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In this review article, we discuss the model for end-stage liver disease (MELD) score and its dual purpose in general and transplant hepatology. As the landscape of liver disease and transplantation has evolved considerably since the advent of the MELD score, we summarise emerging concepts, methodologies, and technologies that may improve mortality prognostication in the future. Finally, we explore how these novel concepts and technologies may be incorporated into clinical practice.

Background & aimsPolicy changes in the United States have lengthened overall waiting times for patients with hepatocellular carcinoma (HCC). We investigated temporal trends in utilization of locoregional therapy (LRT) and associated waitlist outcomes among liver transplant (LT) candidates in the United States.MethodsData for primary adult LT candidates listed from 2003 to 2018 who received HCC exception were extracted from the Organ Procurement and Transplantation Network database. Explant histology was examined, and multivariable competing risk analysis was used to evaluate the association between LRT type and waitlist dropout.ResultsThere were 31,609 eligible patients with at least 1 approved HCC exception, and 34,610 treatments among 24,145 LT candidates. The proportion with at least 1 LRT recorded increased from 42.3% in 2003 to 92.4% in 2018. Chemoembolization remains the most frequent type, followed by thermal ablation, with a notable increase in radioembolization from 3% in 2013 to 19% in 2018. An increased incidence of LRT was observed among patients with tumor burden beyond Milan criteria, higher α-fetoprotein level, and more compensated liver disease. Receipt of any type of LRT was associated with a lower risk of waitlist dropout; there was no significant difference by number of LRTs. In inverse probability of treatment weighting-adjusted analysis, radioembolization or ablation as the first LRT was associated with a reduced risk of waitlist dropout compared with chemoembolization.ConclusionsIn a large nationwide cohort of LT candidates with HCC, LRT, and in particular radioembolization, increasingly was used to bridge to LT. Patients with greater tumor burden and those with more compensated liver disease received more treatments while awaiting LT. Bridging LRT was associated with a lower risk of waitlist dropout.

BackgroundAccurate prediction of outcome among liver transplant candidates with hepatocellular carcinoma (HCC) remains challenging. We developed a prediction model for waitlist dropout among liver transplant candidates with HCC.MethodsThe study included 18,920 adult liver transplant candidates in the United States listed with a diagnosis of HCC, with data provided by the Organ Procurement and Transplantation Network. The primary outcomes were 3-, 6-, and 12-month waitlist dropout, defined as removal from the liver transplant waitlist due to death or clinical deterioration.ResultsUsing 1,181 unique variables, the random forest model and Spearman's correlation analyses converged on 12 predictive features involving 5 variables, including AFP (maximum and average), largest tumor size (minimum, average, and most recent), bilirubin (minimum and average), INR (minimum and average), and ascites (maximum, average, and most recent). The final Cox proportional hazards model had a concordance statistic of 0.74 in the validation set. An online calculator was created for clinical use and can be found at: http://hcclivercalc.cloudmedxhealth.com/.ConclusionIn summary, a simple, interpretable 5-variable model predicted 3-, 6-, and 12-month waitlist dropout among patients with HCC. This prediction can be used to appropriately prioritize patients with HCC and their imminent need for transplant.

The liver transplantation (LT) population is aging, with the need for transplant being driven by the growing prevalence of nonalcoholic steatohepatitis (NASH). Older LT recipients with NASH may be at an increased risk for adverse outcomes after LT. Our objective is to characterize outcomes in these recipients in a large multicenter cohort. All primary LT recipients ≥65 years from 2010 to 2016 at 13 centers in the Re-Evaluating Age Limits in Transplantation (REALT) consortium were included. Of 1023 LT recipients, 226 (22.1%) were over 70 years old, and 207 (20.2%) had NASH. Compared with other LT recipients, NASH recipients were older (68.0 versus 67.3 years), more likely to be female (47.3% versus 32.8%), White (78.3% versus 68.0%), Hispanic (12.1% versus 9.2%), and had higher Model for End-Stage Liver Disease-sodium (21 versus 18) at LT (P

The Model for End-Stage Liver Disease (MELD) score, which estimates mortality within 90 days, determines priority for liver transplantation (LT). However, longer-term outcomes on the wait list for patients who are initially listed with low MELD scores are not well characterized. All adults listed for primary LT at a single, high-volume center from 2005 to 2012 with an initial laboratory MELD score of 22 or lower were evaluated. Excluded were those patients listed with MELD exception points who underwent living donor liver transplantation (LDLT) or transplantation at another center, or who were removed from the wait list for nonmedical reasons. Outcomes and causes of death were identified by United Network for Organ Sharing, the National Death Index, and an electronic medical record review. Multivariate competing risk analysis evaluated predictors of death compared to deceased donor liver transplantation (DDLT); 893 patients were listed from 2005 to 2012. By the end of follow-up, 27% had undergone DDLT, and 31% were removed from the wait list for death or clinical deterioration. In a competing risks assessment, only MELD score of 6-9, older age, lower serum albumin, lower body mass index, and diabetes conferred an increased risk of wait-list dropout compared to DDLT. Listing for simultaneous liver-kidney transplantation was protective against wait-list dropout. Of the patients included, 275 patients died or were delisted for being too sick; 87% of the identifiable causes of death were directly related to end-stage liver disease or hepatocellular carcinoma. In conclusion, patients with low listing MELD scores remain at a significant risk for death due to liver-related causes and may benefit from early access to transplantation, such as LDLT or acceptance of high-risk donor livers. Predictors of death compared to transplantation may allow for early identification of patients who are at risk for wait-list mortality.

Background: Donors with hyperbilirubinemia are often not utilized for liver transplantation (LT) due to concerns about potential liver dysfunction and graft survival. The potential to mitigate organ shortages using such donors remains unclear. Methods: This study analyzed adult deceased donor data from the United Network for Organ Sharing database (2002–2022). Hyperbilirubinemia was categorized as high total bilirubin (3.0–5.0 mg/dL) and very high bilirubin (≥5.0 mg/dL) in brain‐dead donors. We assessed the impact of donor hyperbilirubinemia on 3‐month and 3‐year graft survival, comparing these outcomes to donors after circulatory death (DCD). Results: Of 138 622 donors, 3452 (2.5%) had high bilirubin and 1999 (1.4%) had very high bilirubin levels. Utilization rates for normal, high, and very high bilirubin groups were 73.5%, 56.4%, and 29.2%, respectively. No significant differences were found in 3‐month and 3‐year graft survival between groups. Donors with high bilirubin had superior 3‐year graft survival compared to DCD (hazard ratio.83, p =.02). Factors associated with inferior short‐term graft survival included recipient medical condition in intensive care unit (ICU) and longer cold ischemic time; factors associated with inferior long‐term graft survival included older donor age, recipient medical condition in ICU, older recipient age, and longer cold ischemic time. Donors with ≥10% macrosteatosis in the very high bilirubin group were also associated with worse 3‐year graft survival (p =.04). Discussion: The study suggests that despite many grafts with hyperbilirubinemia being non‐utilized, acceptable post‐LT outcomes can be achieved using donors with hyperbilirubinemia. Careful selection may increase utilization and expand the donor pool without negatively affecting graft outcome. [ABSTRACT FROM AUTHOR]

Background: Despite advancements in liver transplantation (LT) over the past two decades, liver re‐transplantation (re‐LT) presents challenges. This study aimed to assess improvements in re‐LT outcomes and contributing factors. Methods: Data from the United Network for Organ Sharing database (2002–2021) were analyzed, with recipients categorized into four‐year intervals. Trends in re‐LT characteristics and postoperative outcomes were evaluated. Results: Of 128,462 LT patients, 7254 received re‐LT. Graft survival (GS) for re‐LT improved (91.3%, 82.1%, and 70.8% at 30 days, 1 year, and 3 years post‐LT from 2018 to 2021). However, hazard ratios (HRs) for GS remained elevated compared to marginal donors including donors after circulatory death (DCD), although the difference in HRs decreased in long‐term GS. Changes in re‐LT causes included a reduction in hepatitis C recurrence and an increase in graft failure post‐primary LT involving DCD. Trends identified included recent decreased cold ischemic time (CIT) and increased distance from donor hospital in re‐LT group. Meanwhile, DCD cohort exhibited less significant increase in distance and more marked decrease in CIT. The shortest CIT was recorded in urgent re‐LT group. The highest Model for End‐Stage Liver Disease score was observed in urgent re‐LT group, while the lowest was recorded in DCD group. Analysis revealed shorter time interval between previous LT and re‐listing, leading to worse outcomes, and varying primary graft failure causes influencing overall survival post‐re‐LT. Discussion: While short‐term re‐LT outcomes improved, challenges persist compared to DCD. Further enhancements are required, with ongoing research focusing on optimizing risk stratification models and allocation systems for better LT outcomes. [ABSTRACT FROM AUTHOR]