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Published on: July 3, 2013
Renal Function Parameters and Serum Sodium Enhance Prediction of Wait-List Outcomes in Pediatric Liver
Leanne Thalji1, Nassir M Thalji2, Julie K Heimbach3
1Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMN.
Insights
The Pediatric End-Stage Liver Disease (PELD) score may underestimate mortality risk in children awaiting liver transplantation (LT). Incorporating renal function and serum sodium levels improves prediction of wait-list outcomes, potentially optimizing LT prioritization.
Area of Science:
- Pediatric Hepatology
- Transplantation Medicine
- Nephrology
Background:
- The Pediatric End-Stage Liver Disease (PELD) score is used for liver transplantation (LT) prioritization.
- Concerns exist that PELD underestimates mortality risk in pediatric LT candidates.
- Renal dysfunction and serum sodium disturbances are known negative prognosticators not included in PELD.
Purpose of the Study:
- To evaluate the effect of renal dysfunction and serum sodium on 90-day wait-list death/deterioration in pediatric LT candidates (<12 years).
- To assess if incorporating these parameters improves prediction compared to the PELD score alone.
Main Methods:
- Retrospective analysis of 4,765 pediatric patients (<12 years) listed for isolated LT in the US (2002-2018).
- Evaluated estimated glomerular filtration rate (eGFR), dialysis status, and serum sodium as predictors of 90-day outcomes.
- Developed a multivariable model including PELD, eGFR, dialysis, and sodium.
Main Results:
- 4.8% of patients died or deteriorated within 90 days of listing.
- Lower eGFR and dialysis were significant univariate predictors of 90-day death/deterioration.
- Serum sodium was a significant nonlinear predictor, with risk increased at both extremes.
- The multivariable model incorporating PELD, eGFR, dialysis, and sodium showed improved performance and calibration over PELD alone.
Conclusions:
- Listing eGFR, dialysis, and serum sodium are potent, independent predictors of 90-day wait-list outcomes in pediatric LT candidates.
- These factors capture risks not accounted for by the PELD score.
- Incorporating these variables may improve risk stratification, optimize LT prioritization, and reduce reliance on exceptions.
Background And Aims:
Reliance on exception points to prioritize children for liver transplantation (LT) stems from concerns that the Pediatric End-Stage Liver Disease (PELD) score underestimates mortality. Renal dysfunction and serum sodium disturbances are negative prognosticators in adult LT candidates and various pediatric populations, but are not accounted for in PELD. We retrospectively evaluated the effect of these parameters in predicting 90-day wait-list death/deterioration among pediatric patients (<12 years) listed for isolated LT in the United States between February 2002 and June 2018.
Approach And Results:
Among 4,765 patients, 2,303 (49.3%) were transplanted, and 231 (4.8%) died or deteriorated beyond transplantability within 90 days of listing. Estimated glomerular filtration rate (eGFR) (hazard ratio [HR] 1.09 per 5-unit decrease, 95% confidence interval [CI] 1.06-1.10) and dialysis (HR 7.24, 95% CI 3.57-14.66) were univariate predictors of 90-day death/deterioration (P < 0.001). The long-term benefit of LT persisted in patients with renal dysfunction, with LT as a time-dependent covariate conferring a 2.4-fold and 17-fold improvement in late survival among those with mild and moderate-to-severe dysfunction, respectively. Adjusting for PELD, sodium was a significant nonlinear predictor of outcome, with 90-day death/deterioration risk increased at both extremes of sodium (HR 1.20 per 1-unit decrease below 137 mmol/L, 95% CI 1.16-1.23; HR per 1-unit increase above 137 mmol/L 1.13, 95% CI 1.10-1.17, P < 0.001). A multivariable model incorporating PELD, eGFR, dialysis, and sodium demonstrated improved performance and superior calibration in predicting wait-list outcomes relative to the PELD score.
Conclusions:
Listing eGFR, dialysis, and serum sodium are potent, independent predictors of 90-day death/deterioration in pediatric LT candidates, capturing risk not accounted for by PELD. Incorporation of these variables into organ allocation systems may highlight patient subsets with previously underappreciated risk, augment ability of PELD to prioritize patients for transplantation, and ultimately mitigate reliance on nonstandard exceptions.
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