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Outcome of Liver Transplant Patients With High Urgent Priority

Are We Doing the Right Thing?

de Boer, Jacob D., MD1,2; Braat, Andries E., MD, PhD2; Putter, Hein, PhD3; de Vries, Erwin, MSc1; Strassburg, Christian H., MD, PhD4; Máthé, Zoltán, MD, PhD5; van Hoek, Bart, MD, PhD6; Braun, Felix, MD, PhD7; van den Berg, Aad P., MD, PhD8; Mikulic, Danko, MD, PhD9; Michielsen, Peter, MD, PhD10; Trotovsek, Blaz, MD, PhD11; Zoller, Heinz, MD, PhD12; de Boer, Jan, MD1; van Rosmalen, Marieke D., MD1; Samuel, Undine, MD, PhD13; Berlakovich, Gabriela, MD14; Guba, Markus, MD, PhD15 on behalf of the Eurotransplant Liver and Intestine Advisory Committee (ELIAC)

doi: 10.1097/TP.0000000000002526
Original Clinical Science—Liver
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Background. About 15% of liver transplantations (LTs) in Eurotransplant are currently performed in patients with a high-urgency (HU) status. Patients who have acute liver failure (ALF) or require an acute retransplantation can apply for this status. This study aims to evaluate the efficacy of this prioritization.

Methods. Patients who were listed for LT with HU status from January 1, 2007, up to December 31, 2015, were included. Waiting list and posttransplantation outcomes were evaluated and compared with a reference group of patients with laboratory Model for End-Stage Liver Disease (MELD) score (labMELD) scores ≥40 (MELD 40+).

Results. In the study period, 2299 HU patients were listed for LT. Ten days after listing, 72% of all HU patients were transplanted and 14% of patients deceased. Patients with HU status for primary ALF showed better patient survival at 3 years (69%) when compared with patients in the MELD 40+ group (57%). HU patients with labMELD ≥45 and patients with HU status for acute retransplantation and labMELD ≥35 have significantly inferior survival at 3-year follow-up of 46% and 42%, respectively.

Conclusions. Current prioritization for patients with ALF is highly effective in preventing mortality on the waiting list. Although patients with HU status for ALF have good outcomes, survival is significantly inferior for patients with a high MELD score or for retransplantations. With the current scarcity of livers in mind, we should discuss whether potential recipients for a second or even third retransplantation should still receive absolute priority, with HU status, over other recipients with an expected, substantially better prognosis after transplantation.

1 Eurotransplant International Foundation, Leiden, The Netherlands.

2 Division of Transplantation, Department of Surgery, Leiden University Medical Center, Leiden, The Netherlands.

3 Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands.

4 Universitätsklinikum Bonn, Medizinische Klinik und Poliklinik, Bonn, Germany.

5 Department of Transplantation and Surgery, Semmelweis Medical University, Budapest, Hungary.

6 Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands.

7 Klinik fur Allgemeine, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein Campus Kiel, Kiel, Germany.

8 Department of Gastroenterology, University Medical Center Groningen, Groningen, The Netherlands.

9 Department of Surgery, Clinical Hospital Merkur, Zagreb, Croatia.

10 Department of Gastroenterology and Hepatology, University Hospital Antwerp, Antwerpen, Belgium.

11 Department of Abdominal Surgery, University Medical Center Ljubljana, Ljubljana, Slovenia.

12 Klinik für Innere Medizin II–Hepatologie, Tirol Kliniken GmbH, Innsbruck, Austria.

13 Eurotransplant International Foundation, Leiden, The Netherlands.

14 Division of Transplantation, Department of Surgery, Medical University of Vienna, Austria.

15 Department of General-, Visceral-, and Transplant Surgery, University of Munich, Munich, Germany.

Received 12 July 2018. Revision received 2 October 2018.

Accepted 29 October 2018.

The authors declare no funding or conflicts of interest.

J.D.d.B., A.v.d.B., A.B., and M.G. conceptualized and designed the study. Jan de Boer, M.v.R., E.d.V., C.H.S., Z.M., B.v.H., F.B., D.M., P.M., B.T., G.B., and M.G. acquired the data. Jacob de Boer, E.d.V., and H.P. statistically analyzed the data. Jacob de Boer, E.d.V., A.B., A.v.d.B., G.B., and M.G. analyzed and interpreted the data. Jacob de Boer, U.S., A.B., A.v.d.B., and M.G. drafted the manuscript. Jacob de Boer, M.G., A.B., H.P., A.v.d.B., E.d.V., C.H.S., Z.M., B.v.H., F.B., D.M., P.M., B.T., G.B., H.Z., J.d.B., M.v.R., and U.S. critically revised the manuscript. U.S., A.B., and M.G. supervised the study.

Supplemental digital content (SDC) is available for this article. Direct URL citations appear in the printed text, and links to the digital files are provided in the HTML text of this article on the journal’s Web site (www.transplantjournal.com).

Correspondence: Jacob de Boer, MD, Eurotransplant International Foundation, P.O. Box 2304, NL - 2301 CH Leiden, The Netherlands. (jacob.deboer@eurotransplant.org).

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