Performance of risk prediction models for post-liver transplant patient and graft survival over time.
Given liver transplantation organ scarcity, selection of recipients and donors to maximize post-transplant benefit is paramount. Several scores predict post-transplant outcomes by isolating elements of donor and recipient risk, including the donor risk index, Balance of Risk, pre-allocation score to predict survival outcomes following liver transplantation/survival outcomes following liver transplantation (SOFT), improved donor-to-recipient allocation score for deceased donors only/improved donor-to-recipient allocation score for both deceased and living donors (ID2EAL-D/-DR), and survival benefit (SB) models. No studies have examined the performance of these models over time, which is critical in an ever-evolving transplant landscape. This was a retrospective cohort study of liver transplantation events in the UNOS database from 2002 to 2021. We used Cox regression to evaluate model discrimination (Harrell's C) and calibration (testing of calibration curves) for post-transplant patient and graft survival at specified post-transplant timepoints. Sub-analyses were performed in the modern transplant era (post-2014) and for key donor-recipient characteristics. A total of 112,357 transplants were included. The SB and SOFT scores had the highest discrimination for short-term patient and graft survival, including in the modern transplant era, where only the SB model had good discrimination (C ≥ 0.60) for all patient and graft outcome timepoints. However, these models had evidence of poor calibration at 3- and 5-year patient survival timepoints. The ID2EAL-DR score had lower discrimination but adequate calibration at all patient survival timepoints. In stratified analyses, SB and SOFT scores performed better in younger (< 40 y) and higher Model for End-Stage Liver Disease (≥ 25) patients. All prediction scores had declining discrimination over time, and scores relying on donor factors alone had poor performance. Although the SB and SOFT scores had the best overall performance, all models demonstrated declining performance over time. This underscores the importance of periodically updating and/or developing new prediction models to reflect the evolving transplant field. Scores relying on donor factors alone do not meaningfully inform post-transplant risk.
Shaffer L
，Abu-Gazala S
，Schaubel DE
，Abt P
，Mahmud N
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2024 Scholars' Research Symposium Abstract: Analysis of First 50 Liver Transplants in a Rural Midwest Medical Center.
Chronic liver disease, a progressive deterioration of liver function, has become a significant health problem in the United States. According to the National Vital Statistics Report 2017 from the Center for Disease Control and Prevention, approximately 4.5 million adults have been diagnosed with chronic liver disease and cirrhosis (end-stage liver disease), which is 1.8% of the adult population. Liver transplant (LT) is the only definitive treatment with a long-term survival benefit for patients with end-stage liver disease. Over 9,000 LTs are performed in the United States each year. Avera McKennan Hospital and University Center is home to the only LT center in the state of South Dakota. The first LT was performed in 2016 and since then, 50 LTs have been performed to date. In this study, transplant recipient and donor characteristics were reviewed and compared to national data. Also, the study included an assessment of the overall experience with LT at this center.
This study was IRB approved through Avera McKennan Hospital. A retrospective review of all LTs between November 2016 and July 2022 was performed. Donor information and recipient details were reviewed from a prospectively maintained transplant database. This regional data was then compared to national data using the Scientific Registry of Transplant Recipients (SRTR). Recipient data included age, gender, race/ethnicity, body mass index (BMI), etiology of liver disease, model for end-stage liver disease (MELD) score at transplant, and length of post-transplant hospital stay (LOS). Donor information included age, gender, BMI, cause of death, and cold ischemia time (CIT).
During the study period, 50 LTs were performed. Of these, multi-organ transplants were performed in 5 recipients, all of whom received combined liver and kidney transplants. The most common indication for LT was end-stage liver disease due to alcoholic cirrhosis, which represented the primary diagnosis in 54% of the recipients, vs 35.2% nationally. Hepatocellular carcinoma was present in 20% of the patients. Recipient characteristics included 30 men and 20 women with a median age of 52 years and a median BMI of 28.7 kg/m2 respectively. The most common race/ethnicity was white followed by Native American at 62% and 36%, respectively. The median MELD score at transplant was 33.5 and the median length of post-transplant LOS was 9-days. This center has a cumulative 98% death-censored graft survival rate and 85.7% patient survival rate at one year after transplant. With regards to medical urgency, 42% of the patients received transplants with MELD greater than or equal to 35 and 34% of the patients with MELD 30-34 compared to the national averages of 20.9% and 18.3%, respectively, in 2020. The median donor age was 29-years and median BMI was 26.1 kg/m2. The main cause of donor death was head trauma at 52%, followed by anoxia, and cerebrovascular stroke at 30% and 18%, respectively. Median CIT was 10.77 hours.
LT recipients in South Dakota had higher MELD scores compared to the national average. Native Americans, who represent an underserved population and are under-represented within national transplant database, accounted for more than a third of the total LT recipients. End-stage liver disease, due to alcoholic cirrhosis, was the most common primary pathology necessitating LT exceeding the national rate by 18.8%. Part of the comprehensive liver transplant care was the provision for interventions focused on addressing alcohol relapse and medical adherence through systematic integration of behavioral therapies and addiction treatments.
Hardie K
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