ABSTRACT
BACKGROUND: The reduction of liver transplant wait list mortality remains a priority for transplant programs and depends on the accurate stratification of patients by mortality risk. Although estimation of 90-day mortality by Model for End-Stage Liver Disease (MELD) score has improved wait list survival, it is unclear how contemporary wait list mortality can best be diminished given the preponderance of listed patients with low MELD scores and long wait times. METHODS: In this intention-to-treat analysis of 289 consecutively listed patients with over 5 years of follow-up, we aimed to determine the contribution of late mortality to overall wait list outcome and identify clinical predictors that would help discriminate long-term survivors from fatalities. RESULTS: Seventy percent of wait list deaths occurred in patients listed with MELD scores less than 20, and 40% of deaths occurred in patients waiting longer than 1 year. Hypoalbuminemia at listing was a significant predictor of late mortality in all patients in both univariate and multivariate analyses, and it was most discriminatory among patients with MELD scores of 20 or less. CONCLUSION: Our data suggest that hypoalbuminemia at listing reveals a vulnerable population of low MELD patients who are underserved by their MELD score over time. Such patients comprise almost 40% of the contemporary wait list and contribute substantially to list mortality given their poor access to transplantation. Targeting these at-risk patients with grafts from living or extended criteria donors may thus significantly diminish overall list mortality, and future initiatives to decrease overall wait list mortality must focus on improved risk stratification for low MELD patients.
Subject(s)
Hypoalbuminemia/blood , Hypoalbuminemia/mortality , Liver Diseases/blood , Liver Diseases/mortality , Liver Transplantation , Serum Albumin/analysis , Waiting Lists/mortality , Biomarkers/blood , Decision Support Techniques , Down-Regulation , Female , Humans , Hypoalbuminemia/diagnosis , Intention to Treat Analysis , Kaplan-Meier Estimate , Liver Diseases/diagnosis , Liver Diseases/surgery , Male , Middle Aged , Patient Selection , Proportional Hazards Models , Retrospective Studies , Risk Assessment , Risk Factors , Serum Albumin, Human , Severity of Illness Index , Time FactorsABSTRACT
KEY POINTS: 1. Donor assessment scores can be used to prognosticate recipient outcomes but are often not clinically relevant. 2. The donor risk index, the survival outcomes following liver transplantation score, and the Donor Model for End-Stage Liver Disease score have specific advantages and disadvantages with respect to accuracy and ease of use. 3. The significance of the donor assessment is undermined by an allocation system that sometimes limits ideal donor-recipient matching and whose sole objective is the minimization of wait-list mortality instead of the benefit of transplantation.
Subject(s)
Donor Selection/methods , End Stage Liver Disease/surgery , Liver Transplantation , Tissue Donors , Donor Selection/statistics & numerical data , End Stage Liver Disease/diagnosis , End Stage Liver Disease/mortality , Humans , Prognosis , Reproducibility of Results , Treatment Outcome , Waiting ListsABSTRACT
A 50-year old female presented herself with abdominal bloating and pain in the Emergengy Department. The symptoms persisted and a clinical evaluation was made. A lesion suspect for a giant duodenal diverticulum was seen on the CT-scan, which was confirmed by enteroclysis. Surgical resection was performed. The diagnosis was histological confirmed after surgery. Small bowel diverticula are relatively common, with an estimated 5 - 22% incidence in the healthy population. They are usually asymptomatic, but can present with abdominal pain and weight loss. Complications such as bleeding and perforation can occur. Surgical resection is the treatment of choice in symptomatic patients.
