NEW YORK (Reuters Health) - Liver transplant recipients whose indication for transplant was hepatitis C virus (HCV) cirrhosis have markedly poorer survival compared to patients transplanted for alcoholic liver disease (ALD), researchers have found.
According to Dr. Michael R. Lucey of the University of Wisconsin, Madison and colleagues: “Except in patients with very low or very high Model for End-Stage Liver Disease (MELD) scores, HCV status has a significant negative impact on the survival benefit of liver transplantation. In contrast, the presence of ALD does not influence liver transplant survival benefit.”
In their study, the researchers considered the effect of etiology and severity of underlying liver disease (HCV infection and ALD) on the transplant survival benefit, which encompasses both pre- and post-transplant events -- something that has not been done previously, they note.
They analyzed data from the Scientific Registry of Transplant Recipients on 38,899 adults placed on the U.S. transplant waiting list for deceased donor liver transplantation between September 2001 and December 2006. Subjects were classified into one of four cells of an HCV x ALD 2x2 table according to their status with regard to these conditions.
Overall, 27.8% of the study cohort had ALD and 42.5% had were HCV positive.
According to a report in the August issue of Hepatology, patients with HCV infection had increased waiting list mortality (HR, 1.19) and post-transplant mortality (HR, 1.26) compared to HCV-negative patients, and this effect was greater in patients with both HCV infection and ALD.
The survival benefit of liver transplantation for patients with HCV was decreased at intermediate MELD scores of 9-29 (15% to 33% increased hazard of death) but increased at MELD scores greater than 30 (41% survival benefit).
In contrast, ALD had no effect on mortality for patients on the waiting list or who had undergone a liver transplant and having ALD did not influence the survival benefit of transplantation at any MELD score, the researchers found.
In an editorial published with the study, Dr. Sumeet K. Asrani and colleagues from the Mayo Clinic College of Medicine, Rochester, Minnesota, discuss the implications of these findings if a “benefit-based transplant policy” were to be adopted in the face of an organ shortage that mandates rationing of a scarce resource.
The data, they write, suggest that “compared to patients with ALD who have comparable MELD score, patients with HCV should be given a lower priority when their MELD is intermediate (score of 9 to 29), whereas patients with HCV who have higher MELD score should be given an even higher priority than candidates at the same MELD score with another diagnosis.”
For such a benefit-based transplant policy to be implemented, Dr. Asrani and colleagues note, the transplant community “must be willing to accept this departure from the traditional thinking: because some patients with hepatitis C will experience poor outcome, they will be placed at lower priority than patients without HCV who are faced with the same (or even lower) risk of death while waiting.”
Summing up, Dr. Asrani and co-authors say this study is “an important step” in the continued debate on which variables matter in predicting survival benefit of liver transplantation and whether an organ allocation system based on predicted survival benefit can be equitably implemented.
Reference:
Hepatology 2009;50:352-354,400-406.
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