Liver Transplants: Transplanting the Sickest Patients First Provides the Best Outcomes
Summary
- Donor livers are allocated first to the sickest patients for transplant.
- Miller School digestive health and liver disease specialist Dr. David Goldberg conducted a study to assess that system.
- Dr. Goldberg’s work verified that the current system minimizes pre-transplant mortality.
For years, transplant hepatologists have debated the ideal ways to allocate scarce donor livers to give patients the best chances for long-term survival. In the current system, the sickest patients move to the front of the line. However, many physicians have asked whether transplant preference should be given to those who receive the greatest survival benefit, including increased lifespan and improved quality of life.
Now, in a study published in the journal Hepatology, David Goldberg, M.D., and colleagues, have shown that the current system is the most effective.
“I have been a vocal advocate for changing the system,” said Dr. Goldberg, associate professor in the Division of Digestive Health and Liver Diseases at the University of Miami Miller School of Medicine. “But the data tell a different story. While our models showed a slightly increased post-transplant survival rate under a modified survival benefit-based approach, the difference is negligible, and there’s potential to decrease the overall number of transplants.”
Liver Transplant Simulation Models
Liver transplants can produce almost miraculous results, but there aren’t enough organs. Some patients die waiting. Under the current system, each patient is prioritized based on their Model for End-Stage Liver Disease (MELD) score, which assesses their liver disease severity and how soon they will need a transplant. A MELD score of 40 would indicate the patient has a roughly 70% to 80% chance of dying in the subsequent three months. A score of 10 or lower equates to a 5% to 10% risk of three-month mortality.
Still, many hepatologists felt priority should be given to patients who had the greatest chance for long-term survival (up to five years after transplant). The problem has been predicting long-term survival.
To remedy this, Dr. Goldberg and his co-authors, including Ezekiel Emanuel, M.D., Ph.D., a medical ethicist at the University of Pennsylvania, developed a series of models to predict intermediate and long-term transplant survival and simulate the impact of liver allocation changes.
“We used our models to estimate how long each patient was expected to live, both before and after transplant, calculated the difference and re-ranked them,” said Dr. Goldberg. “We wanted to see whether we could develop a better system that saves more lives.”
Pre-Transplant Survival Difference
Over a five-year horizon, the average post-transplant survival under the revised system was quite small: 4.24 years, compared to 4.19 years with the current approach. However, the model also predicted a decrease in the number of transplants and an increase in waitlist mortality—as many as 400 patients a year.
Though this is not what we expected, it does validate the existing system, and we can now focus our attention on other important issues.
Dr. David Goldberg
Dr. Goldberg notes that, to some degree, survival benefit has always been built into the current system because the organ shortage requires transplant centers to ration organs to the patients who are expected to have good post-transplant outcomes. Patients must undergo batteries of tests to even qualify for the transplant list. This process is designed to ensure recipients do not have major heart disease or other serious health issues.
“The study found that we already do a good job of selecting transplant candidates,” said Dr. Goldberg. “Ultimately, when we looked at the survival difference following transplant, it was quite small. However, the survival difference pre-transplant was astronomical.”
The study’s results surprised the authors, many of whom had advocated for survival benefit over sickest-first. Even though the group had proven themselves wrong, they embraced the findings.
“This is how science works,” said Dr. Goldberg. “You test your hypothesis, and you adhere to the results. Though this is not what we expected, it does validate the existing system, and we can now focus our attention on other important issues.”
Tags: Division of Digestive Health and Liver Diseases, Dr. David Goldberg, liver transplant, Liver Transplantation