title: Mortality Risk Factors Among Patients With Cirrhosis and a Low Model for End-Stage Liver Disease Sodium Score (≤15): An Analysis of Liver Transplant Allocation Policy Using Aggregated Electronic Health Record Data.
abstract: Although the Model for End-Stage Liver Disease sodium (MELD Na) score is now used for liver transplant allocation in the United States, mortality prediction may be underestimated by the score. Using aggregated electronic health record data from 7834 adult patients with cirrhosis, we determined whether the cause of cirrhosis or cirrhosis complications was associated with an increased risk of death among patients with a MELD Na score ≤15 and whether patients with the greatest risk of death could benefit from liver transplantation (LT). Over median follow-up of 2.3 years, 3715 patients had a maximum MELD Na score ≤15. Overall, 3.4% were waitlisted for LT. Severe hypoalbuminemia, hepatorenal syndrome, and hepatic hydrothorax conferred the greatest risk of death independent of MELD Na score with 1-year predicted mortality >14%. Approximately 10% possessed these risk factors. Of these high-risk patients, only 4% were waitlisted for LT, despite no difference in nonliver comorbidities between waitlisted patients and those not listed. In addition, risk factors for death among waitlisted patients were the same as those for patients not waitlisted, although the effect of malnutrition was significantly greater for waitlisted patients (hazard ratio 8.65 [95% CI 2.57-29.11] vs. 1.47 [95% CI 1.08-1.98]). Using the MELD Na score for allocation may continue to limit access to LT.
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.
authors.forename: K
authors.initials: K
authors.lastname: Atiemo
authors.affiliation: Department of Transplantation, London Health Sciences Centre, Western University, London, Ontario, Canada.
authors.forename: A
authors.initials: A
authors.lastname: Skaro
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Division of Hepatology, Department of Medicine, Chicago, IL.
authors.forename: H
authors.initials: H
authors.lastname: Maddur
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Department of Preventive Medicine, Feinberg School of Medicine, Chicago, IL.
authors.forename: L
authors.initials: L
authors.lastname: Zhao
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Department of Preventive Medicine, Feinberg School of Medicine, Chicago, IL.
authors.forename: S
authors.initials: S
authors.lastname: Montag
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Division of Hepatology, Department of Medicine, Chicago, IL.|Department of Preventive Medicine, Feinberg School of Medicine, Chicago, IL.
authors.forename: L
authors.initials: L
authors.lastname: VanWagner
authors.affiliation: Center for Health Information Partnerships, Institute for Public Health and Medicine, Chicago, IL.
authors.forename: S
authors.initials: S
authors.lastname: Goel
authors.affiliation: Center for Health Information Partnerships, Institute for Public Health and Medicine, Chicago, IL.
authors.forename: A
authors.initials: A
authors.lastname: Kho
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.
authors.forename: B
authors.initials: B
authors.lastname: Ho
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL.
authors.forename: R
authors.initials: R
authors.lastname: Kang
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL.|Department of Pediatrics, Feinberg School of Medicine, Chicago, IL.
authors.forename: J L
authors.initials: JL
authors.lastname: Holl
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.
authors.forename: M M
authors.identifier: http://orcid.org/0000-0001-9333-463X
authors.initials: MM
authors.lastname: Abecassis
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Division of Hepatology, Department of Medicine, Chicago, IL.
authors.forename: J
authors.initials: J
authors.lastname: Levitsky
authors.affiliation: Northwestern University Transplant Research Collaborative (NUTORC), Comprehensive Transplant Center (CTC), Feinberg School of Medicine, Chicago, IL.|Center for Healthcare Studies, Institute for Public Health and Medicine, Chicago, IL.
authors.forename: D P
authors.initials: DP
authors.lastname: Ladner
mesh_terms: D057286:Electronic Health Records; D058625:End Stage Liver Disease / Q000401:mortality* / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008103:Liver Cirrhosis / Q000401:mortality* / Q000601:surgery; D016031:Liver Transplantation / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D015233:Models, Statistical; D011379:Prognosis; D040841:Resource Allocation; D012189:Retrospective Studies; D018570:Risk Assessment; D012720:Severity of Illness Index; D012964:Sodium / Q000097:blood; D009927:Tissue and Organ Procurement / Q000379:methods; D014481:United States; D014850:Waiting Lists / Q000401:mortality*
chemical_list: D012964:Sodium
keywords: cirrhosis; classification systems: Model for EndStage Liver Disease (MELD); clinical research/practice; health services and outcomes research; liver transplantation/hepatology; patient characteristics; patient survival