score above 35. Patients with high MELD scores had higher rates of pretransplant acute kidney injury and dialysis (p < 0.001), admission to the intensive care unit (ICU) or intubation (p < 0.001), intraoperative blood product transfusions (p < 0.001) and post-transplantation acute kidney injury and dialysis (p < 0.001), as well as longer ICU (p < 0.001) and hospital stays (p = 0.002). One- and 3-year patient survival in recipients with MELD scores of 35 or lower was 93.1% and 84.9% versus 85.0% and 80.0% in recipients with MELD scores above 35 (p = 0.37). One- and 3-year graft survival in recipients with MELD scores of 35 or lower was 91.7% and 90.9% versus 77.2% and 72.8% in recipients with MELD scores above 35 (p < 0.001). Prior liver transplant was an independent predictor of patient mortality, and no independent predictors of graft failure were identified. When MELD was replaced with D-MELD (donor age × recipient MELD), it predicted graft failure but not patient survival.Conclusion:No difference in patient mortality was found between MELD groups. Graft survival was significantly lower in recipients with MELD scores above 35. D-MELD may potentially be used as an adjunct in determining risk of graft failure in recipients with high MELD scores.

Interfacility Transfer for Nonelective Cholecystectomy in High MELD Patients: An ACS-NSQIP Analysis

IntroductionInterfacility transfer to a referral center is often considered for patients with liver disease undergoing nonelective cholecystectomy given management complexities and perioperative risk. We sought to determine the association between the Model for End Stage Liver Disease (MELD) score, transfer frequency, and outcomes in those patients using a national database. Materials and methodsThe ACS-NSQIP participant use files were queried for nonelective open or laparoscopic cholecystectomy from 2016 to 2018. Patients were grouped according to low (6-11), intermediate (12-18), or high (>18) MELD. In the high MELD group, patient characteristics and outcomes were compared between transferred and nontransferred patients and multivariate regression was performed to evaluate independent predictors of outcomes. Outcomes included in-hospital mortality, complications, length-of-stay (LOS), and 30-d reoperation and readmission. Results30,171 subjects were included. Transfer was more likely as MELD increased (19.5% high versus 12.1% low, P < 0.001). High MELD patients had increased LOS, reoperation, readmission, and mortality rates compared to low MELD. In high MELD patients (n = 1016), those transferred were more likely older, white, obese, and septic. Transferred patients had increased mortality (7.6% versus 4.2%, P = 0.044), LOS, reoperation, and complications. After controlling for differences between transferred and nontransferred patients, transfer status was not independently associated with mortality (OR = 1.593, P = 0.177), postoperative complications or LOS, but was associated with increased risk for reoperation. Sepsis and laparoscopic surgery were independently associated with higher and lower mortality, respectively. ConclusionsTransfer status is not independently associated with mortality, postoperative complications, or prolonged LOS, suggesting patients with advanced liver disease undergoing acute cholecystectomy may not benefit from interfacility transfer.

Quality of Life and Its Determinants in Liver Transplantation Candidates: A Missed Link in Liver Care Program during the Waiting Time for Liver Transplantation.

Background: The health-related quality of life (HRQOL) in the before liver transplantation (LT) stage has not been studied as much as that after the LT stage. We aimed to assess HRQOL and its determinants before the LT stage.Methods: As a cross-sectional study, HRQOL of all adult patients (n=632) referred to the LT center of Shiraz, Iran in 2018-2019 were assessed. Demographic, socioeconomic, medical, and paraclinical data were requested. Physical (PCS) and mental (MCS) aspects of HRQOL were assessed using the SF36 questionnaire. Univariable, multivariable (linear regression), and confirmatory factor analysis were performed utilizing SPSS 20 and Mplus 6.1 software. P<0.05 was considered to be significant.Results: The mean age of the patients was 47.6±12.3 years, while 414 (65.6%) were men, and the mean, score of the model for end-stage liver disease (MELD) was 18.36±5.58. The mean score of QOL, PCS, and MCS was 50.01±21.73, 46.23±23.23, and 53.78±23.91 (out of 100), respectively. Vitality had the most association with HRQOL, while role limitations had the lowest. The multivariable analysis revealed that unemployment (P<0.001), anemia (P=0.005), weight loss (P=0.005), diabetes mellitus (DM) (P=0.009), low MELD score (P=0.027), and drug use (P=0.03) were the significant determinants of HRQOL, respectively.Conclusion: The present study showed that HRQOL in the LT candidates was at the intermediate level, while their PCS and MCS are at the low and moderate levels, respectively. Furthermore, physical performance, job status, anemia, weight loss, MELD score, DM, and drug use should be considered as the significant determinants of HRQOL in the LT candidates.

Risk stratification for isolated tricuspid valve surgery assisted using the Model for End-Stage Liver Disease score

ObjectiveIsolated tricuspid valve surgery is perceived as high-risk. This perception is nurtured by patients who often present with substantial liver dysfunction, which is inappropriately reflected in current surgical risk scores (eg, the Society of Thoracic Surgeons [STS] score has no specific tricuspid model). The Model for End-Stage Liver Disease (MELD) has was developed as a measure for the severity of liver dysfunction. We report scores and outcomes for our patient population. MethodsWe calculated STS, European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (ESII), and MELD scores for all of our patients who received isolated tricuspid valve surgery between 2011 and 2020 (n = 157). We determined the MELD score, stratified patients into 3 groups (MELD <10: low, n = 53; 10 to <20: intermediate, n = 78; ≥20: high, n = 26) and describe associated outcomes. ResultsPatients were 72 ± 10 years old and 43% were male. Mean STS score was 4.9 ± 3.5% and ESII was 7.2 ± 6.6%. Mortality was 8.9% at 30 days and 65% at latest follow-up (95% CI, 51%-76%). Median follow-up was 4.4 years (range, 0-9.7 years). Although ESII and STS score accurately predicted 30-day mortality at low MELD scores (observed to expected [O/E] for ESII score = 0.8 and O/E for STS score = 1.0) and intermediate MELD (O/E for ESII score = 0.7, O/E for STS score = 1.0), mortality was underestimated at high MELD (O/E for ESII score = 3.0, O/E for STS score = 4.7). This subgroup also had higher incidence of new-onset hemodialysis. Besides MELD category, recent congestive heart failure, endocarditis, and hemodialysis were also associated with 30-day mortality. ConclusionsFor isolated tricuspid valve regurgitation, classic surgical risk stratification with STS or ESII scores failed to predict perioperative mortality if there was evidence of severe liver dysfunction. Preoperative MELD assessment might be useful to assist in proper risk assessment for isolated tricuspid valve surgery.

Balancing Outcome vs. Urgency in Modern Liver Transplantation.

BackgroundCurrent allocation mechanisms for liver transplantation (LT) overemphasize emergency, leading to poorer longtime outcomes. The utility was introduced to recognized outcomes in allocation. Recently, Molinari proposed a predictive outcome model based on recipient data.AimsThe aims of this study were to validate this model and to combine it with the utility to emphasize outcome in allocation.MethodsWe retrospectively analyzed 734 patients who were transplanted between January 2010 and December 2019. Points were assigned as in Molinari's model and the score sum was correlated with observed 90-day mortality. The utility was calculated as the product of 1-year survival times 3-month mortality on the waiting list. The weighting of different compounds was introduced, and utility curves were calculated. Model for End-Stage Liver Disease (MELD) scores according to maximal utility were determined.ResultsIn total, 120 patients (16.3%) had died within 90 days after LT. Higher MELD score, obesity, and hemodialysis prior to LT were confirmed risk factors. Overall survival was 83.8 and 77.4% after 90 days and 12 months, respectively. General utility culminated at MELD scores >35 in the overall population. Emphasizing the outcome shifted the maximal utility to lower MELD scores depending on Molinari scores.ConclusionsEmphasizing outcome, at least in certain recipient risk categories, might improve the longtime outcomes and might be integrated into allocation models.

Living donor liver transplantation versus donation after brain death and donation after circulatory death liver transplantation in the US

While previous research has compared outcomes between living donor liver transplantation (LDLT) and deceased donor liver transplantation, evidence is lacking regarding how donation after circulatory death (DCD) vs donation after brain death (DBD) affects this comparison. Using data from the Scientific Registry of Transplant Recipients for adults listed for liver transplant from 2012 to 2018, we compared 5-year patient and graft survival, readmissions, posttransplant chronic kidney disease (CKD), and return to work for 25,151 patients who underwent LDLT (1223 [4.9%]), DCD-LT (1431 [6.4%]), and DBD-LT (22,497 [89.4%]). LDLT recipients were significantly more likely to have a Model for End-Stage Liver Disease (MELD) score < 15 and to be working prior to transplant (P < 0.001 for both). At 5 years posttransplant, LDLT recipients had significantly more readmissions, but significantly less CKD and better survival than DBD-LT and DCD-LT recipients, as well as significantly better graft survival than DCD-LT recipients (P ≤ 0.01 for all). Significantly more LDLT recipients also returned to work for income (P < 0.01). This study shows a clear advantage of LDLT vs DCD-LT. This information should be weighed in transplantation decisions for patients such as those with low MELD scores who will realistically only be considered for DCD-LT.

Postreperfusion syndrome in liver transplantation: Outcomes, predictors, and application for recipient selection.

This study aimed to identify risk factors for postreperfusion syndrome (PRS) and its impact on LT outcomes. Data analysis was performed in 1021 adult patients undergoing donation after brain death (DBD) LT to identify PRS incidence, the risk factors for PRS development, and its impact on LT outcomes. The overall incidence of PRS was 16.1%. Independent risk factors for PRS included donor age (odds ratio (OR) 1.01, P=.02), donor body mass index (BMI) (OR 1.04, P=.003), moderate macrosteatosis (OR 2.48, P=.02), and cold ischemia time (CIT) (OR 1.06, P=.02). On multivariable analysis for 30-day graft failure, PRS (hazard ratio (HR) 3.49; P<.001) and Model for End-stage Liver Disease (MELD) score (HR 1.01; P=.05) were independent risk factors. Patients were categorized into four distinct groups based on PRS risk groups and MELD groups, which showed different 1-year graft survival (P<.001). There were comparable outcomes between low PRS risk- high MELD and high PRS risk - low MELD group (P=.33). Donor age, donor BMI, moderate macrosteatosis, and CIT were identified as risk factors for the development of PRS in LT using DBD grafts. PRS risk evaluation may improve donor-to-recipient matching based on their MELD scores.

Clinical Analysis of Factors Affecting Hospital Mortality After Liver Transplant in Patients With High Model for End-Stage Liver Disease Score

This study was undertaken to identify poor prognostic factors in patients with high Model for End-Stage Liver Disease (MELD) scores. From September 2001 to December 2017, living donor liver transplant and deceased donor liver transplant were performed in 851 (84.4%) and 157 patients (15.6%), respectively, in our center. Eighty-one patients (8.0%) with MELD scores ≥ 35 were classified as patients with high MELD scores. The overall survival rates in patients with high MELD scores were significantly worse than those in patients with low MELD scores (P=.005). However, no significant difference in survival was found between the 2 groups when in-hospital mortality was excluded. In-hospital mortality occurred in 18 patients (22.2%), and the main cause of death was sepsis (n=14, 77.8%). On univariate analysis, the risk factors for in-hospital mortality were mean age (P=.028), mean MELD score (P=.045), intubation status (P < .001), culture positivity (P=.042), and encephalopathy grade 3 or 4 (P=.014). On multivariate analysis, age (P=.006), intubation status (P=.042), and culture positivity (P=.036) were significant. The main cause of in-hospital mortality was sepsis, and the risk factors for in-hospital mortality of patients with high MELD score were older age, preoperative intubation, and culture positivity. Special attention should be paid to the prevention and treatment of infection in the liver transplant of patient with high MELD scores.

Assessment of Variation in Liver Transplant Training in North America: A National Survey of Transplant Surgery Fellows

Introduction: The current requirement for the fellows to receive the certificate of completion is to participate and log 45 liver transplant cases performed as "principal role." The study aims to address fellow readiness and independence, stratified by median MELD (Model for End-Stage Liver Disease) of the center. Methods: An anonymous survey was created using the Qualtrics panel. Questions evaluated demographics, program structure, operative autonomy, and confidence in managing postoperative complications. Results: The response rate was 69%. Second-year fellows in low MELD programs were more likely to perform liver transplants as primary surgeons (25% vs. 50%; p-0.02) and arterial reconstructions (12.5% vs. 50%; p-0.04) than fellows in a high MELD program. In terms of comfort level in managing postoperative complications – bleeding, vascular complications, biliary complications we found no difference between the fellows when stratified by regional MELD scores. Conclusions: Significant regional variations exist in liver transplant training in the US. Therefore, the American Society of Transplant Surgeons (ASTS) should incorporate MELD into the total case requirement for graduation.

Preoperative MELD score predicts mortality and adverse outcomes following radical cystectomy: analysis of American College of Surgeons National Surgical Quality Improvement Program.

The model for end-stage liver disease (MELD) has been widely used to predict the mortality and morbidity of various surgical procedures. We aimed to correlate a high preoperative MELD score with adverse 30-day postoperative complications following radical cystectomy. Patients who underwent elective, non-emergency radical cystectomy were identified from the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database from 2005 to 2017. Patients were categorized according to a calculated MELD score. The primary outcomes of this study were 30-day postoperative mortality, morbidity, and length of hospital stay following radical cystectomy. For further sensitivity analysis, propensity score matching was used to yield a total of 1387 matched pairs and primary outcomes were also assessed in the matched cohort. Compared with patients with a MELD < 10, those with MELD ⩾ 10 had significantly higher rates of mortality [odds ratio (OR) = 1.71, p = 0.004], major complications (OR = 1.42, p < 0.001), and prolonged hospital stay (OR = 1.29, p < 0.001) on multivariate analysis. Following risk-adjustment for race, propensity-matched groups revealed that patients with MELD score ⩾ 10 were significantly associated with higher mortality (OR = 1.85, p = 0.008), major complications (OR = 1.34, p < 0.001), yet similar length of hospital stay (OR = 1.17, p = 0.072). MELD score ⩾ 10 is associated with higher mortality and morbidity in patients undergoing radical cystectomy compared with lower MELD scores. Risk-stratification using MELD score may assist clinicians in identifying high-risk patients to provide adequate preoperative counseling, optimize perioperative conditions, and even consider nonsurgical alternatives.

Bone Marrow-Derived Stem Cells for Patients with Liver Cirrhosis: A Systematic Review and Meta-analysis.

To date, studies have shown inconsistent results of treatment with bone marrow-derived stem cells (BMDSC) for patients with liver cirrhosis. This study aims to compare the efficacy and safety of BMDSC and standard therapy for liver cirrhosis. Articles from PubMed, Embase, and the Cochrane library were searched from inception to April 2018. The index included Model for End-stage Liver Disease (MELD), alanine aminotransferase (ALT), albumin, total bilirubin (TBIL), prothrombin time (PT), Child-Pugh score, and all-cause mortality. A total of 9 studies with a total of 424 patients with liver cirrhosis were included in final meta-analysis. BMDSC therapy was associated with lower MELD within 3 months (P = .010), while it had no significant impact on MELD after 6 months (P = .074). There were no differences between BMDSC and standard therapy for ALT within 3 months (P = .336) and after 6 months (P = .379). BMDSC did not affect albumin level within 3 months (P = .196) and after 6 months (P = .840). BMDSC reduced the TBIL level within 3 months (P = .037) and was not associated with the TBIL level after 6 months (P = .914). There were no differences between BMDSC and standard therapy for PT within 3 months (P = .167) and after 6 months (P = .484). The Child-Pugh scores within 3 months (P = .342) and after 6 months (P = .133) were not associated with BMDSC treatment for liver cirrhosis patients. Finally, the BMDSC was not associated with the risk of all-cause mortality, as compared with standard therapy (P = .622). BMDSC treatment for patients with liver cirrhosis could improve short-term MELD and TBIL, but not the risk of mortality, as compared with standard therapy.