title: Liver transplantation in highest acuity recipients: identifying factors to avoid futility.
abstract: OBJECTIVE
  To identify medical predictors of futility in recipients with laboratory Model of End-Stage Liver Disease (MELD) scores of 40 or more at the time of orthotopic liver transplantation (OLT).
  
  
  BACKGROUND
  Although the survival benefit for transplant patients with the highest MELD scores is indisputable, the medical and economic effort to bring these highest acuity recipients through OLT presents a major challenge for every transplant center.
  
  
  METHODS
  This study was undertaken to analyze outcomes in patients with MELD scores of 40 or more undergoing OLT during the period February 2002 to December 2010. The analysis was focused on futile outcome (3-month or in-hospital mortality) and long-term posttransplant outcome. Independent predictors of futility and failure-free survival were identified and a futility risk model was created.
  
  
  RESULTS
  During the study period, 1522 adult cadaveric OLTs were performed, and 169 patients (13%) had a MELD score of 40 or more. The overall 1, 3, 5, and 8-year patient survivals were 72%, 64%, 60%, and 56%. Futile outcome occurred in 37 patients (22%). MELD score, pretransplant septic shock, cardiac risk, and comorbidities were independent predictors of futile outcome. Using all 4 factors, the futility risk model had a good discriminatory ability (c-statistic 0.75). Recipient age per year, life-threatening postoperative complications, hepatitis C, and metabolic syndrome were independent predictors for long-term survival in nonfutile patients (Harrels c-statistic 0.72).
  
  
  CONCLUSIONS
  Short- and long-term outcomes of recipients with MELD scores of 40 or more are primarily determined by disease-specific factors. Cardiac risk, pretransplant septic shock, and comorbidities are the most important predictors and can be used for risk stratification in these highest acuity recipients.
authors.affiliation: Department of *Surgery †The Dumont-UCLA Transplant Center, and Departments of ‡Hepatology ¶Cardiology §Biomathematics, David Geffen School of Medicine at University of California, Los Angeles, Los Angeles ∥Department of Hepatology and Gastroenterology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California.
authors.forename: Henrik
authors.initials: H
authors.lastname: Petrowsky
authors.forename: Abbas
authors.initials: A
authors.lastname: Rana
authors.forename: Fady M
authors.initials: FM
authors.lastname: Kaldas
authors.forename: Anuj
authors.initials: A
authors.lastname: Sharma
authors.forename: Johnny C
authors.initials: JC
authors.lastname: Hong
authors.forename: Vatche G
authors.initials: VG
authors.lastname: Agopian
authors.forename: Francisco
authors.initials: F
authors.lastname: Durazo
authors.forename: Henry
authors.initials: H
authors.lastname: Honda
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Gornbein
authors.forename: Victor
authors.initials: V
authors.lastname: Wu
authors.forename: Douglas G
authors.initials: DG
authors.lastname: Farmer
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Hiatt
authors.forename: Ronald W
authors.initials: RW
authors.lastname: Busuttil
mesh_terms: D002140:California / Q000453:epidemiology; D018572:Disease-Free Survival; D005260:Female; D005500:Follow-Up Studies; D006084:Graft Rejection / Q000453:epidemiology / Q000517:prevention & control*; D006085:Graft Survival; D017052:Hospital Mortality / Q000639:trends; D006801:Humans; D015994:Incidence; D017093:Liver Failure / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation; D008297:Male; D018447:Medical Futility; D008875:Middle Aged; D011183:Postoperative Complications; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome