Impact of MELD-based allocation on end-stage renal disease after liver transplantation.

Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
American Journal of Transplantation (Impact Factor: 6.19). 08/2011; 11(11):2372-8. DOI: 10.1111/j.1600-6143.2011.03703.x
Source: PubMed

ABSTRACT The proportion of patients undergoing liver transplantation (LT), with concomitant renal dysfunction, markedly increased after allocation by the model for end-stage liver disease (MELD) score was introduced. We examined the incidence of subsequent post-LT end-stage renal disease (ESRD) before and after the policy was implemented. Data on all adult deceased donor LT recipients between April 27, 1995 and December 31, 2008 (n = 59 242), from the Scientific Registry of Transplant Recipients, were linked with Centers for Medicare & Medicaid Services' ESRD data. Cox regression was used to (i) compare pre-MELD and MELD eras with respect to post-LT ESRD incidence, (ii) determine the risk factors for post-LT ESRD and (iii) quantify the association between ESRD incidence and mortality. Crude rates of post-LT ESRD were 12.8 and 14.5 per 1000 patient-years in the pre-MELD and MELD eras, respectively. Covariate-adjusted post-LT ESRD risk was higher in the MELD era (hazard ratio [HR]= 1.15; p = 0.0049). African American race, hepatitis C, pre-LT diabetes, higher creatinine, lower albumin, lower bilirubin and sodium >141 mmol/L at LT were also significant predictors of post-LT ESRD. Post-LT ESRD was associated with higher post-LT mortality (HR = 3.32; p < 0.0001). The risk of post-LT ESRD, a strong predictor of post-LT mortality, is 15% higher in the MELD era. This study identified potentially modifiable risk factors of post-LT ESRD. Early intervention and modification of these risk factors may reduce the burden of post-LT ESRD.

  • [Show abstract] [Hide abstract]
    ABSTRACT: The accuracy of creatinine-based estimated GFR (eGFR) in assessing the prevalence of chronic kidney disease (CKD) and associated mortality after liver transplantation (LTx) is unknown. Using measured GFR (mGFR) by iothalamate clearance, we determined the prevalence of the entire spectrum of renal dysfunction and the impact of CKD on mortality after LTx. A database that prospectively tracks all LTx recipients at this academic transplant program from 1985 to 2012 was queried to identify all adult primary LTx recipients. Our post-LTx protocol incorporates GFR measurement by iothalamate clearance at regular intervals. A multistate model was used to assess the prevalence of CKD, kidney transplant and death after LTx. Time-dependent Cox regression analysis was performed to evaluate the impact of mGFR and eGFR changes on survival. A total of 1,211 transplant recipients were included. At the time of LTx, the median age was 54 years, 60% were male and 86% were Caucasian. At 25 years after LTx, 54% of patients died, 9% underwent kidney transplantation, whereas 7%, 21% and 18% had mGFR >60, 59-30 and <30 ml/min/1.73m(2) respectively. The risk of death increased when mGFR decreased below 30 ml/min/1.73m(2): HR=2.67 (95% CI=1. 80-3.96) for GFR=29-15 ml/min/1.73m(2) and HR=5.47(95% CI=3.10-9.65) for GFR<15 ml/min/1.73m(2). Compared to mGFR, eGFR underestimated mortality risk in LTx recipients with an eGFR of 30-90 ml/min/1.73m(2). An overwhelming majority of LTx recipients develop CKD. The risk of death increases exponentially when GFR<30 ml/min/1.73m(2). Creatinine-based eGFR underestimates the mortality risk in a large proportion of patients.
    Journal of Hepatology 04/2014; · 9.86 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: To provide an approach to the care of liver transplant (LT) patients, a growing patient population with unique needs. A literature search of PubMed for guidelines and review articles using the keywords "liver transplantation", "long term complications" and "medical management" was conducted, resulting in 77 articles. As a result of being on immunosuppression, LT recipients are at increased risk of infections and must be screened regularly for metabolic complications and malignancies. Although immunosuppression is key to maintaining allograft health after transplantation, it comes with its own set of medical issues to follow. Physicians following LT recipients must be aware of the greater risk for hypertension, diabetes, dyslipidemia, renal failure, metabolic bone disease and malignancies in these patients, all of whom require regular monitoring and screening. Vaccination, quality of life, sexual function and pregnancy must be specifically addressed in transplant patients.
    Canadian journal of gastroenterology & hepatology. 04/2014; 28(4):213-9.
  • [Show abstract] [Hide abstract]
    ABSTRACT: To assess our experience with the use and management of everolimus-based regimens post-liver transplantation and to redefine the potential role of this drug in current clinical practice.
    World journal of transplantation. 06/2014; 4(2):122-32.

Full-text (2 Sources)

Available from
May 22, 2014