End-stage liver disease candidates at the highest model for end-stage liver disease scores have higher wait-list mortality than status-1A candidates§


  • Potential conflict of interest: Nothing to report.

  • This research was presented, in part, as a free communication at the American Transplant Congress 2009, held May 30 to June 3, 2009, in Boston, MA.

  • §

    The views expressed herein are those of the authors and not necessarily those of the U.S. Government.

  • Dr. Sharma was the recipient of an American Society of Transplantation/Roche Clinical Science Faculty Development grant for 2008-2010. Dr. Sharma is also supported by National Institutes of Health (NIH) grant KO8 DK-088946. The statistical methodology development and analysis for this investigation was supported in part by NIH grant 2 R01 DK070869 to Dr. Schaubel. Drs. Sharma, Schaubel, and Gong are also supported by Michigan Institute for Health and Clinical Research NIH-Clinical and Translational Sciences Award UL1RR024986. This research was funded by the Scientific Registry of Transplant Recipients (SRTR) contract number 231-00-0116 from the Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services. This study was approved by HRSA's SRTR project officer. HRSA has determined that this study satisfies the criteria for the Institutional Review Board exemption described in the “Public Benefit and Service Program” provisions of 45 CFR 46.101(b)(5) and HRSA Circular 03. The authors would like to thank Ms. Shauna Leighton, Medical Editor, Arbor Research Collaborative for Health, Ann Arbor, MI, for providing editorial assistance.

  • See Editorial on Page 14


Candidates with fulminant hepatic failure (Status-1A) receive the highest priority for liver transplantation (LT) in the United States. However, no studies have compared wait-list mortality risk among end-stage liver disease (ESLD) candidates with high Model for End-Stage Liver Disease (MELD) scores to those listed as Status-1A. We aimed to determine if there are MELD scores for ESLD candidates at which their wait-list mortality risk is higher than that of Status-1A, and to identify the factors predicting wait-list mortality among those who are Status-1A. Data were obtained from the Scientific Registry of Transplant Recipients for adult LT candidates (n = 52,459) listed between September 1, 2001, and December 31, 2007. Candidates listed for repeat LT as Status-1 A were excluded. Starting from the date of wait listing, candidates were followed for 14 days or until the earliest occurrence of death, transplant, or granting of an exception MELD score. ESLD candidates were categorized by MELD score, with a separate category for those with calculated MELD > 40. We compared wait-list mortality between each MELD category and Status-1A (reference) using time-dependent Cox regression. ESLD candidates with MELD > 40 had almost twice the wait-list mortality risk of Status-1A candidates, with a covariate-adjusted hazard ratio of HR = 1.96 (P = 0.004). There was no difference in wait-list mortality risk for candidates with MELD 36-40 and Status-1A, whereas candidates with MELD < 36 had significantly lower mortality risk than Status-1A candidates. MELD score did not significantly predict wait-list mortality among Status-1A candidates (P = 0.18). Among Status-1A candidates with acetaminophen toxicity, MELD was a significant predictor of wait-list mortality (P < 0.0009). Posttransplant survival was similar for Status-1A and ESLD candidates with MELD > 20 (P = 0.6). Conclusion: Candidates with MELD > 40 have significantly higher wait-list mortality and similar posttransplant survival as candidates who are Status-1A, and therefore, should be assigned higher priority than Status-1A for allocation. Because ESLD candidates with MELD 36-40 and Status-1A have similar wait-list mortality risk and posttransplant survival, these candidates should be assigned similar rather than sequential priority for deceased donor LT. (Hepatology 2012)