title: Variable Use of Model for End-Stage Liver Disease Exception Points in Patients With Neuroendocrine Tumors Metastatic to the Liver and Its Impact on Patient Outcomes.
abstract: BACKGROUND
  The role of liver transplantation in management of patients with metastatic neuroendocrine tumors (NETs) is controversial. Because many such patients have low waitlist priority, centers may apply for model for end-stage liver disease (MELD) exception points to increase likelihood of receiving a liver transplant. No formal criteria exist for application or receipt of exception points for this indication. Few studies have assessed waitlist and posttransplantation outcomes in patients with metastatic NETs, and none examined the impact of exception points.
  
  
  METHODS
  We analyzed all adult patients waitlisted for liver transplantation for metastatic NETs between February 27, 2002, and June 4, 2014, and fit a multivariable model to evaluate the association between exception point status and posttransplantation outcomes.
  
  
  RESULTS
  There was variable use of MELD exception points across the United Network for Organ Sharing regions. Patients with an approved MELD exception were nearly twice as likely to be transplanted as those without exceptions (70.8% vs 39.1%, P < 0.001), and half as likely to be removed for death or clinical deterioration (9.2% vs 18.2%, P = 0.046). In multivariable models, posttransplantation survival was not associated with receipt of exception points, whereas risk of posttransplant mortality increased significantly with elevated serum total bilirubin level at transplantation. The 3-year posttransplant patient survival was 78% in transplant recipients with metastatic NETs whose total bilirubin level at transplantation was 1.3 mg/dL or less, compared to 36% in those with total bilirubin greater than 1.3 mg/dL.
  
  
  CONCLUSIONS
  Serum total bilirubin may serve as a predictor of poor posttransplant survival in patients with metastatic NETs and could help risk-stratify patients applying for MELD exception points.
authors.forename: Yael R
authors.initials: YR
authors.lastname: Nobel
authors.forename: David S
authors.initials: DS
authors.lastname: Goldberg
mesh_terms: D000328:Adult; D001663:Bilirubin / Q000097:blood; D015415:Biomarkers / Q000097:blood; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D008113:Liver Neoplasms / Q000097:blood / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018358:Neuroendocrine Tumors / Q000097:blood / Q000401:mortality / Q000556:secondary* / Q000601:surgery*; D018579:Patient Selection; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D009927:Tissue and Organ Procurement; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014850:Waiting Lists / Q000401:mortality
chemical_list: D015415:Biomarkers; D001663:Bilirubin