Older age, MELD score predict survival among patients declined for early LT
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LONDON — Lower MELD score predicted short- and long-term survival in patients with severe alcohol-associated hepatitis who were declined for early liver transplantation, according to research presented at the International Liver Congress.
“Early liver transplantation for severe alcohol-associated hepatitis is controversial. There are no formal U.S. UNOS policies for indications for transplantation for severe alcohol-associated hepatitis,” Christine Hsu, MD, assistant professor at Georgetown University, said, “Our group has shown that there are generally good outcomes for liver transplantation for severe alcohol-associated hepatitis with a 1-year survival of 94% and an estimated 3-year survival of 84%. However, organ transplant is a scarce resource.”
In a retrospective, multicenter study, Hsu and colleagues analyzed 134 patients (median age, 49 years; 57% men) with severe alcohol-associated hepatitis (AH) from five American Consortium of Early Liver Transplantation for Alcohol-Associated Hepatitis (ACCELERATE-AH) sites who were evaluated and declined for early LT from 2012 to 2021. All patients had MELD scores greater than 20 (median MELD-Na = 33) with less than 6 months of abstinence at LT evaluation.
Researchers defined liver recompensation as a MELD score less than 15 without evidence of variceal bleeding, ascites requiring diuretic or overt hepatic encephalopathy requiring medication. The study objective was to identify clinical factors associated with short- and long-term mortality in patients with severe AH patients who were declined for LT.
According to study results, the most common reasons patients were declined were psychosocial factors (62%), clinical improvement (16%), medical comorbidities (9%) and finances/insurance (4%). The probability of survival at 3 months, 6 months and 1 year was 58%, 55% and 48%, respectively, and the probability of recompensation at the same time points was 4%, 4% and 6%.
Multivariable analysis showed lower MELD-Na (adjusted OR = 0.8) and absence of grade 3 or 4 hepatic encephalopathy (aOR = 0.02) associated with survival at 3 months; 6-month survival associated with lower MELD-Na (aOR = 0.9), stable partnership (aOR = 2) and either private insurance (aOR = 3.4) or Medicare (aOR = 4.7) compared with Medicaid.
Among patients declined because of clinical improvement, 93% were alive at 6 months but only 15% achieved recompensation. Median MELD scores at 1 month, 3 months, 6 months and 1 year were 28, 26, 15 and 12 among survivors.
“Among patients even with clinical improvement who were declined for transplantation, the probability of being alive compensated is only 20% at 1 year and being alive decompensated is 60% at 1 year,” Hsu concluded. “Even the best-case scenario, where we assume patients with follow-up missing data are recompensated, the probability of 1-year alive compensated is only 33%.
“Increased age and MELD score at time of transplantation evaluation predicted short-term mortality and only the history of failed alcohol rehab predicted long-term death.”
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Hsu C, et al. Abstract OS031. Presented at: International Liver Congress; June 22-26, 2022; London (hybrid meeting).
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