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Heterotopic Auxiliary Rat Liver Transplantation With Flow-regulated Portal Vein Arterialization in Acute Hepatic Failure
Published on: September 13, 2014
The Landscape of Status 1B by Exception for Pediatric Acute on Chronic Liver Failure-High Risk, High Mortality, and
Leslie A Mataya1,2, Therese Bittermann3,4,5, Hongyan Liu6
1Division of Critical Care Medicine, Lurie Children's Hospital, Chicago, Illinois, USA.
Insights
One-third of children with acute on chronic liver failure (ACLF) receive Status 1B liver transplant listing via exception. These children had similar outcomes to those listed by explicit criteria, suggesting a need for further research.
Area of Science:
- Pediatric Hepatology
- Transplantation Immunology
- Critical Care Medicine
Background:
- Acute on chronic liver failure (ACLF) is a severe condition associated with high mortality due to multiorgan failure.
- Liver transplantation (LT) is a critical intervention for children with ACLF.
Purpose of the Study:
- To compare the characteristics and outcomes of children with ACLF listed for LT under Status 1B using explicit criteria versus exception criteria.
- To investigate regional variations in the utilization of exception criteria for listing children with ACLF.
Main Methods:
- Retrospective analysis of 367 children with ACLF listed as Status 1B for LT between 2007 and 2019 from the United Network for Organ Sharing (UNOS) database.
- Exclusion of children with metabolic diseases and malignancies.
- Comparison of demographic data, organ failure incidence, MELD/PELD scores, transplantation rates, and pre-/post-LT mortality between explicit and exception listing groups.
Main Results:
- 30% (110/367) of children with ACLF were listed under exception criteria.
- No significant differences in age, sex, race/ethnicity, or diagnosis between the groups.
- Exception group had lower incidence of organ failures and MELD/PELD scores at listing and removal, but similar transplantation rates and pre-/post-LT mortality.
- Regional disparities in exception listing utilization were observed, with higher rates in regions 2 and 10.
- Reasons for exception listing included critical illness and high risk of waitlist mortality.
Conclusions:
- Approximately one-third of children with ACLF listed as Status 1B for LT utilize exception criteria.
- Children listed by exception demonstrated comparable pre- and post-transplant mortality to those listed by explicit criteria.
- Further investigation is warranted to elucidate the specific factors contributing to the heightened risk in children listed by exception.
Background:
Acute on chronic liver failure (ACLF) leads to increased mortality from multiorgan failure.
Methods:
Our objective was to evaluate differences in characteristics and outcomes of children with ACLF listed as Status 1B for liver transplantation (LT) by (1) explicit criteria or (2) exception. We identified 367 children with ACLF who were listed Status 1B for LT in the United Network for Organ Sharing (UNOS) database between January 2007 and March 2019. Children with metabolic diseases and malignancies were excluded.
Results:
Of 367 children with ACLF listed as Status 1B, 110 (30%) were listed by exception. There were no differences between groups in age, sex, race/ethnicity, or diagnosis. Incidence of cumulative organ failures and MELD/PELD scores were lower in the exception group at waitlisting and at waitlist removal (all p < 0.05). There were regional differences in exception utilization with regions 2 and 10 having a higher proportion of exception listing (43% and 47% vs. overall 30%, p = 0.03). There was no difference in transplantation rate, recovery without transplant, or pre-/post-LT mortality between groups. Narrative summaries in the exception group cited the critical or refractory nature of the patient's illness, with increased risk of waitlist mortality as reasons for urgent LT.
Conclusion:
Our study showed that one third of children with ACLF listed as Status 1B receive this designation using exception criteria. Children listed by exception had similar pre-/post-LT mortality compared to the explicit group. Further study is needed to understand why these children are at higher risk than expected.
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