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Combined heart-liver transplantation in the MELD era: do waitlisted patients require exception status?
J M Schaffer1, P Chiu, S K Singh
1Department of Cardiothoracic Surgery, Stanford Hospital and Clinics, Stanford, CA.
Insights
Combined heart-liver transplants (HLT) show improved survival. However, HLT candidates face higher waitlist mortality than isolated heart or liver transplant candidates, suggesting allocation systems may underestimate their risk.
Area of Science:
- Transplantation Medicine
- Organ Allocation Systems
- Cardiovascular and Hepatic Physiology
Background:
- Combined heart-liver transplant (HLT) is a critical option for patients with simultaneous end-stage heart and liver failure.
- Current organ allocation systems may not adequately address the unique risks faced by HLT candidates.
Purpose of the Study:
- To compare waitlist mortality and post-transplant survival for combined heart-liver transplant (HLT) candidates versus isolated heart transplant (HRT) and isolated liver transplant (LIV) candidates.
- To evaluate the effectiveness of current organ allocation policies for patients requiring HLT.
Main Methods:
- Analysis of United Network for Organ Sharing database data.
- Examination of cumulative incidences of transplant and mortality in waitlisted candidates.
- Stratification by disease severity and multivariable survival modeling.
Main Results:
- HLT candidates exhibited significantly higher waitlist mortality (26% at 1 year) compared to HRT (12%) and LIV (14%) candidates.
- Post-transplant survival did not differ significantly between HLT and isolated transplant recipients.
- HLT was associated with enhanced survival (HR, 0.41; P=.008), while HRT alone was not.
- HLT recipients were more likely to receive local organ allocation (90%) than HRT (60%) or LIV (73%) candidates.
Conclusions:
- The current organ allocation systems may underestimate the mortality risk for patients awaiting combined heart-liver transplantation.
- Improved risk assessment and allocation strategies are needed for HLT candidates to mitigate waitlist mortality.
Abstract:
Combined heart-liver transplant (HLT) is a viable therapy for patients with concomitant end-stage heart and liver failure. Using data from the United Network for Organ Sharing database, we examined the cumulative incidences of transplant and mortality in waitlisted candidates for HLT, isolated heart transplant (HRT) and isolated liver transplant (LIV) in the Model for End-Stage Liver Disease era. The incidence of waitlist mortality was higher in HLT candidates than in HRT candidates (p = 0.001, 26% vs. 12% at 1 year) or LIV candidates (p = 0.005, 26% vs. 14% at 1 year). These differences persisted after stratifying by disease severity. Posttransplant survival was not significantly different between HLT and HRT recipients or between HLT and LIV recipients. In a multivariable model, undergoing HLT was associated with enhanced survival for HLT candidates (hazard ratio, 0.41; confidence interval, 0.21-0.79; p = 0.008), but undergoing HRT alone was not. Interestingly, 90% of HLT recipients were allocated an organ locally, compared to 60% of HRT candidates and 73% of LIV candidates (both p < 0.001). These data suggest that the current cardiac and liver allocation systems may underestimate the risk of death for patients with concomitant end-stage heart and liver failure on the HLT waitlist.
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