Comparing High- and Low-Model for End-Stage Liver Disease Living-Donor Liver Transplantation to Determine Clinical Efficacy: A Systematic Review and Meta-Analysis (CHALICE Study)

Abstract

Introduction: Various studies have demonstrated that low-Model for End-Stage Liver Disease (MELD) living-donor liver transplant (LDLT) recipients have better outcomes with improved patient survival than deceased-donor liver transplantation (DDLT) recipients. LDLT recipients gain the most from being transplanted at MELD <25-30; however, some existing data have outlined that LDLT may provide equivalent outcomes in high-MELD and low-MELD patients, although the term "high" MELD is arbitrarily defined in the literature and various cut-off scores are outlined between 20 and 30, although most commonly, the dividing threshold is 25. The aim of this meta-analysis was to compare LDLT in high-MELD with that in low-MELD recipients to determine patient survival and graft survival, as well as perioperative and postoperative complications.

Methods: Following PROSPERO registration CRD-42021261501, a systematic database search was conducted for the published literature between 1990 and 2021 and yielded a total of 10 studies with 2183 LT recipients; 490 were HM-LDLT recipients and 1693 were LM-LDLT recipients.

Results: Both groups had comparable mortality at 1, 3 and 5 years post-transplant (5-year HR 1.19; 95% CI 0.79-1.79; p-value 0.40) and graft survival (HR 1.08; 95% CI 0.72, 1.63; p-value 0.71). No differences were observed in the rates of major morbidity, hepatic artery thrombosis, biliary complications, intra-abdominal bleeding, wound infection and rejection; however, the HM-LDLT group had higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay.

Conclusions: The high-MELD LDLT group had similar patient and graft survival and morbidities to the low-MELD LDLT group, despite being at higher risk for pulmonary infection, abdominal fluid collection and prolonged ICU stay. The data, primarily sourced from high-volume Asian centers, underscore the feasibility of living donations for liver allografts in high-MELD patients. Given the rising demand for liver allografts, it is sensible to incorporate these insights into U.S. transplant practices.

Keywords: high MELD; liver transplant; living donor; living donor liver transplant (LDLT).

Figure 1

Search strategy and study selection used in this systematic review as per PRISMA protocol.

Figure 2

Quality assessment of included studies. Green present; yellow equivocal [21,22,23,24,25,26,27,28,29,30].

Figure 3

Forest plot depicting hazard ratios for overall patient survival at 1 year (A), 3 years (B) and 5 years (C) post-transplant, demonstrating equivalent outcomes in HM-LDLT and LM-LDLT recipients [22,23,24,25,26,27,28,29,30].

Figure 3

Forest plot depicting hazard ratios for overall patient survival at 1 year (A), 3 years (B) and 5 years (C) post-transplant, demonstrating equivalent outcomes in HM-LDLT and LM-LDLT recipients [22,23,24,25,26,27,28,29,30].

Figure 4

Forest plot depicting hazard ratios for overall graft survival at 1 year (A), 3 years (B) and 5 years (C) post-transplant, demonstrating equivalent outcomes in HM-LDLT and LM-LDLT recipients [22,24,26,27].

Figure 5

Forest plot of operative and postoperative variables. (A) Total morbidity, (B) hepatic artery thrombosis, (C) biliary complications, (D) wound infection, (E) intra-abdominal bleeding, (F) pulmonary infection, (G) abdominal fluid collection, (H) rejection, (I) operative time, (J) length of ICU stay, (K) length of hospital stay. HM-LDLT and LM-LDLT recipients had equivalent rates of total morbidity (A), hepatic artery thrombosis (B), biliary complications (C), wound infection (D) intra-abdominal bleeding (E), rejection (G) and length of hospital stay; however, HM-LDLT recipients had higher likelihood of pulmonary infection (F), abdominal fluid collection (G) and prolonged ICU stay [21,23,24,25,26,27,28,29,30].

Figure 5

Forest plot of operative and postoperative variables. (A) Total morbidity, (B) hepatic artery thrombosis, (C) biliary complications, (D) wound infection, (E) intra-abdominal bleeding, (F) pulmonary infection, (G) abdominal fluid collection, (H) rejection, (I) operative time, (J) length of ICU stay, (K) length of hospital stay. HM-LDLT and LM-LDLT recipients had equivalent rates of total morbidity (A), hepatic artery thrombosis (B), biliary complications (C), wound infection (D) intra-abdominal bleeding (E), rejection (G) and length of hospital stay; however, HM-LDLT recipients had higher likelihood of pulmonary infection (F), abdominal fluid collection (G) and prolonged ICU stay [21,23,24,25,26,27,28,29,30].

Figure 5

Forest plot of operative and postoperative variables. (A) Total morbidity, (B) hepatic artery thrombosis, (C) biliary complications, (D) wound infection, (E) intra-abdominal bleeding, (F) pulmonary infection, (G) abdominal fluid collection, (H) rejection, (I) operative time, (J) length of ICU stay, (K) length of hospital stay. HM-LDLT and LM-LDLT recipients had equivalent rates of total morbidity (A), hepatic artery thrombosis (B), biliary complications (C), wound infection (D) intra-abdominal bleeding (E), rejection (G) and length of hospital stay; however, HM-LDLT recipients had higher likelihood of pulmonary infection (F), abdominal fluid collection (G) and prolonged ICU stay [21,23,24,25,26,27,28,29,30].

Figure 5

Forest plot of operative and postoperative variables. (A) Total morbidity, (B) hepatic artery thrombosis, (C) biliary complications, (D) wound infection, (E) intra-abdominal bleeding, (F) pulmonary infection, (G) abdominal fluid collection, (H) rejection, (I) operative time, (J) length of ICU stay, (K) length of hospital stay. HM-LDLT and LM-LDLT recipients had equivalent rates of total morbidity (A), hepatic artery thrombosis (B), biliary complications (C), wound infection (D) intra-abdominal bleeding (E), rejection (G) and length of hospital stay; however, HM-LDLT recipients had higher likelihood of pulmonary infection (F), abdominal fluid collection (G) and prolonged ICU stay [21,23,24,25,26,27,28,29,30].