H. J. Braun1, D. Adelmann1, M. Tavakol1, A. Mello1, C. U. Niemann1, N. L. Ascher1 1University Of California – San Francisco,San Francisco, CA, USA
Introduction:
At our center, the majority of patients listed for liver transplantation (LT) are referred as outpatients by local and regional hepatologists (traditional). However, an increasingly large number of patients are placed on our waiting list after undergoing expedited workup (expedited), whereby they undergo urgent evaluation in the hospital. The purpose of this study was to compare the outcomes of expedited versus traditional patients and to determine whether the method of evaluation and acuity of presentation impact outcome after transplantation.
Methods:
All adult patients who underwent LT at our institution between 6/1/2012 and 12/31/2016 were reviewed. Patients were excluded if they received a transplant: 1) from a living donor, 2) as a retransplant, 3) for acute liver failure. We compared demographic data, intraoperative details, and outcomes from expedited versus traditional patients using Wilcoxon Rank Sum tests and Chi Squared tests. Survival was analyzed with Kaplan-Meier curves, and Cox regression was used to look at predictors of patient survival.
Results:
549 patients were included; 136 (24.7%) expedited, 413 (75.3%) traditional. Expedited patients were significantly younger (58 vs. 60, p<0.001), with greater median MELD at transplant (35 vs. 14, p<0.001), fewer diagnoses of hepatocellular carcinoma (HCC; 14% vs. 62.2%, p<0.001) and a higher percentage of patients requiring dialysis prior to transplant (47.9% vs. 33.3%, p=0.02). Expedited patients spent a shorter time on the waiting list (13 days versus 249 days, p<0.001), but there were no differences in perioperative or donor variables. Between expedited and traditional, there was no significant difference in survival at 30 days (p=0.77) or at 1 year (p=0.26) post-transplant (Figure 1). In the univariate regression analysis, the following variables were associated with an increased risk of death: creatinine at listing (HR 1.3, p=0.04), recipient of liver from a donation after cardiac death donor (DCD, HR=3.27, p=0.006); expedited evaluation (HR 2.56, p=0.01). In multivariate analysis, only DCD remained statistically significant (HR 3.26, p=0.009).
Conclusion:
Expedited LT evaluation occurs quickly but utilizes inpatient resources. It also impacts decision making during our selection committee meetings, as the acuity of these patients on presentation can be dramatic. In this review of our data, we found no significant difference in post-transplant survival for expedited versus traditional patients. Future efforts will focus on examining the cost-effectiveness of the inpatient evaluation and analyzing selection committee notes for expedited versus traditional patients.
