High-MELD living-donor liver transplants show acceptable outcomes, similar to deceased-donor transplants, offering hope for reducing donor shortages.
Transplanting liver tissue from a healthy living person to a patient in serious need is safe, increases the donor pool, and saves lives, Thomas G. Cotter, MD, MSCP, and colleagues report in Liver Transplantation.
“Living-donor liver transplantation among patients with MELD scores of 25 or above can be done safely,” Dr. Cotter notes. “The procedure can have outcomes comparable to those in lower Model for End-Stage Liver Disease (MELD)living-donor recipients and in similarly sick deceased-donor recipients.”
Many Liver Transplant Candidates Die on the Waitlist
Building on their previous research that showed positive living-donor liver transplant (LDLT) outcomes in the US in recent years, Dr. Cotter and colleagues analyzed 2010-2021 Organ Procurement & Transplantation Network (OPTN) and United Network for Organ Sharing (UNOS) data from adult LDLT recipients.
The researchers stratified LDLT cases into low- (<15), intermediate- (15-24), and high-MELD (≥25) recipient groups. Of 3,558 LDLTs, 45.1% were low-MELD, 45.4% were intermediate-MELD, and 9.5% were high-MELD. Over the 12-year study period, the annual number of LDLTs increased from 282 to 569, and the proportion of high-MELD LDLTs increased from 3.9% to 7.7%.
They also stratified LDLT facility volume into low (<3 LDLTs per year), medium (3-20 LDLTs per year), and high (>20 LDLTs per year), and found that 47.8% of high-MELD LDLTs were performed in high-volume centers, and 42.1% took place in intermediate-volume centers.
The authors compared outcomes between MELD-stratified LDLT groups as well as between MELD-stratified LDLT and donation-after-brain-death liver transplant (DBDLT) recipients. Using Kaplan-Meier analysis, they compared graft survival rates; and using multivariable Cox proportional hazards modeling, they identified factors linked with graft outcomes.
Although graft survival was significantly higher in low-MELD than in high-MELD LDLT recipients (adjusted HR, 1.36, 95% CI, 1.03-1.79), 5-year survival in both groups was over 70.0%.
Five-year graft survival in high-MELD recipients of grafts from living versus dead donors were similar: 71.5% and 77.3%, respectively (adjusted HR, 1.25; 95% CI, 0.99-1.58; Figure).
For high-MELD LDLT recipients, facility volume (medium volume: adjusted HR, 0.21; 95% CI, 0.08-0.56; and high volume: adjusted HR, 0.41; 95% CI, 0.19-0.87) and recipient need for life support (adjusted HR, 3.63; 95% CI, 1.24-10.57) were significantly linked with risk for graft failure.
Expanding High-MELD LDLT Can Decrease Mortality
“In the US, patients with MELD 25-28 are now waiting longer for deceased-donor offers,” Dr. Cotter says, yet high-MELD LDLT is performed in only a few transplant centers. “We are hopeful that our excellent transplant outcomes among high-MELD living-donor transplant recipients may save lives by incentivizing practice expansion and by keeping more deceased donors available in the pool.”
He and his coauthors recommend that more centers with experience performing the procedure consider expanding their LDLT services to high-MELD patients, to increase the donor pool and decrease waitlist mortality risk.
“Living-donor liver transplant is a particularly great option for candidates who need a liver transplant but who may not be competitive enough in a MELD-score-based donor allocation system,” Dr. Cotter suggests. “In future research, we hope to determine if an upper MELD score threshold exists.”