Mortality Risk Factors Among Patients With Cirrhosis and a Low Model for End-Stage Liver Disease Sodium Score (≤15): An Analysis of Liver Transplant Allocation Policy Using Aggregated Electronic Health Record Data

K. Atiemo, A. Skaro, H. Maddur, L. Zhao, S. Montag, L. VanWagner, S. Goel, A. Kho, B. Ho, R. Kang, J. L. Holl, M. M. Abecassis, J. Levitsky, D. P. Ladner

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Abstract

Although the Model for End-Stage Liver Disease sodium (MELD Na) score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7834 adult patients with cirrhosis, we determined whether the cause of cirrhosis or cirrhosis complications was associated with an increased risk of death among patients with a MELD Na score ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over median follow-up of 2.3 years, 3715 patients had a maximum MELD Na score ≤15. Overall, 3.4% were waitlisted for LT. Severe hypoalbuminemia, hepatorenal syndrome, and hepatic hydrothorax conferred the greatest risk of death independent of MELD Na score with 1-year predicted mortality >14%. Approximately 10% possessed these risk factors. Of these high-risk patients, only 4% were waitlisted for LT, despite no difference in nonliver comorbidities between waitlisted patients and those not listed. In addition, risk factors for death among waitlisted patients were the same as those for patients not waitlisted, although the effect of malnutrition was significantly greater for waitlisted patients (hazard ratio 8.65 [95% CI 2.57–29.11] vs. 1.47 [95% CI 1.08–1.98]). Using the MELD Na score for allocation may continue to limit access to LT.

LanguageEnglish (US)
Pages2410-2419
Number of pages10
JournalAmerican Journal of Transplantation
Volume17
Issue number9
DOIs
StatePublished - Sep 1 2017

Fingerprint

End Stage Liver Disease
Electronic Health Records
Fibrosis
Sodium
Transplants
Mortality
Liver
Liver Transplantation
Hydrothorax
Hepatorenal Syndrome
Hypoalbuminemia
Malnutrition
Comorbidity

Keywords

  • cirrhosis
  • classification systems: Model for EndStage Liver Disease (MELD)
  • clinical research/practice
  • health services and outcomes research
  • liver transplantation/hepatology
  • patient characteristics
  • patient survival

ASJC Scopus subject areas

  • Immunology and Allergy
  • Transplantation
  • Pharmacology (medical)

Cite this

@article{669f0015808f4fd9858a87e693c4ec2b,
title = "Mortality Risk Factors Among Patients With Cirrhosis and a Low Model for End-Stage Liver Disease Sodium Score (≤15): An Analysis of Liver Transplant Allocation Policy Using Aggregated Electronic Health Record Data",
abstract = "Although the Model for End-Stage Liver Disease sodium (MELD Na) score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7834 adult patients with cirrhosis, we determined whether the cause of cirrhosis or cirrhosis complications was associated with an increased risk of death among patients with a MELD Na score ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over median follow-up of 2.3 years, 3715 patients had a maximum MELD Na score ≤15. Overall, 3.4{\%} were waitlisted for LT. Severe hypoalbuminemia, hepatorenal syndrome, and hepatic hydrothorax conferred the greatest risk of death independent of MELD Na score with 1-year predicted mortality >14{\%}. Approximately 10{\%} possessed these risk factors. Of these high-risk patients, only 4{\%} were waitlisted for LT, despite no difference in nonliver comorbidities between waitlisted patients and those not listed. In addition, risk factors for death among waitlisted patients were the same as those for patients not waitlisted, although the effect of malnutrition was significantly greater for waitlisted patients (hazard ratio 8.65 [95{\%} CI 2.57–29.11] vs. 1.47 [95{\%} CI 1.08–1.98]). Using the MELD Na score for allocation may continue to limit access to LT.",
keywords = "cirrhosis, classification systems: Model for EndStage Liver Disease (MELD), clinical research/practice, health services and outcomes research, liver transplantation/hepatology, patient characteristics, patient survival",
author = "K. Atiemo and A. Skaro and H. Maddur and L. Zhao and S. Montag and L. VanWagner and S. Goel and A. Kho and B. Ho and R. Kang and Holl, {J. L.} and Abecassis, {M. M.} and J. Levitsky and Ladner, {D. P.}",
year = "2017",
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T1 - Mortality Risk Factors Among Patients With Cirrhosis and a Low Model for End-Stage Liver Disease Sodium Score (≤15)

T2 - American Journal of Transplantation

AU - Atiemo, K.

AU - Skaro, A.

AU - Maddur, H.

AU - Zhao, L.

AU - Montag, S.

AU - VanWagner, L.

AU - Goel, S.

AU - Kho, A.

AU - Ho, B.

AU - Kang, R.

AU - Holl, J. L.

AU - Abecassis, M. M.

AU - Levitsky, J.

AU - Ladner, D. P.

PY - 2017/9/1

Y1 - 2017/9/1

N2 - Although the Model for End-Stage Liver Disease sodium (MELD Na) score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7834 adult patients with cirrhosis, we determined whether the cause of cirrhosis or cirrhosis complications was associated with an increased risk of death among patients with a MELD Na score ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over median follow-up of 2.3 years, 3715 patients had a maximum MELD Na score ≤15. Overall, 3.4% were waitlisted for LT. Severe hypoalbuminemia, hepatorenal syndrome, and hepatic hydrothorax conferred the greatest risk of death independent of MELD Na score with 1-year predicted mortality >14%. Approximately 10% possessed these risk factors. Of these high-risk patients, only 4% were waitlisted for LT, despite no difference in nonliver comorbidities between waitlisted patients and those not listed. In addition, risk factors for death among waitlisted patients were the same as those for patients not waitlisted, although the effect of malnutrition was significantly greater for waitlisted patients (hazard ratio 8.65 [95% CI 2.57–29.11] vs. 1.47 [95% CI 1.08–1.98]). Using the MELD Na score for allocation may continue to limit access to LT.

AB - Although the Model for End-Stage Liver Disease sodium (MELD Na) score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7834 adult patients with cirrhosis, we determined whether the cause of cirrhosis or cirrhosis complications was associated with an increased risk of death among patients with a MELD Na score ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over median follow-up of 2.3 years, 3715 patients had a maximum MELD Na score ≤15. Overall, 3.4% were waitlisted for LT. Severe hypoalbuminemia, hepatorenal syndrome, and hepatic hydrothorax conferred the greatest risk of death independent of MELD Na score with 1-year predicted mortality >14%. Approximately 10% possessed these risk factors. Of these high-risk patients, only 4% were waitlisted for LT, despite no difference in nonliver comorbidities between waitlisted patients and those not listed. In addition, risk factors for death among waitlisted patients were the same as those for patients not waitlisted, although the effect of malnutrition was significantly greater for waitlisted patients (hazard ratio 8.65 [95% CI 2.57–29.11] vs. 1.47 [95% CI 1.08–1.98]). Using the MELD Na score for allocation may continue to limit access to LT.

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KW - patient characteristics

KW - patient survival

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JO - American Journal of Transplantation

JF - American Journal of Transplantation

SN - 1600-6135

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