Median Model For End-stage Liver Disease Research Articles

Dual Graft Living Donor Liver Transplantation for High Acuity Patients: A Single-Center Experience

The outcomes of dual graft living donor liver transplantation (DGLDLT) in high acuity patients remain underreported. The objective of this study was to report long-term outcomes from a single center in this select group of patients. This was a retrospective review of patients who underwent DGLDLT between 2012 and 2017 (n= 10). High acuity patients were defined as patients with model for end stage liver disease (MELD) ≥30 or Child Pugh score ≥11. We looked at 90-day morbidity and mortality and 5-year overall survival (OS). The median MELD score and Child Pugh score were 30 (26.7-35) and 11 (11-11.2). The median recipient weight was 105 (95.2-113.7) and ranged from 82 to 132kg. Out of 10 patients, 4 (40%) required perioperative renal replacement therapy, and 8 (80%) required hospital admission for optimization. The estimated graft to recipient weight ratio (GRWR) with right lobe graft alone was <0.8 in all patients, between 0.75 and 0.65 in 5 (50%) patients, and <0.65 in 5 (50%) patients. The 90-day mortality was 3/10 (30%), and there were 3/10 (30%) deaths during long-term follow-up. Among 155 high acuity patients, the 1-year OS with standard LDLT, standard LDLT with GRWR <0.8, and DGLDLT was 82%, 76%, and 58%, respectively (P= 0.123). With a median follow-up of 40.6 (1.9-74.4) months, the 5-year OS for DGLDLT was 50%. The use of DGLDLT in high acuity patients should be prudent and low GRWR grafts should be considered a viable alternative in selected patients.

Spontaneous Retroperitoneal Hematoma: A Deadly Complication for Patients Awaiting Liver Transplant.

Patients with end-stage liver disease (ESLD) are at increased risk for hemorrhage and spontaneous retroperitoneal hematoma (sRPH) and also carry a high mortality rate. We sought to review the natural history of sRPH in patients with ESLDat a single center. All patients admitted to a single transplantation intensive care unit (TICU) at Froedtert and the Medical College of Wisconsin Transplant Center between June 2016 and August 2018 were retrospectively reviewed. Six ESLD patients with sRPH were studied. Clinical outcome measures were liver disease severity, sRPH treatment, and patient survival. Six patients were included, four male and two female patients, with a median age of 56.5 years (range 30-67 years). All had alcohol-induced liver cirrhosis. The median Model for End-Stage Liver Disease (MELD) score at the time of sRPH diagnosis was 40 (range 30-43). The most commonly identified source of bleeding was from lumbar arteries. One patient had recurrent bleeding after embolization and underwent repeat embolization. Five patients died. The median time to death from the diagnosis of sRPH was 7.2 days (range 2-12 days). The patient who survived following embolization had the lowest MELD score. Critically ill cirrhotic patients with sRPH have a significant mortality rate. Embolization is successful, albeit seldom. This is the largest retrospective series of sRPH in cirrhotic patients in theliterature.

Quantitative Analysis of Liver Disease Using MRI-Based Radiomic Features of the Liver and Spleen.

Background: Radiomics extracts quantitative image features to identify biomarkers for characterizing disease. Our aim was to characterize the ability of radiomic features extracted from magnetic resonance (MR) imaging of the liver and spleen to detect cirrhosis by comparing features from patients with cirrhosis to those without cirrhosis. Methods: This retrospective study compared MR-derived radiomic features between patients with cirrhosis undergoing hepatocellular carcinoma screening and patients without cirrhosis undergoing intraductal papillary mucinous neoplasm surveillance between 2015 and 2018 using the same imaging protocol. Secondary analyses stratified the cirrhosis cohort by liver disease severity using clinical compensation/decompensation and Model for End-Stage Liver Disease (MELD). Results: Of 167 patients, 90 had cirrhosis with 68.9% compensated and median MELD 8. Combined liver and spleen radiomic features generated an AUC 0.94 for detecting cirrhosis, with shape and texture components contributing more than size. Discrimination of cirrhosis remained high after stratification by liver disease severity. Conclusions: MR-based liver and spleen radiomic features had high accuracy in identifying cirrhosis, after stratification by clinical compensation/decompensation and MELD. Shape and texture features performed better than size features. These findings will inform radiomic-based applications for cirrhosis diagnosis and severity.

Combined liver transplantation and sleeve gastrectomy: Report of a brief-interval staged approach.

Pretransplantation bariatric surgery in patients with high Model for End-Stage Liver Disease (MELD) score is fraught with risks. Bariatric surgery after liver transplantation (LT) may be complicated by surgical adhesions but could have advantages if performed at the time of transplantation. We investigated a method of brief-interval staging combining LT and sleeve gastrectomy (SG). LT recipients with a body mass index (BMI) > 40 kg/m 2 received an SG during the same hospitalization as the LT (LT/SG), at the same time as a planned brief-interval return to the operating room for biliary anastomosis. Differences in intraoperative attributes of the LT (Stage 1) versus SG (Stage 2) procedures were analyzed using Wilcoxon signed-rank test with significance p < 0.05 and compared with patients with obesity having a two-stage LT without SG. A total of 14 cases {median MELD score 33 (interquartile range [IQR], 18-40)} were compared with 28 controls; 60% were critically ill prior to surgery with mechanical ventilation, vasopressors, or continuous renal replacement therapy. Median interval between procedures was 16.1 (IQR, 12.5-22.7) hours for cases and 12.2 (IQR, 11.1-16.6) hours for controls, p =0.27. Median BMI at LT/SG was 47.0(IQR, 41.7-51.3) kg/m 2 versus 38.1 (IQR, 35.7-39.8) kg/m 2 for controls, p < 0.001. At 1 year, median excess body weight loss was 74.0% (IQR, 46.2%-78.7%) in cases and 15.8% (IQR, -5.4% to 62.6%) in controls, p =0.13; total weight loss was 38.1% (IQR, 23.9-42.9) in cases versus 7.7% (IQR, -2.4% to 27.6%) for controls, p =0.03. Graft survival at 1 year was 92.9% for cases and 89.3% for controls with similar early postoperative outcomes. This proof-of-concept study revealed that a brief-interval SG during LT is feasible in patients with high MELD and resulted in sustained weight loss at 1 year with similar graft survival. Further studies are needed to determine an optimal strategy.

P9.49: Efficacy and Long-term Prognosis of Liver Transplantation For Porto-Pulmonary Hypertension

Objective: Porto-pulmonary hypertension (PoPH) refers to pulmonary hypertension based on severe portal hypertension. Severe PoPH has a very high perioperative mortality rate and is still considered a contraindication for liver transplantation (LT). We analyze efficacy and long-term prognosis of liver transplantation for porto-pulmonary hypertension from our center. Methods: A retrospective analysis was performed on 5 patients with PoPH who received liver transplantation in Beijing Friendship Hospital from Jan. 2013 to March 2022, in order to analyze postoperative follow-up results and long-term survival. Results: Five patients with PoPH with a mean age of 35.6 ± 18.6 years (60% females), were included in the analysis. Their primary diseases were hepatic spongiosis, Caroli disease, hepatitis B cirrhosis, drug-induced cirrhosis and primary sclerosing cholangitis. All patients were measured by Swan-Ganz catheterization of right heart, among them, the mean of the highest mean pulmonary artery pressure(mPAP) level before LT were 46.6mmHg(27-58mmHg). The mean of their highest systolic pulmonary artery pressure(SPAP) level measured under echocardiography was 101.36mmHg(51-154mmHg) before LT. The median Model for End-Stage Liver Disease (MELD) score was 16(14-20) at PoPH diagnosis. All patients had been on pulmonary vasodilator therapy(including ambrisentan, remodulin and sildenafil) for more than six months to lower pulmonary artery pressure to mPAP<35mmHg, that can achieve surgical indications before LT. The operations went smoothly, except in one case where pulmonary artery pressure suddenly increased during surgery ended smoothly after the addition of remodulin. Two patients underwent a second liver transplant at 6 months and 65 months postoperatively, and one patient died of acute heart failure after the second transplantation, while the remaining four patients survived. The follow-up time of the survived patients were 29.7, 46.9, 56, 85.2 months. The longest follow-up among them was over seven years. SPAP of them decreased 15.4, 129, 65.3, 20mmHg after LT. Two patient was discontinued pulmonary arterial pressure medications within 1 year after surgery because SPAP were down to normal, and other patients still on medication. Conclusion: Patients with pulmonary vasodilator therapy before LT can have excellent long-term outcomes post-transplant. Oral pulmonary vasodilator therapy can be effective treatment to qualify patients for LT.

Cardiac risk factors limiting survival to liver transplantation in patients with nonalcoholic fatty liver disease.

BACKGROUNDNonalcoholic fatty liver disease (NAFLD) describes the hepatic manifestations of metabolic syndrome, which is estimated to affect 25% of adults, and currently represents the second most common indication for liver transplant in the United States. Studies have shown that patients with NAFLD are at an increased risk for heart failure, arrhythmia, and coronary artery disease (CAD), which may impact outcomes of liver transplantation. However, it remains unclear whether the presence of cardiac disease affects survival prior to liver transplant. If so, this would represent an important opportunity to optimize cardiac status and improve outcomes before liver transplant.AIMTo identify cardiac factors that impact survival to liver transplantation in patients with NAFLD and on the transplant waitlist.METHODSThe aim of this study was to identify cardiac risk factors that limit survival to transplant in patients with NAFLD. We performed a retrospective analysis of patients with NAFLD listed for liver transplant at a tertiary academic medical center in the United States from January 2015 to January 2021, identified through United Network of Organ Sharing registry. Exclusion criteria included a concurrent etiology of liver disease and removal from the transplant list due to chemical dependency, lack of social support, improvement in liver disease, or being lost to follow-up. We manually reviewed patient charts including electrocardiogram, echocardiogram, and cardiac catheterization reports as well as physician notes to identify cardiac disease states (i.e., heart failure, arrhythmia, valvular disease and CAD) and other related diagnoses. We performed a survival analysis by Cox proportional hazards regression model to analyze the association between cardiac factors at the time listed for transplant and death or clinical deterioration prior to transplant.RESULTSBetween January 2015 and January 2021, 265 patients with nonalcoholic fatty liver disease were listed for liver transplant at our institution. Our patient sample had a median age of 63 and an even distribution between sexes. The median Model for End-Stage Liver Disease (MELD) score was 17 and the median body mass index was 31.6. Of these 265 patients, 197 (74.3%) survived to transplant and 68 (25.7%) died or clinically deteriorated prior to transplant. The presence of mild or moderate CAD represented a hazard ratio of 2.013 (95%CI 1.078-3.759, P = 0.029) for death or clinical deterioration when compared to patients without CAD, after adjustment for age, sex, and MELD. MELD represented an adjusted hazard ratio of 1.188. CONCLUSIONMild or moderate CAD represents a hazard for waitlist mortality prior to liver transplant in patients with NAFLD. Aggressive management of CAD may be needed to improve patient outcomes.

Impact of major hepatocellular carcinoma policy changes on liver transplantation for hepatocellular carcinoma in the United States.

Since its inception in 2002, Model for End-Stage Liver Disease (MELD)-based allocation has undergone a series of revisions, especially with respect to exception points. Hepatocellular carcinoma (HCC) is the most common indication for MELD exceptions, and as a result of higher transplant proportions and lower waitlist mortality, a series of policy changes have been implemented to deprioritize HCC transplants. We examined the impact of HCC exception policy changes on transplant and waitlist mortality rates. We evaluated Organ Procurement and Transplantation Network/United Network for Organ Sharing data on adult patients from January 1, 2005, to June 4, 2021, focusing on waitlist mortality and deceased donor liver transplantation (DDLT) proportions. The data were divided into four policy eras: (1) MELD 22 points at waitlisting with an increase in points every 3 months (i.e., elevator) (January 2005-October 2015), (2) delay and cap at MELD 34 points (October 2015-May 2019), (3) delay and fixed exceptions based on donor service area (DSA) median MELD at transplantation minus three (MMaT-3; May 2019-February 2020), and (4) delay and fixed exceptions based on the MMaT-3 of centers within 250 nautical miles (i.e., acuity circles; February 2020-June 2021). We evaluated (a) changes in the proportions of DDLTs for patients with HCC exceptions within each era nationally and by DSA and (b) waitlist mortality in the three recent policy eras, focusing on mortality in the 6 months after the 6-month delay period. The percentage of adult DDLT with HCC exceptions decreased through the four eras: 22.9% (n=14,049), 17.9% (n=4598), 14.3% (n=851), and 12.4% (n=1425), respectively. Of the 51 DSAs analyzed, the annual percent change in DDLTs for patients with HCC exceptions was negative (i.e., decreased) in 47 (92.2%). Waitlist mortality remained stable. All HCC policy implementations led to a decrease in the percentage of transplants for HCC without an increase in waitlist mortality. The impact is not uniform across geographic areas.

Early Impact of MMaT-3 Policy on Liver Transplant Waitlist Outcomes for Hepatocellular Carcinoma.

Background.To reduce the disparity in access to liver transplant (LT), United Network for Organ Sharing implemented an exception policy in May 2019, which capped hepatocellular carcinoma (HCC) exception score to the median Model for End-Stage Liver Disease (MELD) at transplant within the donor service area minus 3 points (MMaT-3) after the 6-mo wait period. We aimed to evaluate how this policy affected HCC waitlist outcomes.Methods.Using United Network for Organ Sharing data, we analyzed waitlist outcomes in HCC patients at the time they received exception points from in the pre-MMaT era (August 15, 2017, to November 15, 2018) and MMaT era (June 1, 2019, to August 30, 2020). Comparisons were made within the HCC group and HCC versus non-HCC (at time of listing) groups in the pre-MMaT and MMaT eras and regions were grouped as low, medium, and high MELD based on MMaT.Results.HCC group: LT probability within HCC patients decreased by 20% (subhazard ratio [sHR], 0.78; 95% confidence interval [CI], 0.74-0.85) between the eras and decreased by 41% in low MELD regions (sHR, 0.59; 95% CI, 0.52-0.66). Waitlist dropout was unchanged. Matched HCC versus non-HCC groups: HCC patients had 80% higher LT probability (sHR, 1.84; 95% CI, 1.71-1.99) than non-HCC patients in the pre-MMaT era; which decreased to a 14% higher LT probability in MMaT era. In low and medium regions, HCC patients had over twofold higher LT probability in the pre-MMaT era, which decreased to a ~20% higher probability (sHR, 1.14; 95% CI, 1.06-1.23) in the MMaT era. After implementation of the acuity circle policy, HCC patients had lower LT probability (sHR, 0.84; 95% CI, 0.74-0.94) than non-HCC patients.Conclusions.The geographic disparity between HCC and non-HCC patients has improved with the MMaT-3 policy. Despite lower LT probability for HCC patients, waitlist dropout was not adversely impacted.

Pediatric liver transplantation outcomes from a single center in Thailand.

BACKGROUNDLiver transplantation (LT) has become an acceptable curative method for children with several liver diseases, especially irreversible acute liver failure and chronic liver diseases. King Chulalongkorn Memorial Hospital is one of Thailand’s largest liver transplant centers and is responsible for many pediatric cases.AIMTo report the experience with pediatric LT and evaluate outcomes of living-related vs deceased-donor grafts.METHODSThis evaluation included children who underwent LT between August 2004 and November 2019. Data were retrospectively reviewed, including demographics, diagnoses, laboratory values of donors and recipients, the pediatric end-stage liver disease (PELD) or model for end-stage liver disease (MELD) score, graft source, wait time, perioperative course, postoperative complications, and survival rates. Continuous data were reported using the median and interquartile range. The Mann–Whitney U-test was used to compare the wait time between the living-related and deceased-donor groups. The chi-square or Fisher's exact test were used to compare the frequencies of between-group complications. Survival rates were calculated using the Kaplan–Meier method.RESULTSNinety-four operated pediatric liver transplant patients were identified (54% were females). The median age at transplantation was 1.2 (0.8-3.8) years. The median PELD and MELD scores were 20 (13-26.8) and 19.5 (15.8-26.3), respectively. Most grafts (81.9%) were obtained from living-related donors. The median wait time for the living donors was significantly shorter compared with the deceased donors at 1.6 (0.3-3.1) mo vs 11.2 (2.1-33.3) mo (P = 0.01). Most patients were diagnosed with biliary atresia (74.5%), and infection was the most common complication within 30 d post-transplantation (14.9%). Without a desensitization protocol, 9% of transplants were ABO-incompatible. Eight hepatitis B core antibodies (anti-HBc)-negative recipients received positive anti-HBc grafts without different observed complications. The overall survival rate was 93.6% and 90.3% at 1 and 5 years, respectively. No graft loss during follow-up was noted among survivors.CONCLUSIONA significant number of pediatric LT cases were reported in Thailand. Based on relatively comparable outcomes, ABO-incompatible and HBc antibody-positive grafts may be considered in an organ shortage situation.

The Requirement of Isoflurane and Remifentanil During Liver Transplantation Using Bispectral Index and Surgical Pleth Index: An Observational Study

During liver transplantation (LT), patients and surgical factors potentially influence the pharmacokinetics of the anesthetic agents. The aim of this study was to investigate the requirement of isoflurane and remifentanil according to severity of liver disease during LT under balanced anesthesia. We enrolled 44 patients undergoing LT. Anesthetic depth was maintained within the bispectral index score of 40 to 60 and Surgical Pleth Index of 20 to 60. Patients were divided into 2 groups according to their median Model for End-Stage Liver Disease (MELD) score: low MELD group and high MELD group. We compared end-tidal inhaled anesthetics and remifentanil consumption. Patients were divided into 2 groups according to median value of MELD score: MELD score <16 (low MELD group; n=20) or MELD ≥16 (high MELD group; n=20). There was no significant difference between the 2 groups in end-tidal concentration of isoflurane during 3 phases. However, the remifentanil requirement was lower in the high MELD group during the dissection and anhepatic phases (mean (SD), 0.105 (0.067) vs 0.064 (0.055) µg/kg/min; P=.037, and 0.167 (0.096) vs 0.108 (0.079) µg/kg/min; P=.039, respectively; low MELD group vs high MELD group) with no significant difference during the neohepatic phase. The severity of liver dysfunction based on MELD score affected the intraoperative remifentanil requirement during LT. Patients with cirrhosis are required to use analgesics appropriate to their individual patient characteristics in clinical practice.

Changing opportunities for liver transplant for patients with hepatocellular carcinoma.

Aim was to study the early impact of acuity circle-based allocation implementation system on liver transplantation for hepatocellular carcinoma (HCC) patients. We assessed characteristics of HCC and non-HCC deceased donor orthotopic liver transplants (OLT) in the year before (2/2019-2/2020) and after (3/2020-2/2021) introduction of the acuity circle policy using the Organ Procurement and Transplantation Network (OPTN)/United Network for Organ Sharing (UNOS) database. Total OLTs reduced from 6699 in the preacuity circle era to 6660 in the postacuity circle era (-.6%); this decrease is mostly driven by a decrease in HCC transplants (1529 to 1351; -11.6%). Six out of 11 regions had a reduction in the absolute number and percentage of HCC transplants with significant reductions in regions 2 (-37.8%, p<.001) and 4 (-28.3%, p=.001). The introduction of median model for end-stage liver disease (MELD) at transplant minus 3 (MMaT-3) exception points, has created differential opportunities for HCC patients, in low-MELD as opposed to high-MELD areas, despite having the same disease. This effect has become more prominent following the implementation of acuity circle-based allocation system. Ongoing investigation of these trends is needed to ensure that HCC patients are not disparately disadvantaged due to their location.

Spontaneous portosystemic shunt embolization in liver transplant recipients with recurrent hepatic encephalopathy

Introduction and objectivesSpontaneous portosystemic shunts (SPSS) are a common cause of recurrent hepatic encephalopathy (HE). Shunt occlusion is an effective and safe procedure when performed in patients with cirrhosis and preserved liver function. We aimed to describe our experience with SPSS embolization after liver transplantation (LT). PatientsWe identified five patients who underwent SPSS embolization after LT. Clinical, biochemical and technical procedure data were collected. ResultsAt presentation, all patients had developed graft cirrhosis and HE after LT. Median Model for End-stage Liver Disease (MELD) at embolization was 9 (range 7-12), median Child-Pugh was 8 (range 7-9). Splenorenal and mesocaval shunt were the most frequent types of SPSS found. Three patients have been completely free of HE. Of the two patients who had HE recurrence after embolization, one patient had two episodes of HE which was controlled well with medications. The other patient required three embolizations because of recurrent HE. Median follow-up was 4.4 years (range 1.0-5.0) and MELD score at last follow up was 13 (range 10-18) and median Child-Pugh score B, 7 points (range 5-12). ConclusionsSPSS can be considered as a cause of HE after LT. SPSS embolization is feasible and safe in LT recipients.

Geographic Variation in the Utilization of HCV-viremic Donors into HCV-negative Recipients

We read with great interest the article by Cotter et al1 in which they identified that the practice of liver transplantation (LT) from hepatitis C virus (HCV)-viremic donors to HCV-negative recipients (D HCV+/R−) has increased with notable geographic variation. While the authors should be congratulated on a substantial effort, we wish to place emphasis on several points to place their studies in the proper context. First, the geographic variation is driven by a variety of factors. As the authors described, the rate of acute HCV infections in each geographic region appeared to be concordant with the practice of D HCV+/R−. However, that alone does not account for the variation in geographic utilization. Da et al2 reported a regional difference of 59.7% to 84.2% in conversion rates of HCV donors from the potential to actually used donors, likely reflective of regional experience and institutional policies. In addition, marginal grafts in LT such as those from old donors3 and donation after circulatory death (DCD)4 are known to show geographical and center differences in their utilization. The geographical variation in the practice of D HCV+/R− likely derives from a combination of these factors. Second, “racial disparity” in the practice of D HCV+/R− is prone to be influenced by several factors. The proportion of Caucasian recipients in the D HCV+/R− was significantly higher than other ethnic groups, which “raises the possibility of racial disparity” in authors’ study.1 However, additional demographics are important to take into consideration. The proportions of Caucasians as donors, not only as recipients, in the D HCV+/R− group was significantly higher, which could arise from the geographic variation. In addition, this study examined recipients without evidence of HCV infection. Liver disease cause varies on the waiting list by race: Caucasians make up 93.2% of HCV− LT candidates, whereas African Americans account for 79.8%.5 These characteristics could have influenced the differences of race in the D HCV+/R− practice. Nonetheless, more research is warranted to explore this important observation. Finally, there seems to be a causal relationship between the practice of D HCV+/R− and median Model for End-Stage Liver Disease (MELD) scores. The highly utilizing regions are “among the regions with the lowest median MELD scores.” Among the regions with the lowest rates of the D HCV+/R− practices, “regions 4 and 7 have many of the states with higher waitlist mortality rates.” The authors conclude that higher utilization of D HCV+/R− may improve waitlist mortality and decrease median MELD scores. However, the practice of using other marginal grafts showed different patterns. The majority of elderly donors were used in region 9, where waiting times and MELD scores are among the highest.3 Region 4 has significantly increased the DCD LT utilization.4 These results suggest that factors other than the practice of marginal grafts also play a role in median MELD scores and waiting list mortality. Despite these critiques, LT from HCV-viremic donors is a promising strategy to expand donor pool. Further detailed investigations in long-term outcomes and patient selection criteria would be helpful to further advance the practice of LT from HCV-viremic donors.

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.

The MELD Score Is Superior to the Maddrey Discriminant Function Score to Predict Short-Term Mortality in Alcohol-Associated Hepatitis: A Global Study.

Several scoring systems predict mortality in alcohol-associated hepatitis (AH), including the Maddrey discriminant function (mDF) and model for end-stage liver disease (MELD) score developed in the United States, Glasgow alcoholic hepatitis score in the United Kingdom, and age, bilirubin, international normalized ratio, and creatinine score in Spain. To date, no global studies have examined the utility of these scores, nor has the MELD-sodium been evaluated for outcome prediction in AH. In this study, we assessed the accuracy of different scores to predict short-term mortality in AH and investigated additional factors to improve mortality prediction. Patients admitted to hospital with a definite or probable AH were recruited by 85 tertiary centers in 11 countries and across 3 continents. Baseline demographic and laboratory variables were obtained. The primary outcome was all-cause mortality at 28 and 90 days. In total, 3,101 patients were eligible for inclusion. After exclusions (n = 520), 2,581 patients were enrolled (74.4% male, median age 48 years, interquartile range 40.9-55.0 years). The median MELD score was 23.5 (interquartile range 20.5-27.8). Mortality at 28 and 90 days was 20% and 30.9%, respectively. The area under the receiver operating characteristic curve for 28-day mortality ranged from 0.776 for MELD-sodium to 0.701 for mDF, and for 90-day mortality, it ranged from 0.773 for MELD to 0.709 for mDF. The area under the receiver operating characteristic curve for mDF to predict death was significantly lower than all other scores. Age added to MELD obtained only a small improvement of AUC. These results suggest that the mDF score should no longer be used to assess AH's prognosis. The MELD score has the best performance in predicting short-term mortality.

Pre-Transplant Alpha-Fetoprotein > 25.5 and Its Dynamic on Waitlist Are Predictors of HCC Recurrence after Liver Transplantation for Patients Meeting Milan Criteria.

Simple SummaryIn the setting of liver transplantation, prediction of hepatocellular carcinoma (HCC) recurrence persists as a fundamental issue, and few tools are available during the waitlist. Biological features such as alpha-fetoprotein values are strong predictors, but it is necessary to understand how we can use them. In this study, an AFP cut-off value was individuated and also its dynamic increase on the waitlist was defined as a predictor.Background and Aim: Hepatocellular carcinoma (HCC) recurrence rates after liver transplantation (LT) range between 8 and 20%. Alpha-fetoprotein (AFP) levels at transplant can predict HCC recurrence, however a defined cut-off value is needed to better stratify patients. The aim of this study was to evaluate the rate of HCC recurrence at our centre and to identify predictors, focusing on AFP. Methods: We retrospectively analysed 236 consecutive patients that were waitlisted for HCC who all met the Milan criteria from January 2001 to December 2017 at our liver transplant centre. A total of twenty-nine patients dropped out while they were waitlisted, and 207 patients were included in the final analysis. All survival analyses included the competing-risk model. Results: The mean age was 56.8 ± 6.8 years. A total of 14% were female (n = 29/207). The median MELD (model for end-stage liver disease) at LT was 12 (9–16). The median time on the waitlist was 92 (41–170) days. The HCC recurrence rate was 16.4% (n = 34/208). The mean time to recurrence was 3.3 ± 2.8 years. The median AFP levels at transplant were higher in patients with HCC recurrence (p < 0.001). At multivariate analysis, the AFP value at transplant that was greater than 25.5 ng/mL (AUC 0.69) was a strong predictor of HCC recurrence after LT [sHR 3.3 (1.6–6.81); p = 0.001]. The HCC cumulative incidence function (CIF) of recurrence at 10 years from LT was significantly higher in patients with AFP > 25.5 ng/mL [34.3% vs. 11.5% (p = 0.001)]. Moreover, an increase in AFP > 20.8%, was significantly associated with HCC recurrence (p = 0.034). Conclusions: In conclusion, in our retrospective study, the AFP level at transplant > 25.5 ng/mL and its increase greater than 20.8% on the waitlist were strong predictors of HCC recurrence after LT in a cohort of patients that were waitlisted within the Milan criteria. However further studies are needed to validate these data.

Offer Acceptance Patterns for Liver Donors Aged 70 and Older.

Despite a documented survival benefit, older liver donor (OLD, age ≥70) graft offers are frequently declined, with utilization worsening over the last decade. To understand how offer acceptance varies by center, we studied 1113 eventually transplanted OLD grafts from 2009 to 2017 using Scientific Registry of Transplant Recipients (SRTR) data and random-intercept multilevel logistic regression. To understand how center-level acceptance of OLD graft offers might be associated with waitlist and posttransplant outcomes, we studied all adult, actively listed, liver-only candidates and recipients during the study period using Poisson regression (transplant rate), competing risks regression (waitlist mortality), and Cox regression (posttransplant mortality). Among 117 centers, OLD offer acceptance ranged from 0 (23 centers) to 95 acceptances, with a median odds ratio of 2.88. Thus, a candidate may be three times as likely to receive an OLD graft simply by listing at a different center. Centers in the highest quartile (Q4) of OLD acceptance (accepted 39% of OLD offers) accepted more nationally shared organs (Q4 versus Q1: 14.1% versus 0.0%, P<0.001) and had higher annual liver transplant volume (Q4 versus Q1: 80 versus 21, P<0.001). After adjustment, nationally shared OLD offers (adjusted odds ratio [aOR]: 0.16, 95% confidence interval [CI]: 0.13-0.20) and offers to centers with higher median Model for End-Stage Liver Disease (MELD) at transplant (aOR: 0.74, 95% CI: 0.62-0.87) were less likely to be accepted. OLD offers to centers with higher annual transplant volume were more likely to be accepted (aOR: 1.21, 95% CI: 1.14-1.30). Additionally, candidates listed at centers within the highest quartile of OLD graft offer acceptance had higher deceased donor liver transplantation (DDLT) rates (adjusted incidence rate ratio: 1.45, 95% CI: 1.41-1.50), lower waitlist mortality (adjusted subhazard ratio: 0.76, 95% CI: 0.72-0.76), and similar posttransplant survival (adjusted hazard ratio: 0.93, 95% CI: 0.86-1.01) when compared with those listed at centers in the lowest quartile of OLD graft offer acceptance. The wide variation in OLD offer acceptance supports the need for optimizing the organ offer process and efficiently directing OLD offers to centers more likely to use them.

MELD score is predictive of 90-day mortality after veno-arterial extracorporeal membrane oxygenation support.

The Model for End-Stage Liver Disease (MELD) score was originally described as a marker of survival in chronic liver disease. More recently, MELD and its derivatives, MELD excluding INR (MELD-XI) and MELD with sodium (MELD-Na), have been applied more broadly as outcome predictors in heart transplant, left ventricular assist device placement, heart failure, and cardiogenic shock, with additional promising data to support the use of these scores for prediction of survival in those undergoing veno-arterial extracorporeal membrane oxygenation (VA ECMO). This study assessed the prognostic impact of MELD in patients with cardiogenic shock undergoing VA ECMO via a single-center retrospective review from January 2014 to March 2020. MELD, MELD-XI, and MELD-Na scores were calculated using laboratory values collected within 48 h of VA ECMO initiation. Multivariate Cox regression analyses determined the association between MELD scores and the primary outcome of 90-day mortality. Receiver operating characteristics (ROC) were used to estimate the discriminatory power for MELD in comparison with previously validated SAVE score. Of the 194 patients, median MELD was 20.1 (13.7-26.2), and 90-day mortality was 62.1%. There was a significant association between MELD score and mortality up to 90 days (hazard ratio (HR) = 1.945, 95% confidence interval (95% CI) = 1.244-3.041, p = 0.004) after adjustment for age, indication for VA ECMO, and sex. The prognostic significance of MELD score for 90-day mortality revealed an AUC of 0.645 (95% CI = 0.565-0.725, p < 0.001). MELD-Na score and MELD-XI score were not associated with mortality. MELD score accurately predicts long-term mortality and may be utilized as a valuable decision-making tool in patients undergoing VA ECMO.

From the Editor’s desk…

From the Editor’s desk…

Implementing a robotic liver resection program does not always require prior laparoscopic experience

BackgroundPreliminary experience in laparoscopic liver surgery is usually suggested prior to implementation of a robotic liver resection program.MethodsThis was a retrospective cohort analysis of patients undergoing robotic (RLR) versus laparoscopic liver resection (LLR) for hepatocellular carcinoma at a center with concomitant initiation of robotic and laparoscopic programsResultsA total of 92 consecutive patients operated on between May 2014 and February 2019 were included: 40 RLR versus 52 LLR. Median age (69 vs. 67; p = 0.74), male sex (62.5% vs. 59.6%; p = 0.96), incidence of chronic liver disease (97.5% vs.98.1%; p = 0.85), median model for end-stage liver disease (MELD) score (8 vs. 9; p = 0.92), and median largest nodule size (22 vs. 24 mm) were similar between RLR and LLR. In the LLR group, there was a numerically higher incidence of nodules located in segment 4 (20.0% vs. 16.6%; p = 0.79); a numerically higher use of Pringle’s maneuver (32.7% vs. 20%; p = 0.23), and a shorter duration of surgery (median of 165.5 vs. 217.5 min; p = 0.04). Incidence of complications (25% vs.32.7%; p = 0.49), blood transfusions (2.5% vs.9.6%; p = 0.21), and median length of stay (6 vs. 5; p = 0.54) were similar between RLR and LLR. The overall (OS) and recurrence-free (RFS) survival rates at 1 and 5 years were 100 and 79 and 95 and 26% for RLR versus 96.2 and 76.9 and 84.6 and 26.9% for LLR (log-rank p = 0.65 for OS and 0.72 for RFS).ConclusionsBased on our results, concurrent implementation of a robotic and laparoscopic liver resection program appears feasible and safe, and is associated with similar oncologic long-term outcomes.