Mortality in patients with end-stage liver disease above model for end-stage liver disease 3.0 of 40

Abstract

Background and aims: Since the implementation of the model for end-stage liver disease (MELD) score to determine waitlist priority for liver transplant (LT) in 2002, the score has been capped at 40. Recently, the MELD 3.0 score was proposed to improve upon MELD-Na. Here, we examine waitlist mortality and LT outcomes in patients with MELD 3.0 ≥ 40 to assess the potential impact of uncapping the score.

Approach and results: Adult waitlist registrations for LT from January 2016 to December 2021 were identified in the registry data from the Organ Procurement and Transplant Network. All MELD 3.0 scores were calculated at registration and thereafter. Waitlist mortality for up to 30 days was calculated as well as post-LT survival. There were 54,060 new waitlist registrations during the study period, of whom 2820 (5.2%) had MELD 3.0 ≥ 40 at listing. The 30-day waitlist mortality was high in these patients, yet it increased further in proportion with MELD 3.0 up to a score of 55 with 30-day mortality of 58.3% for MELD 3.0 of 40-44 and 82.4% for ≥50. The multivariable hazard ratio was 1.13 for each point of MELD 3.0, adjusting for several variables including acute-on-chronic liver failure. The number of LT recipients with MELD 40 at transplant increased from 155 in 2002 to 752 in 2021. Posttransplant survival was comparable across MELD strata including MELD of 35-39.

Conclusion: MELD 3.0 scores beyond 40 are associated with increasing waitlist mortality without adversely affecting posttransplant outcome. Uncapping the MELD score in waitlist candidates may lead to greater survival benefit from LT.

FIGURE 1

(A) The 30-day survival of patients with model for end-stage liver disease (MELD) 3.0≥40 at registration: MELD of 40–44 (blue), MELD of 45–49 (red), and MELD of 50+ (black) groups (p

FIGURE 2

(A) The 30-day survival of patients with model for end-stage liver disease (MELD) 3.0≥40 at any time on waitlist, categorized by the first recorded MELD 3.0 score of 40 or greater. Includes follow-up to the earliest of 30days from the first recorded MELD 3.0 of 40 or greater, exception approval date, death, first liver transplant, or December 31, 2021. (B) The p-spline* 30-day mortality by MELD 3.0 score on the first day of MELD 3.0≥40. * The solid curve represents the main effect and the dotted curves the upper and lower bounds of the 95% confidence interval. The short bars at the base of the figure denote the density of data. Log hazards = 0 represents the average risk of mortality for the entire cohort. CI, confidence interval; LT, liver transplant

FIGURE 3

Increasing number of liver transplant recipients with model for end-stage liver disease (MELD)≥40 over time. Total number of liver transplant recipients with MELD of 40–44, 45–49, and 50 or greater at the time of transplant are shown over time plotted (left y axis) and the percentage of total liver transplants performed in patients with MELD as a percentage of total liver transplants (right y axis)

FIGURE 4

(A) Posttransplant survival, categorized by model for end-stage liver disease (MELD) 3.0 at time of transplant (n = 7180). Survival at 1month, 1year, and 2years. (B) Smoothing spline curve for 2-year posttransplant mortality by MELD 3.0 at the time of transplant. LT, liver transplant