Lower rates of receiving model for end-stage liver disease exception and longer time to transplant among nonalcoholic steatohepatitis hepatocellular carcinoma.

Receiving Model for End-Stage Liver Disease (MELD) exception status for hepatocellular carcinoma (HCC) improves wait-list survival and probability of liver transplantation (LT). We aim to evaluate etiology-specific disparities in MELD exception, LT wait-list times, and post-LT outcomes among patients with HCC listed for LT. Using United Network for Organ Sharing 2004-2013 data, we evaluated adults (age > 18 years) with HCC secondary to hepatitis C virus (HCV), nonalcoholic steatohepatitis (NASH), alcoholic cirrhosis (EtOH), hepatitis B virus (HBV), combined EtOH/HCV, and combined HBV/HCV. Multivariate regression models evaluated etiology-specific odds of active exception, probability of receiving LT, and post-LT survival. In total, 10,887 HCC patients were listed for LT from 2004 to 2013. Compared with HCV-HCC patients (86.8%), patients with NASH-HCC (67.7%), and EtOH-HCC (64.4%) had a lower proportion with active MELD exception (P < 0.001). On multivariate regression, NASH-HCC and EtOH-HCC patients had significantly lower odds of active MELD exception compared with HCV-HCC (NASH-HCC-odds ratio [OR], 0.73; 95% confidence interval [CI], 0.58-0.93; P = 0.01; EtOH-HCC-OR, 0.72; 95% CI, 0.59-0.89; P = 0.002). Compared with HCV-HCC patients, NASH-HCC (HR, 0.83; 95% CI 0.76-0.90; P < 0.001), EtOH-HCC (HR, 0.88; 95% CI 0.81-0.96; P = 0.002), and EtOH/HCV-HCC (HR, 0.92; 95% CI 0.85-0.99; P = 0.03) were less likely to receive LT if they had active exception. Without active exception, these discrepancies were more significant (NASH-HCC-HR, 0.22; 95% CI, 0.18-0.27; P < 0.001; EtOH-HCC-HR, 0.22; 95% CI, 0.18-0.26; P < 0.001; EtOH/HCV-HCC-HR, 0.26; 95% CI, 0.22-0.32; P < 0.001). In conclusion, among US adults with HCC listed for LT, patients with NASH-HCC, EtOH-HCC, and EtOH/HCV-HCC were significantly less likely to have active MELD exception compared with HCV-HCC, and those without active exception had a lower likelihood of receiving LT. More research is needed to explore why NASH-HCC patients were less likely to have active MELD exception. Liver Transplantation 22 1356-1366 2016 AASLD.

Young K ，Aguilar M ，Gish R ，Younossi Z ，Saab S ，Bhuket T ，Liu B ，Ahmed A ，Wong RJ ... -  《-》

Liver transplantation in the MELD era--analysis of the OPTN/UNOS registry.

Taniguchi M 《-》

A method for establishing allocation equity among patients with and without hepatocellular carcinoma on a common liver transplant waiting list.

The current organ allocation system for liver transplantation (LT) creates an imbalance between patients with and without hepatocellular carcinoma (HCC). We describe a model designed to re-establish allocation equity among patient groups using transplant benefit as the common endpoint. We enrolled consecutive adult patients entering the waiting list (WL group, n=2697) and undergoing LT (LT group, n=1702) during the period 2004-2009 in the North Italy Transplant program area. Independent multivariable regressions (WL and LT models) were created for patients without HCC and for those with stage T2 HCC. Monte Carlo simulation was used to create distributions of transplant benefit, and covariates such as Model for End-stage Liver Disease (MELD) and alpha-fetoprotein (AFP) were combined in regression equations. These equations were then calibrated to create an "MELD equivalent" which matches HCC patients to non-HCC patients having the same numerical MELD score. Median 5 year transplant benefit was 15.12 months (8.75-25.35) for the non-HCC patients, and 28.18 months (15.11-36.38) for the T2-HCC patients (p<0.001). Independent predictors of transplant benefit were MELD score (estimate=0.89, p<0.001) among non-HCC patients, and MELD (estimate=1.14, p<0.001) and logAFP (estimate=-0.46, p<0.001) among HCC patients. The equation "HCC-MELD"=1.27∗MELD - 0.51∗logAFP+4.59 calculates a numerical score for HCC patients, whereby their transplant benefit is equal to that of non-HCC patients with the same numerical value for MELD. We describe a method for calibrating HCC and non-HCC patients according to survival benefit, and propose that this method has the potential, if externally validated, to restore equity to the organ allocation system.

Vitale A ，Volk ML ，De Feo TM ，Burra P ，Frigo AC ，Ramirez Morales R ，De Carlis L ，Belli L ，Colledan M ，Fagiuoli S ，Rossi G ，Andorno E ，Baccarani U ，Regalia E ，Vivarelli M ，Donataccio M ，Cillo U ，Liver Transplantation North Italy Transplant program (NITp) working group ... -  《-》

Liver Transplantation for Nonalcoholic Steatohepatitis in the US: Temporal Trends and Outcomes.

Cholankeril G ，Wong RJ ，Hu M ，Perumpail RB ，Yoo ER ，Puri P ，Younossi ZM ，Harrison SA ，Ahmed A ... -  《-》

Combination of racial/ethnic and etiology/disease-specific factors is associated with lower survival following liver transplantation in African Americans: an analysis from UNOS/OPTN database.

Higher rates of hepatitis C virus (HCV) recurrence and lower response to HCV antiviral therapy contribute to the lower post-liver transplantation (LT) survival among African Americans with HCV. The current study aims to evaluate race/ethnicity-specific and etiology-specific factors contributing to lower post-LT survival among African Americans in the USA. The 2002-2012 United Network for Organ Sharing registry was utilized to evaluate race/ethnicity-specific post-LT survival among patients with HCV, hepatocellular carcinoma (HCC), alcoholic liver disease (ALD), non-alcoholic steatohepatitis, and cryptogenic cirrhosis. From 2002 to 2012, HCV was the leading indication for LT. While African Americans accounted for 9.5% of all LT during this period, they had the lowest overall and etiology-specific five-yr post-LT survival. On multivariate Cox proportional hazards modeling, African Americans had significantly lower post-LT survival compared with non-Hispanic whites among patients with HCV (HR, 1.30; 95% CI, 1.19-1.41), HCC (HR, 1.49; 95% CI, 1.25-1.79), and ALD (HR, 1.52; 95% CI, 1.19-1.94). In conclusion, African Americans had the lowest post-LT survival among patients with HCV, HCC, and ALD. Race/ethnicity and the etiology of chronic liver disease were observed to have a combined detrimental effect leading to lower survival following LT in African Americans.

Wong RJ ，Ahmed A 《-》