Inaccuracies found in UNOS categorization of ACLF among LT patients, reform needed
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The United Network for Organ Sharing database on acute-on-chronic liver failure categorization in liver transplant patients is discordant with manual chart review and demonstrates the need for policy reform, according to study results.
“ACLF studies that have relied on [United Network for Organ Sharing (UNOS)] and have been driving discussions to change liver transplant policies throughout the world may be providing inaccurate and biased estimates,” Brian P. Lee, MD, MAS, assistant professor at the University of Southern California Keck School of Medicine, told Healio. “Policymakers should ask themselves whether they’ve relied too heavily on these data and acted too quickly. UNOS should reform their data collection to more accurately capture ACLF and to better inform liver transplant allocation policies.”
Lee and colleagues conducted a stratified random sampling among three LT centers between 2013 and 2019 and collected 481 samples from LT recipients aged 18 years and older (median age 55). Of those, 250 had no ACLF, 75 had ACLF grade 1, 79 had ACLF grade 2 and 77 had ACLF grade 3, per UNOS classification. Investigators compared concordance of ACLF classifications by UNOS with blinded manual chart review.
According to study results, concordance of ACLF grade by UNOS compared with chart review was 72% for no ACLF, 64% for grade 1, 56% for grade 2 and 64% for grade 3. Investigators also determined that the overall Cohen’s kappa coefficient was 0.48 (95% CI, 0.42-0.54), which suggests a weak agreement with manual chart review. The most common reason for overestimation of ACLF by UNOS was absence of acute decompensation, with discordant brain and respiratory failure categorization the most common reasons for underestimation.
“We found that UNOS was not categorizing ACLF in concordance or accurately when compared to chart review, which shows the need for UNOS reform and non-UNOS studies to appropriately inform policies in transplant with ACLF,” Lee and colleagues wrote in Journal of Hepatology.
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