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Mo rtality rate o n th e w aitin g
lis t fo r liv e r trans p lan tatio n

M.Vo ic u le s c u , Marian a Mih aila
C e n te r o f In te rn al Me d ic in e
Fu n d e n i C lin ic al In s titu te B u c h are s t

B ac kg ro u n d

- Liv e r tran s p lan tatio n is n o w re c o g n is e d as a
h ig h ly e ffe c tiv e fo rm o f tre atm e n t fo r p atie n ts w ith
e n d s tag e liv e r d is e as e .
- C u rre n tly , o n e an d fiv e y e ar s u rv iv al rate s are
in e x c e s s o f 8 0% .
- A s a c o n s e q u e n c e o f m an y d e v e lo p m e n ts in all
as p e c ts o f tran s p lan tatio n , in d ic atio n s h av e w id e n e d
an d c o n train d ic atio n s h av e b e c o m e fe w e r .

B ac kg ro u n d

- Th e in c re as e in th e n u m b e r o f p atie n ts re fe rre d
fo r tran s p lan tatio n h as n o t b e e n m atc h e d b y an
in c re as e in d o n o r rate s .

- Th e c o n s e q u e n c e o f th e re lativ e s h o rtag e o f
d o n o rs is :
- m o re p atie n ts are o n the w aitin g lis t fo r
tran s p lan tatio n
- th o s e o n th e w aitin g lis t b e c o m e s ic k e r b e fo re
th e y re c e iv e a g raft
- th e re is the lik e lih o o d o f m o re d e ath s o n
th e w aitin g lis t .

O b je c tiv e s

To u n d e rs tan d th e c au s e s o f d e ath an d als o to
id e n tify m arke rs w h ic h c o u ld d e te rm in e p atie n ts at
h ig h ris k o f d y in g o n th e w aitin g lis t, w e u n d e rto o k a
re tro s p e c tiv e an aly s is o f all p atie n ts (ad u lts an d
c h ild re n ) lis te d b e tw e e n J an u ary 2 0 0 1 an d De c e m b e r
2 0 0 2.

Mate rial and m e th o d (1 ) :

• This is a re tro s p e c tiv e s tu d y ;
• 10 9 p atie n ts w e re ac c e p te d fo r tran s p lan tatio n .


• A g e re p a rtit io n :
- ad u lts (>16 y e ars o ld ): m e an ag e 4 7 +/ .3 y e ars
-2
- c h ild re n (<16 y e ars o ld ): b e tw e e n 4 m o n th s an d
1 5 y e ars

• S e x re pa rt itio n :
- 41 fe m ale (37 .6 1 % )
- 66 m ale (62.3 9 % )


E tio lo g y o f C h ro nic Liv e r Dis e as e :
• c h ro n ic h e p atitis :
- HVB : 24 (22.01% )
- HB V+HDV : 15 (17.76% )
- HC V : 30 (27% )
- HB V+HC V : 8 ( 7. 33% )
• alc o h o lic liv e r d is e as e : 9 (8 .2 5 % )
• Wils o n ’s d is e as e : 8 (7 .3 4 % )
• o th e r 1 5 (1 3 .7 6 % ) :
- au to im m u n e h e p atitis
- p rim ary b iliary c irrho s is
- HHC
- m e tab o lic liv e r d is e as e
- b iliary atre s ia

Re s ults (1) :

- C h ild-P u g h s c o re a t a dm is s io n fo r a ll
g ro u ps :
- A =2 (1 .8 3 % )
- B =76 (6 9 .7 2 % )
- C =31 (2 8 .4 4 % )
- C h ild-P u g h s c o re a t a dm is s io n in
pa tie n ts
w h o die d:
- A =0

Re s ults (2) :

• Mo rta lity ra te :
- 16 p atie n ts in 2 4 m o n th s (9 .7 8 % / e ar)
y
• E tio lo g y o f c h ro n ic liv e r dis e a s e in
de c e a s e d pa tie n ts do e s n o t s e e m to
in flu e n c e the m o rta lity ra te :
- h e p atitis v iru s 1 0 (1 2 .9 8 % )
- alc o h o l 2 (22 .2 2 % )
- Wils o n ’s d is e as e 1 (1 2 ,5 % )
- o th e rs 3 (20% )

Re s ults (3) :

C a us es of death were the following:

- liv e r failu re 9 (5 6 .2 2 % )
- h e p ato re n al s y n d ro m e 4 (2 5 % )
- u p p e r d ig e s tiv e b le e d in g 3 (1 8 .7 8 % )

Dis c us s io ns :

- a ne w s c o re is us e d fo r im p ro v in g the m o rtality
rate in the liv e r tran s p lantatio n w aitin g lis t: the
ME LD s c o re (m o d e l fo r e nd s tag e liv e r d is e as e )
- th e ME LD s c o re is hig h ly p re d ic tiv e fo r
e v aluating th e ris k o f d e ath in p atie nts o n th e
w aiting lis t

ME LD s c o re = [0.957 x lo g e c r (m g / l) + 0.37 x lo g e b il
d
(m g / l) + 1.120 x lo g e (INR) + 0.643] x 10
d

Dis c us s io ns :

Waitin g lis t d ata fo r liv e r trans p lantatio n in th e UK
1990 1991 1992 1993 1994 1995 1996 1997

360 4439 504 577 629 675 872 696
N e w pts
re g is te re d

T ra n s pla n t s 358 421 508 534 620 669 640 671
Die d o n 37 30 42 57 51 56 59 66
a c tiv e lis t
R e m o v e d fro m 19 38 35 41 40 41 47 81
UKTS aA tiv e lis t
S c

Dis c us s io ns :

B lo o d T y pe Year
1995 1996 1997 1998 1999 2000 2001
T o ta l P a tie n t s 10475 12734 14947 17807 21063 23561 25746

De a t h s 829 998 1187 1421 1821 1763 1978
Ra te 1 7 7 ,4 1 5 6 ,4 1 4 3 ,8 1 3 7 ,0 1 4 1 ,9 1 1 7 ,2 1 1 4 ,7

O P a tie n t s 5083 6226 7340 8782 10358 11572 12598

De a t h s 437 513 621 751 915 919 1 ,0 1 4

Ra te 1 8 0 ,6 1 5 3 ,3 1 4 6 ,0 1 4 0 ,8 1 3 9 ,6 1 1 9 ,8 1 1 6 ,6

A P a tie n t s 3744 4635 5366 6370 7549 8533 9273
De a t h s 254 336 384 488 645 589 661
Ra te 1 6 2 ,4 1 5 4 ,5 1 3 3 ,2 1 3 5 ,4 1 4 4 ,5 1 1 1 ,7 1 1 1 ,8

B P a tie n t s 1272 1423 1702 2066 2473 2735 3047
De a t h s 111 116 143 139 208 199 228
Ra te 2 0 2 ,0 1 7 4 ,1 1 6 2 ,3 1 2 1 ,7 1 4 3 ,3 1 1 8 ,0 1 1 5 ,8

Dis c us s io ns :

Re p o rte d d e ath s an d an n u al d e ath rate s p e r 1 00 0 p atie n t y e ars

G e n de r Year
1995 1996 1997 1998 1999 2000 2001
T o ta l P a t ie n t s 10475 12734 14947 17807 21063 23561 25746

De a t hs 829 998 1187 1421 1821 1763 1978
Ra te 1 7 7 ,4 1 5 6 ,4 1 4 3 ,8 1 3 7 ,0 1 4 1 ,9 1 1 7 ,2 1 1 4 ,7

F e m a le P a t ie n t s 4728 5584 6440 7498 8827 9830 10686

De a t hs 356 420 486 601 742 701 830
Ra te 1 6 3 ,2 1 4 5 ,4 1 3 4 ,0 1 3 4 ,2 1 3 5 ,1 1 0 9 ,2 1 1 3 ,1

Ma le
O PTN/ RTR
S P a t ie n t s 5747 7150 8507 10309 12236 13731 15060

Dis c us s io ns :
Patient status Year
1995 1996 1997 1998 1999 2000 2001
Total 5572 7352 9452 11782 14258 16565 18505
1 28 29 15 7 14 14 13
2 103 113 - - - - -
2A - - 17 31 45 63 132
2B - - 136 1952 2656 3027 3032
3 2746 3979 7522 7944 9573 11157 12101
4 1854 2236 - - - - -
Temporarily 841 995 1762 1848 1970 2304 3227
inactive
Total (%) 100% 100% 100% 100% 100% 100% 100%
1 0,5% 0,4% 0,2% 0,1% 0,1% 0,1% 0,1%
2 1,8% 1,5% - - - - -
2A - - 0,2% 0,3% 0,3% 0,4% 0,7%
2B - - 1,4% 16,6% 18,6% 18,3% 16,4%
3 49,3% 54,1% 79,6% 67,4% 87,1% 67,4% 65,4%
4 33,3% 30,4% - - - - -
Temporarily 15,1% 13,5% 18,6% 15,7% 13,6% 13,9% 17,4%
inactive

C o n c lus io ns (1) :

- th e annu al m o rtality rate (9.78% ) is s im ilar
to d ata fro m the lite rature (5-12% )


- th e m o rtality rate is NO T in flu e n c e d b y
e tio lo g y o f c h ro n ic liv e r d is e as e
- th e m o rtality rate is in flu e n c e d b y th e s e v e rity
o f th e d is e as e at ad m is s io n to th e w aitin g lis t


- th e m ain c au s e s o f d e ath are re p re s e n te d b y
liv e r failu re , fo llo w e d b y h e p ato -re n al s y n d ro m e an d
u p p e r d ig e s tiv e b le e d in g
- im p ro v e m e n t o f th e m o rtality rate c o u ld b e
o b tain e d th ro u g h a b e tte r c o n tro l o f th e c au s e s o f
d e ath , b e c au s e th e n u m b e r o f d o n o rs c an n o t b e
in flu e n c e d
- th e p re c o c io u s d iag n o s is o f h e p ato -re n al
s y n d ro m e an d p re v e n tio n o f u p p e r d ig e s tiv e b le e d in g
m ay b e th e o n ly m e as u re s th at c an b e tak e n fo r
re d u c in g m o rtality , b e c au s e liv e r failu re c an n o t b e
p re v e n te d b y m e d ic al m e as u re s


- d e s p ite th e in n o v ativ e u s e o f te c h n iq u e s to
m ake fu lle s t u s e o f th e d o n o r p o o l, s u c h as s p littin g
o f liv e rs an d in c re as in g u s e o f m arg in al liv e rs (th o s e
liv e rs w h e re th e re is d o u b t as to in itial g raft fu n c tio n ),
th e d e m an d fo r tran s p lan tatio n is failin g to m e e t th e
s u p p ly
- m o rtality o n th e w aitin g lis t is a s ig n ific an t
p ro b le m an d is like ly to ris e fu rth e r u n til d o n o r
s h o rtag e c an b e re v e rs e d o r alte rn ativ e s trate g ie s c an
b e in tro d u c e d
- tim in g o f re fe rral fo r c o n s id e ratio n o f
tran s p lan tatio n re m ain s p ro b le m atic


- if p atie n ts are re fe rre d an d lis te d e arly fo r
tran s p lan tatio n th e n , b e c au s e o f th e p e rio p e rativ e
ris k an d s m all e arly m o rtality , th e re is a ris k th e
p atie n t’s life m ig h t b e s h o rte n e d
- th e tran s p lan t c lin ic ian s n e e d to e s tab lis h
g u id e lin e s to d e te rm in e w h e n th e p atie n t’s c h an c e s
o f s u rv iv al are s o lo w th at tran s p lan tatio n b e c o m e s
n o lo n g e r in d ic ate d

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