title: Living donor liver transplantation in high-risk vs. low-risk patients: optimization using statistical models.
abstract: Living donors represent a recognized alternative for facilitating the access to transplantation in a period of organ shortage. However, which candidates should be preferentially considered for living-donor liver transplantation (LDLT) is debated. The aim of this study was to create statistical models to determine which strategies of selection for LDLT provide the most efficient contribution. The study included 331 patients listed for deceased-donor transplantation (DDLT) and 128 transplanted with living donors. Statistical models predicting the events following listing were created and combined in a multistate model allowing the testing of different strategies of selection for LDLT and to compare their results. Taking 3-yr survival after listing as the principal end-point, selecting the 20% patients at highest risk of death on the waiting list gave better results than selecting the 20% patients at lowest risk of death after LDLT (70% vs. 64%, respectively). These strategies resulted in waiting list mortality rates of 17% and 8%, respectively. One-year survival after LDLT was lower in high-risk patients (85%) than in low-risk patients (91%). However, the 1-yr survival benefit derived from LDLT was 75% in high-risk patients while it was nil in low-risk patients. In conclusion, LDLT is more effective for overcoming the consequences of organ shortage when performed in patients at high risk of death on the waiting list. On an individual basis, the sickest patients are those who derive the most important benefit from LDLT. This study provides incentives for considering LDLT in high-risk patients.
authors.affiliation: Hepatology-INSERM U481, Hospital Beaujon, Clichy, France. francois.durand@bjn.ap-hop-paris.fr
authors.forename: François
authors.initials: F
authors.lastname: Durand
authors.forename: Jacques
authors.initials: J
authors.lastname: Belghiti
authors.forename: Roberto
authors.initials: R
authors.lastname: Troisi
authors.forename: Olivier
authors.initials: O
authors.lastname: Boillot
authors.forename: Adrian
authors.initials: A
authors.lastname: Gadano
authors.forename: Claire
authors.initials: C
authors.lastname: Francoz
authors.forename: Bernard
authors.initials: B
authors.lastname: de Hemptinne
authors.forename: Alain
authors.initials: A
authors.lastname: Mallet
authors.forename: Dominique
authors.initials: D
authors.lastname: Valla
authors.forename: Jean Louis
authors.initials: JL
authors.lastname: Golmard
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D002423:Cause of Death; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D017093:Liver Failure / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000379:methods / Q000401:mortality*; D019520:Living Donors; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D018579:Patient Selection; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018570:Risk Assessment; D012737:Sex Factors; D016019:Survival Analysis; D009927:Tissue and Organ Procurement; D014850:Waiting Lists