Waitlist Outcomes in Liver Transplant Candidates with High MELD and Severe Hepatic Encephalopathy
Organ Procurement and Transplantation Network and United Network for Organ Sharing (OPTN/UNOS) implemented the Share 35 policy in June 2013 to prioritize the sickest patients awaiting liver transplantation (LT). However, Model for End-Stage Liver Disease (MELD) score does not incorporate hepatic encephalopathy (HE), an independent predictor of waitlist mortality.
To evaluate the impact of severe HE (grade 3–4) on waitlist outcomes in MELD ≥ 30 patients.
Using the OPTN/UNOS database, we evaluated LT waitlist registrants from 2005–2014. Demographics, comorbidities, and waitlist survival were compared between four cohorts: MELD 30–34 with severe HE, MELD 30–34 without severe HE, MELD ≥ 35 with severe HE, and MELD ≥ 35 without severe HE.
Among 10,003 waitlist registrants studied, 41.6% had MELD score 30–34 and 58.4% had MELD ≥ 35. Patients with severe HE had a higher 90-day waitlist mortality in both MELD 30–34 (severe HE 71.1% vs. no HE 56.6%; p < 0.001) and MELD ≥ 35 subgroups (severe HE 85% versus no HE 74.2%; p < 0.001). MELD 30–34 patients with severe HE had similar 90-day waitlist mortality as MELD ≥ 35 patients without severe HE (71.1 vs. 74.2%, respectively; p = 0.35). On multivariate Cox proportional hazards modeling, MELD ≥ 30 patients had 58% greater risk of 90-day waitlist mortality than those without severe HE (HR 1.58, 95% CI 1.53–1.62; p < 0.001).
Patients awaiting LT with MELD score of 30–34 and severe HE should receive priority status for organ allocation with exception MELD ≥ 35.
KeywordsSevere hepatic encephalopathy MELD Share 35 policy Waitlist mortality Liver transplantation
Alcoholic liver disease
Cold ischemia time
Donor Service Area
Hepatitis C virus
Model for End-Stage Liver Disease
Organ Procurement and Network
United Network for Organ Sharing
CG and GC were responsible for study concept and design, acquisition of the data, analysis and interpretation of the data, and drafting and approval of the final manuscript. MH was responsible for acquisition of the data, statistical analyses, and drafting and approval of the final manuscript. ERY was responsible for drafting, critical revision, and approval of the final manuscript. RJW and AA were responsible for the interpretation of the data, study supervision, drafting, critical revision, and approval of the final manuscript. All authors were involved in the final approval of the manuscript submitted and have agreed to be accountable for all aspects of the work.
Compliance with ethical standards
Conflict of interest
All authors declare no conflict of interest in the preparation of this manuscript, including financial, consultant, institutional, and other relationships that might lead to bias.