Korean J Transplant.  2022 Nov;36(Supple 1):S209. 10.4285/ATW2022.F-3480.

Heightened mortality associated with acute on chronic liver failure among waitlist patients with model for end-stage liver disease 3.0 of 40 or higher

• Kim R
• Kwong A
• Mannalithara A
• Bonham CA

• KMID: 2535274
• DOI: http://doi.org/10.4285/ATW2022.F-3480

Abstract

Background
Recently, the Organ Procurement and Transplant Network (OPTN) approved an updated version of the model for end-stage liver disease score, namely MELD 3.0, to replace the current score in determining waitlist priority in liver transplant (LT) in the US. Traditionally, MELD has been capped at 40, which may disadvantage patients with acute on chronic liver failure (ACLF), as their MELD is often >40 and face the highest risk of death. Here, we examine waitlist mortality and LT outcomes in patients with acute on chronic liver failure (ACLF) and MELD 3.0 >40.
Methods
Adult waitlist registrations for LT from January 2016 to December 2021 were identified in the OPTN registry. ACLF was defined according to NACSELD, namely >2 organ failures, including hepatic encephalopathy grade 3–4, vasopressors, me-chanical ventilation, and renal failure. Waitlist mortality for up to 30 days was calculated as well as post-LT survival.
Results
There were 54,060 new waitlist registrants, of whom 2,820 (5.2%) had MELD 3.0 >40 at listing. 1706 (3.2%) met the criteria for ACLF of whom 754 (1.4%) had MELD 3.0 >40. Figure A shows that waitlist mortality continued to increase for MELD 3.0 40 with 30-day mortality of 58.3% for MELD 3.0 40–44 and 82.4% for 50. In Figure B, mortality was significantly higher in patients with ACLF. In the multivariable Cox model, ACLF was associated with a hazard ratio of 1.79 (95% confidence interval [CI], 1.51–2.12) and each point of MELD 1.12 (95% CI, 1.10–1.15), after adjustment for age and diagnosis. In contrast, MELD 3.0 >40 had no significant impact on posttransplant survival.
Conclusions
ACLF is associated with nearly 80% increase in waitlist mortality even among patients with MELD 3.0 >40. Post-transplant outcome was not adversely affected in liver recipients with MELD 3.0 >40. These data call for a policy change includ-ing uncapping the MELD score and/or granting priority points to patients with ACLF.