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Int. J. Surg., Feb 05 2025, | https://doi.org/10.1097/JS9.0000000000002280 Predicting futile outcomes following deceased donor liver transplantation in non-Hcc patients with MELD-Na score above 30: a retrospective international multicenter cohort study

Jo, Hye-Sung MD, PhD^a; Yoon, Young-in MD, PhD^b; Kim, Ki-Hun MD, PhD^b; Tabrizian, Parissa MD, MSc^c; Marino, Rebecca MD^c; Marin-Castro, Pedro MD^d; Andraus, Wellington MD^d; Kim, Jongman MD, PhD^e; Choi, Gyu-Seong MD, PhD^e; Kim, Deok-Gie MD^f; Joo, Dong Jin MD, PhD^f; Florez-Zorrilla, Carlos MD^g; Balci, Deniz MD, PhD^h; Petrowsky, Henrik MD, FEBS, FACSⁱ; Halazun, Karim J MD, FACS^j,*; Kim, Dong-Sik MD, PhD^a,*

^a Division of HBP Surgery and Liver Transplantation, Department of Surgery, Korea University College of Medicine, Seoul, Republic of Korea
^b Department of Surgery, College of Medicine University of Ulsan, Asan Medical Center, Seoul, Republic of Korea
^c Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY, USA
^d Liver and Abdominal Organs Transplantation Division, Department of Gastroenterology, Hospital das Clínicas da Faculdade de Medicina de São Paulo (HC-FMUSP), São Paulo, Brazil
^e Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
^f Department of Surgery, The Research Institute for Transplantation, Yonsei University College of Medicine, Seoul, Republic of Korea
^g Department of HPB and Liver Transplant, Centro Medico Nacional 20 de Noviembre, Mexico
^h Department of General Surgery and Organ Transplantation, Bahcesehir University School of Medicine, Istanbul, Turkey
ⁱ Department of Surgery, Swiss Hepato-Pancreato-Biliary and Transplantation Centre, University Hospital Zurich, Zurich, Switzerland
^j NYU Langone Transplant Institute, NYU Langone Health, New York, NY

^*Corresponding authors: D-S. Kim, K. J. Halazun

Abstract

Background: In the current "sickest first" allocation policy for limited deceased liver grafts, identifying patients "too sick to transplant" before transplantation is crucial to optimize outcomes. This study aimed to predict futile outcomes following deceased donor liver transplantation (DDLT) in patients with Model for End-Stage Liver Disease-Sodium (MELD-Na) scores ≥30.

Methods: This international multicenter study was conducted as part of the International Society of Liver Surgeons. We collected data from patients with a MELD-Na score ≥30 who underwent DDLT. A total of 994 patients were enrolled between 2010-2021, including 654 from the Republic of Korea, 224 from the US, and 116 from other regions. Futility was defined as death within three months or during the hospital stay following a DDLT. After exclusion, 160 (16.6%) patients were classified into a futile group and 803 (83.4%) into a non-futile group.

Results: The MELD-Na scores collected at three time points (listing, matching, and transplantation) were comparable between the groups (P = 0.442, P = 0.180, and P = 0.554, respectively). Regarding concomitant organ failure factors, the futile group showed a higher incidence of organ dysfunction across all measured parameters, including the use of mechanical ventilators, continuous renal replacement therapy (CRRT), pneumonia, bacteremia, and vasopressor use (all P<0.01). Independent risk factors for futile outcome were recipient age (≥65 years), body mass index (<18.5 kg/m2), mechanical ventilator use, CRRT (≥1 week), and prolonged ICU stay before transplantation (≥2 weeks). The futility rate was 53.3% in patients with ≥3 risk factors (P<0.001). We developed a nomogram to predict futility after DDLT based on multivariate regression analysis, which showed a better predictive power than previous models.

Conclusions: The risk factors and new nomogram, which adequately reflect concomitant organ failure before liver transplantation, could effectively predict the risk of futile outcomes after DDLT and contribute to decision-making regarding transplantation eligibility in clinical practice.

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