Should Liver Transplantation in Patients with Model for End-Stage Liver Disease Scores <= 14 Be Avoided? A Decision Analysis Approach

Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA 98195, USA.
Liver Transplantation (Impact Factor: 3.79). 02/2009; 15(2):242-54. DOI: 10.1002/lt.21703
Source: PubMed

ABSTRACT Studies have shown that liver transplantation offers no survival benefits to patients with Model for End-Stage Liver Disease (MELD) scores <or= 14 in comparison with remaining on the waitlist. The consensus of a 2003 transplant community national conference was that a minimum MELD score should be required for placement on the liver waitlist, but no minimum listing national policy was enacted at that time. We developed a Markov microsimulation model to compare results under the present US liver allocation policy with outcomes under a "Rule 14" policy of barring patients with a MELD score of <or=14 from the waitlist or transplantation. For probabilities in the microsimulation model, we used data on all adult patients (>or=18 years) listed for or undergoing primary liver transplantation in the United States for chronic liver disease from 1/1/2003 through 12/31/2007 with follow-up until 2/1/2008. The "Rule 14" policy gave a 3% improvement in overall patient survival over the present system at 1, 2, 3, and 4 years and predicted a 13% decrease in overall waitlist time for patients with MELD scores of 15 to 40. Patients with the greatest benefit from a "Rule 14" policy were those with MELD scores of 6 to 10, for whom a 17% survival advantage was predicted from waiting on the list versus undergoing transplantation. Our analysis supports changing the national liver allocation policy to not allow liver transplantation for patients with MELD <or= 14.

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    ABSTRACT: Patients with chronic liver disease face greater risk of perioperative morbidity and mortality, with the greatest risk among patients with cirrhosis. Both the Child-Pugh score and the Model for End-Stage Liver Disease have been evaluated as predictors of postoperative mortality. Other comorbidities, age, and American Society of Anesthesiologists physical status classification are also important predictors of these outcomes. In patients with liver disease, elective surgeries should be delayed to allow complete evaluation of the severity of liver disease, including the role of transplantation in the event of hepatic decompensation postoperatively.
    Clinics in liver disease 05/2012; 16(2):421-33. DOI:10.1016/j.cld.2012.03.008
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    ABSTRACT: To hypothesize that the product of calculated Model for End-Stage Liver Disease score excluding exception points and donor age (D-MELD) risk capping ± Rule 14 could improve post liver transplant and overall survival after listing.
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    ABSTRACT: Background/Aims: Some patients with portal hypertension due to hepatitis B cirrhosis who were suitable for periesophagogastric devascularization with splenectomy (PDS) also met the indications of liver transplantation (LT), the study compared the effect of PDS and LT, and of PDS followed by LT when required. Methodology: Patients with portal hypertension due to hepatitis B cirrhosis were analyzed. Patients were organized into PDS or LT groups, and PDS followed by LT. Results: The PDS group suffered from lower incidence of severe postoperative complications (p=0.007) and perioperative death (p=0.015) than group LT. The 1-, 3- and 5-year survival rates of the PDS and LT groups were 99.3%, 98.1% and 89.0%, and 91.1%, 85.4% and 79.0%, respectively (p=0.04). There were no significant differences in severe postoperative complications (p=1.000) or perioperative mortality (p=1.000) between the PDS followed by LT and the LT groups, and their 1-, 3- and 5-year survival rates were 91.2%, 82.1% and 82.1%, and 91.1%, 85.4% and 79.0%, respectively (p=0.694). Conclusion: For patients with portal hypertension due to hepatitis B cirrhosis, when they satisfy the indications for both PDS and LT, we appeal to perform PDS as bridging therapy for final liver transplantation.
    Hepato-gastroenterology 05/2013; 60(123). DOI:10.5754/hge12904 · 0.91 Impact Factor

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