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Liver Transplant Evaluation Within
30 Days Improves Pretransplant Survival
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AASLD The Liver Meeting Digital Experience, November 13-16, 2020
Mark Mascolini
Evaluating a person within 30 days of referral for liver transplantation favors lower pretransplant mortality, according to results of a 1118-veteran analysis [1]. Evaluation within 30 days cut about 1 month off the time to listing for transplantation and trimmed almost 4 months off time to transplantation.
Veterans Affairs (VA) researchers who conducted this study noted the wide variability in access to liver transplantation and promptness of evaluation across the United States. Little is known about how time from referral to evaluation for transplantation affects subsequent events and outcomes. The United Network for Organ Sharing (UNOS) tracks only UNOS-listed patients from their time of listing.
Researchers at the Miami VA Medical Center and colleagues at other sites planned this study to explore the impact of early transplant evaluation (no more than 30 days from referral to evaluation by a transplant hepatologist) on (1) pretransplant mortality, (2) time to UNOS listing, (3) time to transplantation, and (4) posttransplant mortality. They also sifted data for predictors of early evaluation and dropping off the transplant list.
This retrospective multicohort analysis plumbed national data from the Veterans Affairs healthcare system on everyone referred for liver transplant from July 2013 through March 2018. The study focused on 1118 veterans evaluated for liver transplant, 832 (74%) of whom had an early (within-30-days) referral and 286 of whom had a delayed evaluation. Of the 832 with an early evaluation, 496 (60%) got listed for transplantation and 336 did not. Of the 286 veterans with a delayed evaluation, 159 (56%) got listed and 127 did not.
Veterans with or without an early evaluation did not differ significantly in age (average 62 years in both groups), in body mass index at referral (28.9 and 29.1 kg/m2), or in proportions with liver cancer at referral (47.4% and 51.1%). MELD score [2] at referral was slightly but significantly higher (worse) in the early-evaluation group than in people with a delayed evaluation (average 15.5 vs 14.6, P = 0.04).
The early-evaluation group did not differ significantly from the delayed-evaluation group in proportion listed for transplantation (59.6% and 55.6%), undergoing transplantation (31.1% and 26.2%), or dropping off the transplant list (19.4% and 22.7%). But veterans with an early evaluation had a significantly lower death rate before transplantation (24.4% vs 34.6%, P = 0.0009) and tended to have a higher death rate after transplantation (3.4% vs 1.4%, P = 0.09).
Early transplant evaluation favored a shorter time from referral to several later events (given as medians):
- Days from referral to evaluation: 23 vs 39, P < 0.0001
- Days from referral to listing: 69 vs 77, P = 0.13 (not significant)
- Days from referral to transplant: 223 vs 367, P = 0.0009
- Days from referral to pretransplant death: 242 vs 402, P < 0.0001
- Days from referral to posttransplant death: 521 vs 947, P = 0.035
Generalized linear regression analysis adjusted for potentially confounding variables determined that veterans who had an early (versus delayed) evaluation spent 29.5 fewer days waiting to get on the transplant list (95% confidence interval [CI] -50.4 to -8.5, P < 0.006) and 115.1 fewer days waiting for transplantation (95% CI -179.5 to -50.7, P < 0.0001).
An adjusted Cox proportional hazards model figured that early evaluation cut the risk of pretransplant mortality by one third (adjusted hazard ratio 0.68, 95% CI 0.5 to 0.9, P = 0.003).
Adjusted logistic regression singled out three factors independently linked to early evaluation: higher MELD score at referral (adjusted odds ratio [aOR] 1.03, 95% CI 1.00 to 1.05, P = 0.02), BCLC stage A versus stage 0 liver cancer (aOR 0.46, 95% CI 0.23 to 0.93, P < 0.001), and greater distance between referring and transplant centers (aOR 0.99, 95% CI 0.99 to 0.99, P = 0.045).
People with tumor progression while waiting for a transplant had nearly 5-fold higher odds of dropping off the transplant list (aOR 4.89, 95% CI 2.96 to 8.08, P < 0.001). But people with diabetes were 40% less likely to drop off the list (aOR 0.60, 95% CI 0.43 to 0.84, P = 0.003). Evaluation within 30 days of referral did not affect chances of dropping off the list.
The VA team suggested three possible explanations for the link between early evaluation and lower pretransplant mortality. Two of the reasons involve the transplant center: Prompter evaluation scheduling may be a marker of better quality care, and early listing may lead to more organ offers. One reason involves the patient: Early evaluation may indirectly indicate greater patient motivation and social support.
The researchers cautioned that the VA referral process differs from procedures outside the VA. Also, the veterans studied do not represent the general US population because a large majority are men, they have better healthcare access than many Americans, and they differ sociodemographically from the population at large in other ways.
References
1. John BV, Dahman B, Schwartz K, et al. Evaluation within thirty days of referral for liver transplantation is associated with reduced mortality. AASLD The Liver Meeting Digital Experience, November 13-16, 2020. Abstract 27.
2. Model for End-stage Liver Disease (MELD) estimates survival with liver disease over the next 3 months. Higher scores indicate a greater need for liver transplantation. UPMC Transplant Services. What is a MELD score? https://www.upmc.com/services/transplant/liver/process/waiting-list/meld-score
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