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Tu1055 High Model for End-Stage Liver Disease (MELD) Score Disproportionately Worsens Liver Transplant Outcomes for Older Recipients
developed severe pain requiring 23-hour observation; a CT scan was negative for hematoma or other complications. One patient developed liver abscess one week after the procedure; this was treated with antibiotics and aspiration by interventional radiology. The specimens were deemed adequate by pathologist in all patients except one, which was reported to be fragmented with very few portal tracts. CONCLUSION: EUS-directed core biopsy of the liver is technically feasible, and compares favorably with transjugular and laparoscopic approach in terms of side effects and cost. It should be considered in patients who are not good candidates for percutaneous biopsy.
to register as organ donors should they were incentivized with few extra MELD points should they need liver transplantation. The most common listed reasons for declining to register for organ donation included religious purposes, concern about poor medical quality should a donor requires medical care, rejecting the idea to have their body cut and feeling that the current organ allocation system is not fair. Conclusion The survey sheds a light on the physicians' attitudes toward liver donation. Innovative ideas are needed to drive more people to donate their organs to cover the gap between organs donation and demand. Table one: Demographics and characteristics of responders, and attitudes toward assigning extra MELD score for donors should they require liver transplantation
Tu1055
AASLD Abstracts
High Model for End-Stage Liver Disease (MELD) Score Disproportionately Worsens Liver Transplant Outcomes for Older Recipients Suzanne R. Sharpton, Sandy Feng, Eric Vittinghoff, Bilal Hameed, Francis Yao, Jennifer C. Lai Background: The proportion of older patients awaiting liver transplantation (LT) is rising. While increased age and MELD at LT are known to increase the risk of graft loss, no studies have explored whether there is a synergistic effect between LT-age and LT-MELD. Methods: All US adult, non-Status 1 recipients of primary deceased donor LT from 2/05-1/10 without MELD exceptions were included (n=15,707). Recipients were categorized by laboratory MELD at LT: low (MELD ,20, n=5,290), mid (MELD 20-27, n=5,112), and high (MELD ≥28, n=5,265). Recipients were also categorized by age at LT: 18-59y (n=12,001), 60-64y (n=2,183), 65-69y (n=1,179), and ≥70y (n=344). The primary outcome was graft loss (death or re-LT). Adjusted Cox models evaluated the combined effects of LT-age and LT-MELD on graft loss. Results: Median LT-age was 54y [interquartile range (IQR), 47-59y]: 2% were ≥70y. Compared to ,60y, recipients ≥70y were more likely to be Caucasian (p ,0.001) and female (p=0.004). List- and LT-MELD were lower in recipients ≥70y (p,0.001). In an additive model excluding interactions, age ≥70y (HR=1.64, 95% CI 1.38-1.96) and LTMELD ≥28 (HR=1.46, 95% CI 1.35-1.58) were both associated with increased risk of graft loss (p,0.001). However, in a model allowing for interaction between LT-age and LTMELD, the risk of graft loss for recipients ≥70y with MELD ≥28 was higher than predicted by the additive model (Table). Among recipients with LT-MELD ≥28, the interaction term was only significant for the LT-recipients ≥70y (HR=1.69; 95% CI 1.12-2.54; p=0.01). One year graft survival for ≥70y LT recipients with MELD ,20, 20-27, and ≥28 was 85%, 75%, and 56%. Conclusions: Compared to ,60y, ≥70y LT recipients with LT-MELD ≥28 experienced a higher risk of graft loss that was multiplicative - and perhaps, prohibitive with one year graft survival of only 56%. The increased risk of graft loss in ≥70y LT recipients was attenuated at lower LT-MELD scores. Our objective data suggest that LT for older recipients at high LT-MELD scores should be undertaken cautiously, if at all.
Tu1057 How Transplant Surgeons Can Overcome the Inevitable Insufficiency of Allograft Size During Adult Living-Donor Liver Transplantation: Strategy for Donor Safety With a Smaller-Size Graft and Excellent Recipient Results Tomohide Hori, Shinji Uemoto Small-for-size grafts are an issue in liver transplantation. Portal venous pressure (PVP) was monitored and intentionally controlled during living-donor liver transplantation (LDLT) in 155 adult recipients. The indocyanine green elimination rate (kICG) was simultaneously measured in 16 recipients and divided by the graft weight (g) to reflect portal venous flow (PVF). The target PVP was ,20 mmHg. Patients were divided by the final PVP (mmHg): Group A, PVP ,12; Group B, 12≤PVP,15; Group C, 15≤PVP, 20; and Group D, PVP≥20. With intentional PVP control, we performed splenectomy and collateral ligation in 80 cases, splenectomy in 39 cases, and splenectomy, collateral ligation, and additional creation in five cases. Thirty-one cases received no modulation. Groups A and B showed good LDLT results, while Groups C and D did not. Final PVP was the most important factor for the LDLT results, and the PVP cutoffs for good outcomes and clinical courses were both 15.5 mmHg. The respective kICG/graft weight cutoffs were 3.5580x10-4/g and 4.0015 x10-4/g. Intentional PVP modulation at ,15 mmHg is a sure surgical strategy for small-for-size grafts, to establish greater donor safety with good LDLT results. The kICG/graft weight value may have potential as a parameter for optimal PVF and a predictor for LDLT results.
Table. Hazard ratio of graft loss and 1y graft survival rates by LT-MELD and LT-age categories. Tu1056 Physicians' Attitudes Toward Organ Donation Ala A. Abdel Jalil, Angela Q. Maldonado, Amer A. Alkhatib Introduction Organ donation has increased over the past decade but the equation between donors and recipients still remains unbalanced. In general, organ donation is viewed favorably by public with 60-90% of survey responders were willing to donate their organs. However, this positive attitude translates to nationwide donation rate of less than 40%. As a consequence of this, organs shortage has raised. Physicians were the leaders to introduce liver transplantation. There is paucity in literature that addresses physicians' attitudes toward organ donation. Methods A multidisciplinary panel of gastroenterology and hepatology fellows and faculty developed a 15-question survey. Design and refinement of survey involved literature review, item generation, small focus group and large group discussions. The survey was pilot-tested in a focus group of 15 attending physicians, fellows and residents at three institutions, for face and content validity, and feasibility. Feedback from the focus group and general gastroenterology meetings was integrated into the final survey. We identified 4000 program directors of residency and fellowship programs in the USA through American Medical Association website, to whom we distributed an electronic anonymous survey and asked them to share it with their trainees and colleagues. We used chi square and student t test to compare physicians who responded that they registered to organ donation (Donors) to those who did not (Non donors). Results We received responses from 724 physicians representing a broad sample of trainees and attending physicians at large and small hospitals across the nation in different specialties and subspecialties. There were no major demographic or characteristic differences between the two groups (see table 1). Donors were more significantly aware about organ shortage problem and its consequences (87.8% vs. 80.1%, p ,0.03). Non donors were slightly more inclined to resist the idea of providing incentive (Few extra MELD points for donors should they need liver transplantation in the future), 52.2% vs. 55.2%, p,0.5). On the other hand, significantly more donors were accepting this concept (37.7% vs. 28.5%, p,0.03). Interestingly 29.9% of Non donors expressed their willingness
AASLD Abstracts
S-1042
to register as organ donors should they were incentivized with few extra MELD points should they need liver transplantation. The most common listed reasons for declining to register for organ donation included religious purposes, concern about poor medical quality should a donor requires medical care, rejecting the idea to have their body cut and feeling that the current organ allocation system is not fair. Conclusion The survey sheds a light on the physicians' attitudes toward liver donation. Innovative ideas are needed to drive more people to donate their organs to cover the gap between organs donation and demand. Table one: Demographics and characteristics of responders, and attitudes toward assigning extra MELD score for donors should they require liver transplantation
Tu1055
AASLD Abstracts
High Model for End-Stage Liver Disease (MELD) Score Disproportionately Worsens Liver Transplant Outcomes for Older Recipients Suzanne R. Sharpton, Sandy Feng, Eric Vittinghoff, Bilal Hameed, Francis Yao, Jennifer C. Lai Background: The proportion of older patients awaiting liver transplantation (LT) is rising. While increased age and MELD at LT are known to increase the risk of graft loss, no studies have explored whether there is a synergistic effect between LT-age and LT-MELD. Methods: All US adult, non-Status 1 recipients of primary deceased donor LT from 2/05-1/10 without MELD exceptions were included (n=15,707). Recipients were categorized by laboratory MELD at LT: low (MELD ,20, n=5,290), mid (MELD 20-27, n=5,112), and high (MELD ≥28, n=5,265). Recipients were also categorized by age at LT: 18-59y (n=12,001), 60-64y (n=2,183), 65-69y (n=1,179), and ≥70y (n=344). The primary outcome was graft loss (death or re-LT). Adjusted Cox models evaluated the combined effects of LT-age and LT-MELD on graft loss. Results: Median LT-age was 54y [interquartile range (IQR), 47-59y]: 2% were ≥70y. Compared to ,60y, recipients ≥70y were more likely to be Caucasian (p ,0.001) and female (p=0.004). List- and LT-MELD were lower in recipients ≥70y (p,0.001). In an additive model excluding interactions, age ≥70y (HR=1.64, 95% CI 1.38-1.96) and LTMELD ≥28 (HR=1.46, 95% CI 1.35-1.58) were both associated with increased risk of graft loss (p,0.001). However, in a model allowing for interaction between LT-age and LTMELD, the risk of graft loss for recipients ≥70y with MELD ≥28 was higher than predicted by the additive model (Table). Among recipients with LT-MELD ≥28, the interaction term was only significant for the LT-recipients ≥70y (HR=1.69; 95% CI 1.12-2.54; p=0.01). One year graft survival for ≥70y LT recipients with MELD ,20, 20-27, and ≥28 was 85%, 75%, and 56%. Conclusions: Compared to ,60y, ≥70y LT recipients with LT-MELD ≥28 experienced a higher risk of graft loss that was multiplicative - and perhaps, prohibitive with one year graft survival of only 56%. The increased risk of graft loss in ≥70y LT recipients was attenuated at lower LT-MELD scores. Our objective data suggest that LT for older recipients at high LT-MELD scores should be undertaken cautiously, if at all.
Tu1057 How Transplant Surgeons Can Overcome the Inevitable Insufficiency of Allograft Size During Adult Living-Donor Liver Transplantation: Strategy for Donor Safety With a Smaller-Size Graft and Excellent Recipient Results Tomohide Hori, Shinji Uemoto Small-for-size grafts are an issue in liver transplantation. Portal venous pressure (PVP) was monitored and intentionally controlled during living-donor liver transplantation (LDLT) in 155 adult recipients. The indocyanine green elimination rate (kICG) was simultaneously measured in 16 recipients and divided by the graft weight (g) to reflect portal venous flow (PVF). The target PVP was ,20 mmHg. Patients were divided by the final PVP (mmHg): Group A, PVP ,12; Group B, 12≤PVP,15; Group C, 15≤PVP, 20; and Group D, PVP≥20. With intentional PVP control, we performed splenectomy and collateral ligation in 80 cases, splenectomy in 39 cases, and splenectomy, collateral ligation, and additional creation in five cases. Thirty-one cases received no modulation. Groups A and B showed good LDLT results, while Groups C and D did not. Final PVP was the most important factor for the LDLT results, and the PVP cutoffs for good outcomes and clinical courses were both 15.5 mmHg. The respective kICG/graft weight cutoffs were 3.5580x10-4/g and 4.0015 x10-4/g. Intentional PVP modulation at ,15 mmHg is a sure surgical strategy for small-for-size grafts, to establish greater donor safety with good LDLT results. The kICG/graft weight value may have potential as a parameter for optimal PVF and a predictor for LDLT results.
Table. Hazard ratio of graft loss and 1y graft survival rates by LT-MELD and LT-age categories. Tu1056 Physicians' Attitudes Toward Organ Donation Ala A. Abdel Jalil, Angela Q. Maldonado, Amer A. Alkhatib Introduction Organ donation has increased over the past decade but the equation between donors and recipients still remains unbalanced. In general, organ donation is viewed favorably by public with 60-90% of survey responders were willing to donate their organs. However, this positive attitude translates to nationwide donation rate of less than 40%. As a consequence of this, organs shortage has raised. Physicians were the leaders to introduce liver transplantation. There is paucity in literature that addresses physicians' attitudes toward organ donation. Methods A multidisciplinary panel of gastroenterology and hepatology fellows and faculty developed a 15-question survey. Design and refinement of survey involved literature review, item generation, small focus group and large group discussions. The survey was pilot-tested in a focus group of 15 attending physicians, fellows and residents at three institutions, for face and content validity, and feasibility. Feedback from the focus group and general gastroenterology meetings was integrated into the final survey. We identified 4000 program directors of residency and fellowship programs in the USA through American Medical Association website, to whom we distributed an electronic anonymous survey and asked them to share it with their trainees and colleagues. We used chi square and student t test to compare physicians who responded that they registered to organ donation (Donors) to those who did not (Non donors). Results We received responses from 724 physicians representing a broad sample of trainees and attending physicians at large and small hospitals across the nation in different specialties and subspecialties. There were no major demographic or characteristic differences between the two groups (see table 1). Donors were more significantly aware about organ shortage problem and its consequences (87.8% vs. 80.1%, p ,0.03). Non donors were slightly more inclined to resist the idea of providing incentive (Few extra MELD points for donors should they need liver transplantation in the future), 52.2% vs. 55.2%, p,0.5). On the other hand, significantly more donors were accepting this concept (37.7% vs. 28.5%, p,0.03). Interestingly 29.9% of Non donors expressed their willingness
AASLD Abstracts
S-1042