Division of Gastroenterology and Hepatology, University of Tennessee Health Science Center, 1211 Union avenue, Suite # 340, Memphis, TN, 38138, USA.
Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA.
Department of Medicine, Santa Clara Valley Medical Center, 751 S. Bascom Street, San Jose, CA, 95128, USA.
Department of Biostatistics, Brown University School of Public Health, 121 S Main St, Providence, RI, 02903, USA.
Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, 1411 E 31st Street, Oakland, CA, 94602, USA.
Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, CA, 94305, USA. firstname.lastname@example.org.
Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 750 Welch Road, Suite # 210, Stanford, CA, 94304, USA. email@example.com.
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.
To evaluate the impact of severe HE (grade 3-4) on waitlist outcomes in MELD ≥ 30 patients.
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.
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).
Patients awaiting LT with MELD score of 30-34 and severe HE should receive priority status for organ allocation with exception MELD ≥ 35.