Highlights
- •Among candidates with ACLF who are listed for liver transplantation, MELD score and ACLF interact in predicting cumulative risk of 90-day waitlist mortality.
- •The impact of ACLF grade on 90-day waitlist mortality is much higher at lower listing MELD score, especially below 25.
- •A validated novel score using MELD score and ACLF grade at listing provides an estimate of 90-day waitlist mortality.
Background & Aims
Among candidates listed for liver transplant (LT), the model for end-stage liver disease
(MELD) score may not capture acute-on-chronic liver failure (ACLF) severity. Data
on the interaction between ACLF and MELD score in predicting waitlist mortality are
scarce.
Methods
We analyzed the UNOS database (01/2002 to 06/2018) for LT listings in adults with
cirrhosis and ACLF (without hepatocellular carcinoma). ACLF grades 1, 2, 3a, and 3b-
were defined using the modified EASL-CLIF criteria.
Results
Of 18,416 candidates with ACLF at listing (mean age 54 years, 69% males, 63% Caucasians),
90-day waitlist mortality (patient death or being too sick for LT) was 21.6% (18%,
20%, 25%, and 39% for ACLF grades 1, 2, 3a, and 3b, respectively). Using a Fine and
Gray regression model, we identified an interaction between MELD and ACLF grade, with
ACLF having a higher impact at lower MELD scores. Other variables included candidate’s
age, sex, liver disease etiology, listing MELD, ACLF grade, obesity, and performance
status. A score developed using parameter estimates from the interaction model on
the derivation cohort (n = 9,181) stratified the validation cohort (n = 9,235) into
quartiles: Q1 (score <10.42), Q2 (10.42-12.81), Q3 (12.82-15.50), and Q4 (>15.50).
Waitlist mortality increased with each quartile from 13%, 18%, 23%, and 36%, respectively.
Observed vs. expected waitlist mortality deciles in the validation cohort showed good calibration
(goodness of fit p = 0.98) and correlation (R = 0.99).
Conclusion
Among selected candidates who have ACLF at listing, MELD score and ACLF interact in
predicting cumulative risk of 90-day waitlist mortality, with higher impact of ACLF
grade at lower listing MELD score. Validating these findings in large prospective
studies will support consideration of both MELD and ACLF when prioritizing transplant
candidates and allocating liver grafts.
Lay summary
In patients with cirrhosis listed for liver transplantation, the presence of multiorgan
failure, a condition referred to as acute-on-chronic liver failure, is associated
with high waiting list mortality rates. Current organ allocation policy disadvantages
patients with this condition. This study describes and validates a new scoring method
that performs better than the currently available scoring systems. Further validation
of this approach may reduce the deaths of patients with cirrhosis and acute-on-chronic
liver failure on the transplant waiting list.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: December 14, 2020
Accepted:
December 3,
2020
Received in revised form:
December 3,
2020
Received:
May 28,
2020
Identification
Copyright
© 2020 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
