Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model

Background & Aims: Uncertainties exist surrounding the timing of liver transplantation (LT) among patients with acute-on-chronic liver failure grade 3 (ACLF-3), regarding whether to accept a marginal quality donor organ to allow for earlier LT or wait for either an optimal organ offer or imp...

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Autores principales:	Suyanpeng Zhang, Sze-Chuan Suen, Cynthia L. Gong, Jessica Pham, Jonel Trebicka, Christophe Duvoux, Andrew S. Klein, Tiffany Wu, Rajiv Jalan, Vinay Sundaram
Formato:	article
Lenguaje:	EN
Publicado:	Elsevier 2021
Materias:	UNOS database organ failure MELD-Na score donor risk index Diseases of the digestive system. Gastroenterology RC799-869
Acceso en línea:	https://doaj.org/article/6af5e606e0c0452f8a540bd6c90b72dd
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spelling	oai:doaj.org-article:6af5e606e0c0452f8a540bd6c90b72dd2021-11-20T05:11:55ZEarly transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model2589-555910.1016/j.jhepr.2021.100367https://doaj.org/article/6af5e606e0c0452f8a540bd6c90b72dd2021-12-01T00:00:00Zhttp://www.sciencedirect.com/science/article/pii/S2589555921001439https://doaj.org/toc/2589-5559Background & Aims: Uncertainties exist surrounding the timing of liver transplantation (LT) among patients with acute-on-chronic liver failure grade 3 (ACLF-3), regarding whether to accept a marginal quality donor organ to allow for earlier LT or wait for either an optimal organ offer or improvement in the number of organ failures, in order to increase post-LT survival. Methods: We created a Markov decision process model to determine the optimal timing of LT among patients with ACLF-3 within 7 days of listing, to maximize overall 1-year survival probability. Results: We analyzed 6 groups of candidates with ACLF-3: patients age ≤60 or >60 years, patients with 3 organ failures alone or 4-6 organ failures, and hepatic or extrahepatic ACLF-3. Among all groups, LT yielded significantly greater overall survival probability vs. remaining on the waiting list for even 1 additional day (p <0.001), regardless of organ quality. Creation of 2-way sensitivity analyses, with variation in the probability of receiving an optimal organ and expected post-transplant mortality, indicated that overall survival is maximized by earlier LT, particularly among candidates >60 years old or with 4-6 organ failures. The probability of improvement from ACLF-3 to ACLF-2 does not influence these recommendations, as the likelihood of organ recovery was less than 10%. Conclusion: During the first week after listing for patients with ACLF-3, earlier LT in general is favored over waiting for an optimal quality donor organ or for recovery of organ failures, with the understanding that the analysis is limited to consideration of only these 3 variables. Lay summary: In the setting of grade 3 acute-on-chronic liver failure (ACLF-3), questions remain regarding the timing of transplantation in terms of whether to proceed with liver transplantation with a marginal donor organ or to wait for an optimal liver, and whether to transplant a patient with ACLF-3 or wait until improvement to ACLF-2. In this study, we used a Markov decision process model to demonstrate that earlier transplantation of patients listed with ACLF-3 maximizes overall survival, as opposed to waiting for an optimal donor organ or for improvement in the number of organ failures.Suyanpeng ZhangSze-Chuan SuenCynthia L. GongJessica PhamJonel TrebickaChristophe DuvouxAndrew S. KleinTiffany WuRajiv JalanVinay SundaramElsevierarticleUNOS databaseorgan failureMELD-Na scoredonor risk indexDiseases of the digestive system. GastroenterologyRC799-869ENJHEP Reports, Vol 3, Iss 6, Pp 100367- (2021)
institution	DOAJ
collection	DOAJ
language	EN
topic	UNOS database organ failure MELD-Na score donor risk index Diseases of the digestive system. Gastroenterology RC799-869
spellingShingle	UNOS database organ failure MELD-Na score donor risk index Diseases of the digestive system. Gastroenterology RC799-869 Suyanpeng Zhang Sze-Chuan Suen Cynthia L. Gong Jessica Pham Jonel Trebicka Christophe Duvoux Andrew S. Klein Tiffany Wu Rajiv Jalan Vinay Sundaram Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model
description	Background & Aims: Uncertainties exist surrounding the timing of liver transplantation (LT) among patients with acute-on-chronic liver failure grade 3 (ACLF-3), regarding whether to accept a marginal quality donor organ to allow for earlier LT or wait for either an optimal organ offer or improvement in the number of organ failures, in order to increase post-LT survival. Methods: We created a Markov decision process model to determine the optimal timing of LT among patients with ACLF-3 within 7 days of listing, to maximize overall 1-year survival probability. Results: We analyzed 6 groups of candidates with ACLF-3: patients age ≤60 or >60 years, patients with 3 organ failures alone or 4-6 organ failures, and hepatic or extrahepatic ACLF-3. Among all groups, LT yielded significantly greater overall survival probability vs. remaining on the waiting list for even 1 additional day (p <0.001), regardless of organ quality. Creation of 2-way sensitivity analyses, with variation in the probability of receiving an optimal organ and expected post-transplant mortality, indicated that overall survival is maximized by earlier LT, particularly among candidates >60 years old or with 4-6 organ failures. The probability of improvement from ACLF-3 to ACLF-2 does not influence these recommendations, as the likelihood of organ recovery was less than 10%. Conclusion: During the first week after listing for patients with ACLF-3, earlier LT in general is favored over waiting for an optimal quality donor organ or for recovery of organ failures, with the understanding that the analysis is limited to consideration of only these 3 variables. Lay summary: In the setting of grade 3 acute-on-chronic liver failure (ACLF-3), questions remain regarding the timing of transplantation in terms of whether to proceed with liver transplantation with a marginal donor organ or to wait for an optimal liver, and whether to transplant a patient with ACLF-3 or wait until improvement to ACLF-2. In this study, we used a Markov decision process model to demonstrate that earlier transplantation of patients listed with ACLF-3 maximizes overall survival, as opposed to waiting for an optimal donor organ or for improvement in the number of organ failures.
format	article
author	Suyanpeng Zhang Sze-Chuan Suen Cynthia L. Gong Jessica Pham Jonel Trebicka Christophe Duvoux Andrew S. Klein Tiffany Wu Rajiv Jalan Vinay Sundaram
author_facet	Suyanpeng Zhang Sze-Chuan Suen Cynthia L. Gong Jessica Pham Jonel Trebicka Christophe Duvoux Andrew S. Klein Tiffany Wu Rajiv Jalan Vinay Sundaram
author_sort	Suyanpeng Zhang
title	Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model
title_short	Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model
title_full	Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model
title_fullStr	Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model
title_full_unstemmed	Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model
title_sort	early transplantation maximizes survival in severe acute-on-chronic liver failure: results of a markov decision process model
publisher	Elsevier
publishDate	2021
url	https://doaj.org/article/6af5e606e0c0452f8a540bd6c90b72dd
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Early transplantation maximizes survival in severe acute-on-chronic liver failure: Results of a Markov decision process model

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