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Young age, high MELD increases waitlist mortality in pediatric biliary atresia cases

MELD score higher than 20 and age younger than 6 months correlated significantly with 2-year mortality among pediatric patients with biliary atresia on the liver transplantation waitlist, according to recently published data.

“Biliary atresia (BA) is an obstructive cholangiopathy that usually arises in the perinatal period,” H.P.J. van der Doef, MD, PhD, from the University of Groningen, the Netherlands, and colleagues wrote. “The overall prognosis of BA patients is greatly affected by mortality before transplantation. We are confident that our prognostic model based on age and MELD score at listing allows a reliable classification of infants with BA into risk groups with different prognoses.”

The study comprised 711 pediatric patients with BA listed for liver transplantation before age 5 years between Jan. 1, 2001, and May 5, 2015. From this cohort, 416 had available MELD scores at listing. Most patients with MELD scores were listed after 2006 (n = 316) and were significantly younger than those without MELD scores.

Age correlated with waitlist mortality and was a greater risk factor for waitlist mortality compared with sex or blood type (P = .001). This remained significant in subgroup analysis of patients with MELD scores.

Patients without MELD scores at listing had significantly higher rates of 2-year waitlist mortality compared with those with MELD scores. While more patients with MELD scores were listed after 2006, the researchers found no significant difference in waitlist mortality between the 2001 to 2006 period and 2007 to 2014.

MELD score (P = .001) and low albumin at listing (P = .02) correlated with waitlist mortality. Waitlist mortality odds increased by a rate of 1.43 per 5 g/dL lower albumin (95% CI, 1.06-1.92).

The researchers observed the highest rates of waitlist mortality in a subgroup analysis of 52 patients younger than 5 months with MELD scores higher than 20. The 52 patients also accounted for 36% of total cohort deaths. Within 6 months after listing, 79% of the subgroup patients received transplantation and 21% died.

During the study, the frequency of living donor transplantations compared with deceased donor transplantations increased from 44% between 2001 and 2006 to 66% between 2007 and 2014 (P = .001). Patients who received a living donor liver had significantly shorter waitlist times than those who received deceased donor livers (median, 0.9 vs. 0.31 years; P = .001).

“Our data support the concept that living donor liver availability shortens the time to transplant of the BA patients and thereby, reduces the risk of mortality on the waiting list,” the researchers wrote. “We do realize, however, that a suitable living donor is not available for any child and that deceased donors remain valuable for young BA patients. Another method to enhance the availability of donors for small children is splitting of the graft and a wider application of split liver donation between adult and pediatric programs is preferable.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.