title: Survival outcomes in liver transplant recipients with Model for End-stage Liver Disease scores of 40 or higher: a decade-long experience.
abstract: BACKGROUND
  The Model for End-stage Liver Disease (MELD) has been used as a prognostic tool since 2002 to predict pre-transplant mortality. Increasing proportions of transplant candidates with higher MELD scores, combined with improvements in transplant outcomes, mandate the need to study surgical outcomes in patients with MELD scores of ≥40.
  
  
  METHODS
  A retrospective longitudinal analysis of United Network for Organ Sharing (UNOS) data on all liver transplantations performed between February 2002 and June 2011 (n = 33,398) stratified by MELD score (<30, 30-39, ≥40) was conducted. The primary outcomes of interest were short- and longterm graft and patient survival. A Kaplan-Meier product limit method and Cox regression were used. A subanalysis using a futile population was performed to determine futility predictors.
  
  
  RESULTS
  Of the 33,398 transplant recipients analysed, 74% scored <30, 18% scored 30-39, and 8% scored ≥40 at transplantation. Recipients with MELD scores of ≥40 were more likely to be younger (P < 0.001), non-White and to have shorter waitlist times (P < 0.001). Overall patient survival correlated inversely with increasing MELD score; this trend was consistent for both short-term (30 days and 90 days) and longterm (1, 3 and 5 years) graft and patient survival. In multivariate analysis, increasing age, African-American ethnicity, donor obesity and diabetes were negative predictors of survival. Futility predictors included patient age of >60 years, obesity, peri-transplantation intensive care unit hospitalization with ventilation, and multiple comorbidities.
  
  
  CONCLUSIONS
  Liver transplantation in recipients with MELD scores of ≥40 offers acceptable longterm survival outcomes. Futility predictors indicate the need for prospective follow-up studies to define the population to gain the highest benefit from this precious resource.
authors.affiliation: Department of Genetics & Genomic Science and Gastroenterology, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
authors.forename: Hina J
authors.initials: HJ
authors.lastname: Panchal
authors.affiliation: Department of Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA.
authors.forename: Joel B
authors.initials: JB
authors.lastname: Durinka
authors.affiliation: Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA.
authors.forename: Jeromy
authors.initials: J
authors.lastname: Patterson
authors.affiliation: Department of Surgery, Albert Einstein Medical Center, Philadelphia, PA, USA.
authors.forename: Farah
authors.initials: F
authors.lastname: Karipineni
authors.affiliation: Department of Surgery, Hofstra-North Shore LIJ School of Medicine, Hempstead, NY, USA.
authors.forename: Sarah
authors.initials: S
authors.lastname: Ashburn
authors.affiliation: Department of Transplantation, North Shore LIJ Hospital, Manhasset, NY, USA.
authors.forename: Eric
authors.initials: E
authors.lastname: Siskind
authors.affiliation: Department of Transplantation, University of Toledo Medical Center, Toledo, OH, USA.
authors.forename: Jorge
authors.initials: J
authors.lastname: Ortiz
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D064591:Allografts; D016009:Chi-Square Distribution; D016208:Databases, Factual; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D053208:Kaplan-Meier Estimate; D008107:Liver Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D018579:Patient Selection; D011237:Predictive Value of Tests; D016016:Proportional Hazards Models; D012189:Retrospective Studies; D012307:Risk Factors; D017741:Survivors / Q000706:statistics & numerical data; D013997:Time Factors; D009927:Tissue and Organ Procurement; D066027:Transplant Recipients / Q000706:statistics & numerical data; D016896:Treatment Outcome; D014481:United States; D055815:Young Adult