Liver Transplant Survival Index for Patients with Model for End-Stage Liver Disease Score ≥ 35: Modeling Risk and Adjusting Expectations in the Share 35 Era

Justin A. Steggerda, Irene K. Kim, Tsuyoshi Todo, Darren Malinoski, Andrew S. Klein, Matthew B. Bloom

    Research output: Contribution to journalArticle

    2 Citations (Scopus)

    Abstract

    Background: The Share 35 policy for liver allocation prioritizes patients with Model for End-Stage Liver Disease (MELD) scores ≥ 35 for regional sharing of liver allografts. To better assess donor-recipient interactions and inform expectations, this study identified factors affecting graft survival independent of MELD score and derived a risk index for transplantation in the MELD ≥ 35 population. Study Design: The United Network for Organ Sharing (UNOS) STAR database was evaluated for deceased donor liver transplants with recipients’ MELD ≥ 35, between January 2006 and June 2016. Data were randomly split into test and validate cohorts. Four individual models of graft survival spanning 90 days to 5 years were evaluated with univariate and multivariate Cox proportional hazards analyses against donor- and recipient-specific characteristics. Significant factors were compiled to generate the Liver Transplant Survival Index (LTSI-35), and survival analyses were performed. Results: Five risk groups (very low, low, moderate, high, and severe) were identified, with 1-year graft survival rates of 90.8% ± 0.2%, 89.3% ± 0.3%, 85.0% ± 0.3%, 79.8% ± 0.3%, and 70.3% ± 0.4% (p < 0.001 across groups), respectively. The greatest risk of graft loss was associated with donation after circulatory death (DCD) donors (1-year hazard ratio [HR] = 1.61 [95% CI 1.26 to 2.05], p = 0.001), recipients’ requiring ventilator support (HR 1.32 [95% CI 1.17 to 1.51], p < 0.001), and recipient portal vein thrombosis (HR 1.21 [95% CI 1.03 to 1.42], p = 0.003). Subgroup analysis revealed increased risk of graft loss with graft macrosteatosis ≥ 30% on pre-donation biopsy at 90 days (HR 1.64 [1.33 to 1.99], p < 0.001). Conclusions: The LTSI-35 identifies risk factors for graft loss in a high-MELD population which, when combined, may portend worse outcomes. The LTSI-35 may be used to influence donor selection, organ allocation, and to inform expectations for allograft survival.

    Original languageEnglish (US)
    JournalJournal of the American College of Surgeons
    DOIs
    StatePublished - Jan 1 2019

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    End Stage Liver Disease
    Transplants
    Graft Survival
    Tissue Donors
    Liver
    Allografts
    Donor Selection
    Mechanical Ventilators
    Survival Analysis
    Portal Vein
    Population
    Thrombosis
    Survival Rate
    Transplantation
    Databases
    Biopsy

    ASJC Scopus subject areas

    • Surgery

    Cite this

    Liver Transplant Survival Index for Patients with Model for End-Stage Liver Disease Score ≥ 35 : Modeling Risk and Adjusting Expectations in the Share 35 Era. / Steggerda, Justin A.; Kim, Irene K.; Todo, Tsuyoshi; Malinoski, Darren; Klein, Andrew S.; Bloom, Matthew B.

    In: Journal of the American College of Surgeons, 01.01.2019.

    Research output: Contribution to journalArticle

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    title = "Liver Transplant Survival Index for Patients with Model for End-Stage Liver Disease Score ≥ 35: Modeling Risk and Adjusting Expectations in the Share 35 Era",
    abstract = "Background: The Share 35 policy for liver allocation prioritizes patients with Model for End-Stage Liver Disease (MELD) scores ≥ 35 for regional sharing of liver allografts. To better assess donor-recipient interactions and inform expectations, this study identified factors affecting graft survival independent of MELD score and derived a risk index for transplantation in the MELD ≥ 35 population. Study Design: The United Network for Organ Sharing (UNOS) STAR database was evaluated for deceased donor liver transplants with recipients’ MELD ≥ 35, between January 2006 and June 2016. Data were randomly split into test and validate cohorts. Four individual models of graft survival spanning 90 days to 5 years were evaluated with univariate and multivariate Cox proportional hazards analyses against donor- and recipient-specific characteristics. Significant factors were compiled to generate the Liver Transplant Survival Index (LTSI-35), and survival analyses were performed. Results: Five risk groups (very low, low, moderate, high, and severe) were identified, with 1-year graft survival rates of 90.8{\%} ± 0.2{\%}, 89.3{\%} ± 0.3{\%}, 85.0{\%} ± 0.3{\%}, 79.8{\%} ± 0.3{\%}, and 70.3{\%} ± 0.4{\%} (p < 0.001 across groups), respectively. The greatest risk of graft loss was associated with donation after circulatory death (DCD) donors (1-year hazard ratio [HR] = 1.61 [95{\%} CI 1.26 to 2.05], p = 0.001), recipients’ requiring ventilator support (HR 1.32 [95{\%} CI 1.17 to 1.51], p < 0.001), and recipient portal vein thrombosis (HR 1.21 [95{\%} CI 1.03 to 1.42], p = 0.003). Subgroup analysis revealed increased risk of graft loss with graft macrosteatosis ≥ 30{\%} on pre-donation biopsy at 90 days (HR 1.64 [1.33 to 1.99], p < 0.001). Conclusions: The LTSI-35 identifies risk factors for graft loss in a high-MELD population which, when combined, may portend worse outcomes. The LTSI-35 may be used to influence donor selection, organ allocation, and to inform expectations for allograft survival.",
    author = "Steggerda, {Justin A.} and Kim, {Irene K.} and Tsuyoshi Todo and Darren Malinoski and Klein, {Andrew S.} and Bloom, {Matthew B.}",
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    T1 - Liver Transplant Survival Index for Patients with Model for End-Stage Liver Disease Score ≥ 35

    T2 - Modeling Risk and Adjusting Expectations in the Share 35 Era

    AU - Steggerda, Justin A.

    AU - Kim, Irene K.

    AU - Todo, Tsuyoshi

    AU - Malinoski, Darren

    AU - Klein, Andrew S.

    AU - Bloom, Matthew B.

    PY - 2019/1/1

    Y1 - 2019/1/1

    N2 - Background: The Share 35 policy for liver allocation prioritizes patients with Model for End-Stage Liver Disease (MELD) scores ≥ 35 for regional sharing of liver allografts. To better assess donor-recipient interactions and inform expectations, this study identified factors affecting graft survival independent of MELD score and derived a risk index for transplantation in the MELD ≥ 35 population. Study Design: The United Network for Organ Sharing (UNOS) STAR database was evaluated for deceased donor liver transplants with recipients’ MELD ≥ 35, between January 2006 and June 2016. Data were randomly split into test and validate cohorts. Four individual models of graft survival spanning 90 days to 5 years were evaluated with univariate and multivariate Cox proportional hazards analyses against donor- and recipient-specific characteristics. Significant factors were compiled to generate the Liver Transplant Survival Index (LTSI-35), and survival analyses were performed. Results: Five risk groups (very low, low, moderate, high, and severe) were identified, with 1-year graft survival rates of 90.8% ± 0.2%, 89.3% ± 0.3%, 85.0% ± 0.3%, 79.8% ± 0.3%, and 70.3% ± 0.4% (p < 0.001 across groups), respectively. The greatest risk of graft loss was associated with donation after circulatory death (DCD) donors (1-year hazard ratio [HR] = 1.61 [95% CI 1.26 to 2.05], p = 0.001), recipients’ requiring ventilator support (HR 1.32 [95% CI 1.17 to 1.51], p < 0.001), and recipient portal vein thrombosis (HR 1.21 [95% CI 1.03 to 1.42], p = 0.003). Subgroup analysis revealed increased risk of graft loss with graft macrosteatosis ≥ 30% on pre-donation biopsy at 90 days (HR 1.64 [1.33 to 1.99], p < 0.001). Conclusions: The LTSI-35 identifies risk factors for graft loss in a high-MELD population which, when combined, may portend worse outcomes. The LTSI-35 may be used to influence donor selection, organ allocation, and to inform expectations for allograft survival.

    AB - Background: The Share 35 policy for liver allocation prioritizes patients with Model for End-Stage Liver Disease (MELD) scores ≥ 35 for regional sharing of liver allografts. To better assess donor-recipient interactions and inform expectations, this study identified factors affecting graft survival independent of MELD score and derived a risk index for transplantation in the MELD ≥ 35 population. Study Design: The United Network for Organ Sharing (UNOS) STAR database was evaluated for deceased donor liver transplants with recipients’ MELD ≥ 35, between January 2006 and June 2016. Data were randomly split into test and validate cohorts. Four individual models of graft survival spanning 90 days to 5 years were evaluated with univariate and multivariate Cox proportional hazards analyses against donor- and recipient-specific characteristics. Significant factors were compiled to generate the Liver Transplant Survival Index (LTSI-35), and survival analyses were performed. Results: Five risk groups (very low, low, moderate, high, and severe) were identified, with 1-year graft survival rates of 90.8% ± 0.2%, 89.3% ± 0.3%, 85.0% ± 0.3%, 79.8% ± 0.3%, and 70.3% ± 0.4% (p < 0.001 across groups), respectively. The greatest risk of graft loss was associated with donation after circulatory death (DCD) donors (1-year hazard ratio [HR] = 1.61 [95% CI 1.26 to 2.05], p = 0.001), recipients’ requiring ventilator support (HR 1.32 [95% CI 1.17 to 1.51], p < 0.001), and recipient portal vein thrombosis (HR 1.21 [95% CI 1.03 to 1.42], p = 0.003). Subgroup analysis revealed increased risk of graft loss with graft macrosteatosis ≥ 30% on pre-donation biopsy at 90 days (HR 1.64 [1.33 to 1.99], p < 0.001). Conclusions: The LTSI-35 identifies risk factors for graft loss in a high-MELD population which, when combined, may portend worse outcomes. The LTSI-35 may be used to influence donor selection, organ allocation, and to inform expectations for allograft survival.

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