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AASLD 2008: Mortality Lower for Early Liver Transplant in Healthier

Patients

Patients with low to mid Model for End-Stage Liver

Disease (MELD) scores benefit more from early liver transplantation than sicker

patients, said Goldstein, MD, from Columbia University, in New York City, here at The Liver Meeting 2008, the

59th Annual Meeting of the American Association for the Study of Liver Diseases.

Dr. Goldstein and his colleagues looked at the 5-year

survival rate from the time patients were put on the waitlist, analyzing United

Network for Organ Sharing (UNOS) data from a 2002 to 2006 study of 22,863

liver-only adult transplant recipients and 43,497 liver transplant waitlist

patients. They looked at both waitlist and post-transplant

mortality. The organ transplants studied included both

living-donor organs and deceased donor high-donor-risk index organs and

low-donor-risk index organs.

Early

timing of liver transplants was key to the analysis. Dr.

Goldstein calculated a " break even " 5-year mortality rate for high-

and low-risk organs to find the best timing for high DRI organ transplantation. For example, for patients with a MELD score of 11 to 14,

survival improved with transplantation at 15 months instead of a projected 21

months, he stated in his presentation.

He

also said during his presentation that living-donor allografts

worked well for patients with MELD scores lower than 15. Dr.

Goldstein said that " living donor allografts

actually outperformed all deceased-donor allografts, "

in the UNOS data.

In

the 4 MELD-score cohorts (<10, 11–18, 19–24, and >25), those

with the lowest and highest MELD scores who received an early living-donor

transplant had 5-year mortality rates higher than the national average: those

with a MELD score lower than 10 had a 3.5% increased mortality rate, and those

with a MELD score higher than 25 had a 7.6% increased mortality rate. However, 5-year mortality decreased for early living-donor

transplants given to patients with MELD scores of 11 to 18 (a 13.4% decrease)

and of 19 to 24 (a 14.8% decrease).

Patients

who received a high DRI organ followed a similar pattern. Those

with a MELD score higher than 25 had a slight improvement in 5-year mortality

rates, but those with MELD scores in the middle 2 cohorts (11 to 18 and 19 to

24) benefited most.

Dr. Goldstein admitted that his conclusions are

" somewhat contradictory to the general MELD principles " of treating

the sickest patients first, since the patients he recommends for early

transplant are " exactly those patients who no one transplants early, "

he told Medscape Gastroenterology. However,

he said that patients with lower MELD scores " have the most to gain "

because they have a better quality of life before and after transplantation and

live longer post-transplant than the sicker patients. When

making transplantation decisions with limited organs, " we should look at

the total benefit for society as a whole, " he said.

http://www.medscape.com/viewarticle/582920?sssdmh=dm1.400275 & src=nlconfnews & spon=20 & uac=12920HV

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@ Baylor/Dallas