A. Bertacco1, J. Merola1, K. Giles1, G. D’Amico1, S. Luczycki1, S. Kulkarni1, P. S. Yoo1, S. Emre1, D. Mulligan1, M. Rodriguez-Davalos1 1Yale University School Of Medicine,Surgery/Transplantation,New Haven, CT, USA
Introduction Patients with high Model for End-stage Liver Disease (MELD) scores have high risk for death without liver transplant (LT). The impact of MELD in predicting post liver transplant outcomes has been criticized. Several better predictive scoring systems using donor and recipient data have been developed. The aim of this study is to assess how donor quality impacts the outcomes of liver transplant recipients with a MELD >35 or acute liver failure (Status 1a) under the current allocation system.
Materials and Methods This is a retrospective IRB approved study, of adult patients with MELD >35 or Status 1a who received LT from 7/2006 to 7/2015 were included. We excluded pediatric transplant and living donor recipients. Recipient demographics, etiology, previous transplant, combined liver-kidney transplant, quality of donor were analyzed. ECD donors were defined as age >65yrs, BMI >35, HBcAb positive, HCV seropositive, DCD (donation after circulatory death), split liver, CIT (Cold Ischemia Time) >12 hrs, Total Bilirubin >2mg/dl, and/or requirement of more than 2 vasopressors. Survival rates in recipients transplanted with high-risk donors (ECD) and standard criteria donors (SCD) were compared using the Kaplan-Meier methods.
Results 56 patients with MELD >35 received LT during the study period (35 male and 21 female). Mean age was 51 years. 11 (19.6%) patients had acute liver failure (ALF) and 20 (35.7%) were in ICU at time of transplant. Six (10.7%) patients needed ventilator support. Ten of the 56 (17.8%) patients received combined liver-kidney transplants (CLKT) and Three patients had previous LT.
Mean MELD for patients with chronic liver disease was 41.4. Most common indication was HCV(37.5%) followed by ETOH (16.07%). In ALF cases, 1 (9.2%) had HBV related, 4 (36.3%) had drug induced, and 6 (54.5%) were unknown etiology.
Seventeen (30.3%) patients were transplanted with ECD grafts. Patient survival at 90 days was equal in both ECD and SCD groups (93% and 97% ns). There was no statistical significance between SCD and ECD groups in terms of 1 and 3 year patient survival (85.7% and 57.1% in ECD vs 76.4% and 56.8% SCD. (p=0.661)
Conclusions Donor organ quality does not seem to play a role in early patient survival after LT, although patients with MELD >35 may have worse long-term survival. Our analysis showed no significant difference when we use marginal or standard donors for high MELD or Status 1 recipients. This fact suggests that recipients with high MELD scores or fulminant liver failure may benefit from this pool of grafts. Accepting well selected ECD livers and having timely LT may result in better patient outcomes rather than waiting SCD for a longer period; however, long-term outcomes need to be considered.