Liver transplantation in the Nordic countries - An intention to treat and post-transplant analysis from The Nordic Liver Transplant Registry 1982-2013

Abstract

Aim and background: The Nordic Liver Transplant Registry (NLTR) accounts for all liver transplants performed in the Nordic countries since the start of the transplant program in 1982. Due to short waiting times, donor liver allocation has been made without considerations of the model of end-stage liver disease (MELD) score. We aimed to summarize key outcome measures and developments for the activity up to December 2013.

Materials and methods: The registry is integrated with the operational waiting-list and liver allocation system of Scandiatransplant (www.scandiatransplant.org) and accounted at the end of 2013 for 6019 patients out of whom 5198 were transplanted. Data for recipient and donor characteristics and relevant end-points retransplantation and death are manually curated on an annual basis to allow for statistical analysis and the annual report.

Results: Primary sclerosing cholangitis, acute hepatic failure, alcoholic liver disease, primary biliary cirrhosis and hepatocellular carcinoma are the five most frequent diagnoses (accounting for 15.3%, 10.8%, 10.6%, 9.3% and 9.0% of all transplants, respectively). Median waiting time for non-urgent liver transplantation during the last 10-year period was 39 days. Outcome has improved over time, and for patients transplanted during 2004-2013, overall one-, five- and 10-year survival rates were 91%, 80% and 71%, respectively. In an intention-to-treat analysis, corresponding numbers during the same time period were 87%, 75% and 66%, respectively.

Conclusion: The liver transplant program in the Nordic countries provides comparable outcomes to programs with a MELD-based donor liver allocation system. Unique features comprise the diagnostic spectrum, waiting times and the availability of an integrated waiting list and transplant registry (NLTR).

Keywords: end-stage liver disease; indication; liver transplantation; organ allocation; outcome; registry.

Figure 1.

(A) The total number of first liver transplantations (LTX) performed in the Nordic countries (Denmark, Sweden, Finland and Norway) since 1982 along with the annual number of retransplantations in the same period. (B) The distribution of LTX per. 1 million of the country population (PMP) of the different Nordic countries from 1982 to 2013. (C) Age distribution of recipients at first LTX through the period from 1982 to 2013 for all the Nordic countries combined. (D) The total number of liver recipients older than 60 years (blue), and the same group as the fraction of the total LTX ctivity in the period from 1987 to 2013.

Figure 2.

(A) Patient Kaplan–Meier survival after first liver transplantation (LTX) between 2001 and 2013, subdivided according to model of end-stage liver disease (MELD) score. (B) Patient Kaplan–Meier survival curves per disease category for first LTX during the period of 1982 and 2013. (C) Patient Kaplan–Meier survival curves stratified by retransplantation status for LTX performed between 1982 and 2013. (D) Patient Kaplan–Meier survival curves according to different time periods between 1982 and 2013.