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Liver Transplantation in Highest Acuity Recipients: Identifying Factors to Avoid Futility

Petrowsky, Henrik MD, FACS*,†; Rana, Abbas MD*,†; Kaldas, Fady M. MD, FACS*,†; Sharma, Anuj MD*,†; Hong, Johnny C. MD, FACS*,†; Agopian, Vatche G. MD*,†; Durazo, Francisco MD; Honda, Henry MD; Gornbein, Jeffrey DrPH§; Wu, Victor MD; Farmer, Douglas G. MD, FACS*,†; Hiatt, Jonathan R. MD, FACS*; Busuttil, Ronald W. MD, PhD, FACS*,†

doi: 10.1097/SLA.0000000000000265
Original Articles

Objective: To identify medical predictors of futility in recipients with laboratory Model of End-Stage Liver Disease (MELD) scores of 40 or more at the time of orthotopic liver transplantation (OLT).

Background: Although the survival benefit for transplant patients with the highest MELD scores is indisputable, the medical and economic effort to bring these highest acuity recipients through OLT presents a major challenge for every transplant center.

Methods: This study was undertaken to analyze outcomes in patients with MELD scores of 40 or more undergoing OLT during the period February 2002 to December 2010. The analysis was focused on futile outcome (3-month or in-hospital mortality) and long-term posttransplant outcome. Independent predictors of futility and failure-free survival were identified and a futility risk model was created.

Results: During the study period, 1522 adult cadaveric OLTs were performed, and 169 patients (13%) had a MELD score of 40 or more. The overall 1, 3, 5, and 8-year patient survivals were 72%, 64%, 60%, and 56%. Futile outcome occurred in 37 patients (22%). MELD score, pretransplant septic shock, cardiac risk, and comorbidities were independent predictors of futile outcome. Using all 4 factors, the futility risk model had a good discriminatory ability (c-statistic 0.75). Recipient age per year, life-threatening postoperative complications, hepatitis C, and metabolic syndrome were independent predictors for long-term survival in nonfutile patients (Harrels c-statistic 0.72).

Conclusions: Short- and long-term outcomes of recipients with MELD scores of 40 or more are primarily determined by disease-specific factors. Cardiac risk, pretransplant septic shock, and comorbidities are the most important predictors and can be used for risk stratification in these highest acuity recipients.

Avoidance of futility in the sickest liver transplant recipients presents a major challenge for every transplant center. Posttransplant futility in recipients with highest Model of End-Stage Liver Disease scores (≥40) is primarily determined by recipient's disease-specific factors rather than demographic, donor, or surgery-related characteristics.

Department of *Surgery

The Dumont-UCLA Transplant Center, and Departments of



§Biomathematics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles

Department of Hepatology and Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.

Reprints: Ronald W. Busuttil, MD, PhD, Ronald Reagan UCLA Medical Center, 757 Westwood Plaza, Suite 8236, Los Angeles, CA 90095. Email:

Disclosure: This project was supported by the Pfleger Liver Foundation to Henrik Petrowsky. The authors declare no conflicts of interest.

© 2014 by Lippincott Williams & Wilkins.