Outcome of liver transplant patients with high urgent priority. Are we doing the right thing?

Background About 15% of liver transplantations in Eurotransplant are currently performed in patients with a high-urgency (HU) status. Patients that have acute liver failure or require an acute retransplantation can apply for this status. This study aims to evaluate the efficacy of this prioritization. Methods Patients that were listed for liver transplantation with HU status from 01.01.2007 up to 31.12.2015 were included. Waiting list and posttransplantation outcomes were evaluated and compared with a reference group of patients with labMELD scores ≥40 (MELD 40+). Results In the study period, 2,299 HU patients were listed for liver transplantation. At 10 days after listing, 72% of all HU patients were transplanted and 14% of patients deceased. Patients with HU status for primary acute liver failure showed better patient survival at 3 years (69%) as compared to patients in the MELD 40+ group (57%). HU patients with labMELD≥45 and patients with HU status for acute retransplantation and LabMELD≥35 have significantly inferior survival at 3-year follow-up of 46% and 42%, respectively. Conclusions Current prioritization for patients with acute liver failure is highly effective in preventing mortality on the waiting list. Although patients with HU status for acute liver failure have good outcomes, survival is significantly inferior for patients with a high MELD score or for retransplantations. With the current scarcity of livers in mind, we should discuss whether potential recipients for a second or even third retransplantation should still receive absolute priority, with HU-status, over other recipients with an expected, substantially better prognosis after transplantation. Corresponding author: J.D. de Boer, MD, Medical Staff Eurotransplant. E-mail: jacob.deboer@eurotransplant.org Reprints will not be available from the authors. Authorship Study concept and design: Jacob de Boer (JdB), Aad van den Berg (AvdB), Andries Braat (AB), Markus Guba (MG) Acquisition of data: Jan de Boer (JB), Marieke van Rosmalen (MvR), Erwin de Vries (EV), Christian Strassburg (CS), Zoltan Mathe (ZM), Bart van Hoek (BH), Felix Braun (FB), Danko Mikulic (DM), Peter Michielsen (PM), Blaz Trotovsek (BT), Andreas Pascher (AP), Gabriela Berlakovich (GB), MG. Statistical analysis: JdB, EV, Hein Putter (HP) Analysis and interpretation of data: JdB, EV, AB, AvdB, Gabriela Berlakovich (GB), MG Drafting of the manuscript: JdB, US, AB, AvdB, MG. Critical revision of the manuscript: JdB, MG, AB, HP, AvdB, EV, CS, ZM, BH, FB, DM, PM, BT, AP, GB, HZ, JB, MvR, US. Study supervision: US, AB, MG. Conflicts of interest: The authors of this manuscript have no conflict of interest to disclose. Funding: The manuscript was not prepared by or funded in any part by a commercial organization. No financial support or grants were used for the preparation of this manuscript. Copyright © 2018 Wolters Kluwer Health, Inc. All rights reserved.

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