Low MELD Score No Barrier to Long Survival After Living-Donor TransplantAugust 4, 2022
End-stage liver disease patients at lower risk for death in the short term still reaped the substantial benefits of a living-donor liver transplant (LDLT), a case-control study revealed.
Compared with individuals who remained on the transplant waitlist, those with Model for End-Stage Liver Disease incorporating sodium levels (MELD-Na) scores ranging from 6 to 19 gained an additional 13 to 17 years of life following LDLT, reported John Malamon, PhD, of the University of Colorado in Aurora, and colleagues.
Their study looked at nearly 120,000 waitlist patients, 2.3% of whom ultimately underwent LDLT, and found that these transplants were associated with significant reductions in mortality at 1 year among patients with a MELD-Na of 11 or higher:
- Score of 6-10: adjusted hazard ratio (aHR) 1.13 (95% CI 0.84-1.51)
- Score of 11-13: aHR 0.64 (95% CI 0.47-0.88)
- Score of 14-16: aHR 0.47 (95% CI 0.34-0.66)
- Score of 17-19: aHR 0.43 (95% CI 0.29-0.64)
“Many in the transplant community have questioned the risks and benefits of a transplant for patients with lower MELD-Na scores, particularly given previous studies with deceased donors,” the team wrote in JAMA Surgery. “This study’s findings definitively demonstrate the association of a marked benefit in survival and life-years with receipt of an LDLT.”
Scores of 20 or higher on the MELD-Na (which ranges from 6-40) are associated with a higher risk of death, Malamon’s group noted, and individuals with low scores are often overlooked and not prioritized for transplant. LDLT is typically offered to patients with these lower scores, given that they are less likely to be offered a full organ from a deceased donor, and due to the idea that they may better tolerate a partial graft.
Each year about 20% of patients die while awaiting a new liver or otherwise become too ill for the procedure.
“It was generally agreed on that 15 was perhaps a round number MELD score cutoff for the waitlisted cohort where the risks of a liver transplant start to make sense for the patient,” noted Andrew MacGregor Cameron, MD, PhD, of Johns Hopkins University School of Medicine in Baltimore, in an accompanying editorial.
He added that while donor risk makes the degree of benefit in patients receiving LDLT of critical importance, the current findings suggest a MELD-Na cutoff of 11 for long-term benefit, as this group achieved a survival advantage on the order of 15 years compared with no transplant.
“Perhaps this should be little surprise; liver transplant often seems a miracle to the patients who are fortunate enough to get them and to those of us involved with the procedure,” wrote Cameron. “It’s helpful to quantify that miracle nonetheless and get some guidance about how aggressively to apply it, especially as the risks to the donor are significant.”
For their study, Malamon and colleagues conducted a retrospective, secondary analysis of the Scientific Registry of Transplant Recipient database, which included 119,275 liver transplant candidates from 2012 to 2021. Of those, 2,820 received an LDLT. Excluded were those with prior kidney/liver transplants and those listed for multiorgan transplant or re-transplant. Patients were stratified by MELD-Na score.
LDLT recipients were younger than waitlist candidates (mean 53 vs 55 years, respectively), and a greater proportion were women (47% vs 37%), white (81% vs 70%), and had education beyond high school (62% vs 51%), non-alcoholic steatohepatitis (NASH; 20% vs 16%), or cholestatic liver disease (24% vs 7%).
Among patients who underwent LDLT, the life-years saved were as follows:
- Score of 6-10 on MELD-Na: 13.4 years
- Score of 11-13 on MELD-Na: 16.8 years
- Score of 14-16 on MELD-Na: 13.2 years
- Score of 17-19 on MELD-Na: 17.7 years
The authors acknowledged limitations to the data, including selection bias. Also, only a small number of LDLT recipients had high MELD-Na scores, which precluded analyses in this group.
Malamon reported no disclosures.
A coauthor disclosed being married to the chair of the United Network for Organ Sharing (UNOS) Liver and Intestinal Organ Transplantation Committee.
Cameron did not report any disclosures.