Weak Link in Liver Transplantation Survival

A recent article and editorial (DH Leung et al. Liver Transpl 2016; 22: 1584-92 & editorial by JC Bucuvalas, S Feng 1466-68) provides a better picture of long-term survival for pediatric patients facing the prospect of liver transplantation.

Among patients less than 2 years in the UNOS data sharing registry, there were 994 with biliary atresia (BA) and 221 with other chronic liver disease.

The key data:

  • The overall postlisting mortality was 19.6% with most of this due to wait-list mortality (12.4%).  Posttransplant mortality was 8%.
  • The non-BA patients had a higher wait-list mortality compared with BA patients: 23.9% vs 9.8%
  • Risk factors for mortality included lack of exception points (HR 5.8), and initial creatinine >0.5.  In addition, BA patients without prior abdominal surgery (eg Kasai) was higher (risk was 1.6 times greater) than in those with BA with presumed Kasai.

Reviewing the article, it is not clear to me if patients removed the waitlist (eg due to sepsis and other causes) are included in this analysis.  Thus, the true postlisting mortality may be higher than 20% if all needy individuals are considered.

From the editorial -other aspects:

  • Only one-third of pediatric recipients have optimal outcomes which would include normal LFTs, maintained on monotherapy immunosuppression, normal growth, and free of comorbidity.  In addition, even among those with ‘optimal’ outcomes, many would still have histologic injury.
  • The “incidence of nonstandard exception requests has increased 5-fold and is now used on behalf of 44% of wait-listed children.”  Importantly, children with public insurance were less likely to have petitions for exception PELD points.

My take (with help from editorial): To improve outcomes, this means starting with candidate selection and working on each step: traversing wait-list management and optimizing posttransplant care.

Related blog posts:

Mural in Rockland, ME

Mural in Rockland, ME

Advertisements

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s