Author information

1 Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, 1211 Union avenue, Suite # 340, Memphis, TN, 38138, USA.

2 Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA.

3 Department of Medicine, Santa Clara Valley Medical Center, 751 S. Bascom Street, San Jose, CA, 95128, USA.

4 Department of Biostatistics, Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA.

5 Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, 1411 E 31st Street, Oakland, CA, 94602, USA.

6 Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA. aijazahmed@stanford.edu.

7 Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 750 Welch Road, Suite # 210, Stanford, CA, 94304, USA. aijazahmed@stanford.edu.

Abstract

BACKGROUND: Organ Procurement and Transplantation Network and United Network for Organ Sharing (OPTN/UNOS) implemented the Share 35 policy in June 2013 to prioritize the sickest patients awaiting liver transplantation (LT). However, Model for End-Stage Liver Disease (MELD) score does not incorporate hepatic encephalopathy (HE), an independent predictor of waitlist mortality.

AIM: To evaluate the impact of severe HE (grade 3-4) on waitlist outcomes in MELD ≥ 30 patients.

METHODS: Using the OPTN/UNOS database, we evaluated LT waitlist registrants from 2005-2014. Demographics, comorbidities, and waitlist survival were compared between four cohorts: MELD 30-34 with severe HE, MELD 30-34 without severe HE, MELD ≥ 35 with severe HE, and MELD ≥ 35 without severe HE.

RESULTS: Among 10,003 waitlist registrants studied, 41.6% had MELD score 30-34 and 58.4% had MELD ≥ 35. Patients with severe HE had a higher 90-day waitlist mortality in both MELD 30-34 (severe HE 71.1% vs. no HE 56.6%; p < 0.001) and MELD ≥ 35 subgroups (severe HE 85% versus no HE 74.2%; p < 0.001). MELD 30-34 patients with severe HE had similar 90-day waitlist mortality as MELD ≥ 35 patients without severe HE (71.1 vs. 74.2%, respectively; p = 0.35). On multivariate Cox proportional hazards modeling, MELD ≥ 30 patients had 58% greater risk of 90-day waitlist mortality than those without severe HE (HR 1.58, 95% CI 1.53-1.62; p < 0.001).

CONCLUSION: Patients awaiting LT with MELD score of 30-34 and severe HE should receive priority status for organ allocation with exception MELD ≥ 35.