Increased access to liver transplantation for patients with acute on chronic liver failure after implementation of Share 35 Rule: An analysis from the UNOS database

• Published in: Annals of hepatology Vol. 23; p. 100288
• Main Authors: Laique, Sobia N., Zhang, Nan, Hewitt, Winston R., Bajaj, Jasmohan, Vargas, Hugo E.
• Format: Journal Article
• Language: English
• Published: Mexico Elsevier España, S.L.U 01-07-2021; Elsevier
• Subjects: Acute-On-Chronic Liver Failure - diagnosis; Acute-On-Chronic Liver Failure - mortality; Acute-On-Chronic Liver Failure - surgery; Adult; Aged; Female; Health Policy; Health Services Accessibility - statistics & numerical data; Humans; Liver Transplantation - statistics & numerical data; Male; Middle Aged; Patient Selection; Proportional Hazards Models; Registries; Severity of Illness Index; Survival Rate; Tissue and Organ Procurement - statistics & numerical data; Waiting Lists; Young Adult
• ISSN: 1665-2681; 2659-5982
• DOI: 10.1016/j.aohep.2020.100288

Acute on chronic liver failure (ACLF), leads to high mortality. These patients are at risk of being delisted for liver transplantation (LT). Emerging data shows 1y post-transplant survival of 80–92%. The Share 35 (S35) policy was implemented to prioritize patients with MELD ≥35 on the LT waitlist. Our aim was to compare the LT outcomes of ACLF patients as a result of S35.
Data from the UNOS scientific registry were used to classify ACLF patients using the NACSELD criteria. For the analyses, data were divided into two eras; 2 years before S35 (Era 1) and 2 years after S35 (Era 2). Waitlist status was classified into categories: Transplanted, Death or Too Sick to Transplant and Still Waiting/Other. LT cumulative incidence between the populations in the eras was calculated using Fine and Gray's method. A proportional hazards model was used to investigate the era effect on cumulative incidence of LT.
46,861 patients were reviewed, of which 817 had ACLF. 366 patients (mean MELD: 37.1) were identified in Era 1 and 451 patients (mean MELD: 37.3) in Era 2. We found that ACLF patients were more likely to receive a liver transplant in Era 2 (p=0.0074). In both eras, transplanted patients had a significantly higher survival than those who were not transplanted (p<0.0001).
Our study shows that S35 improved LT rate for ACLF suggesting that there should be broader recognition of ACLF and early transplantation should be pursued.