Digestive Diseases and Sciences

, Volume 63, Issue 6, pp 1647–1653 | Cite as

Waitlist Outcomes in Liver Transplant Candidates with High MELD and Severe Hepatic Encephalopathy

  • Chiranjeevi Gadiparthi
  • George Cholankeril
  • Eric R. Yoo
  • Menghan Hu
  • Robert J. Wong
  • Aijaz Ahmed
Original Article



Organ Procurement and Transplantation Network and United Network for Organ Sharing (OPTN/UNOS) implemented the Share 35 policy in June 2013 to prioritize the sickest patients awaiting liver transplantation (LT). However, Model for End-Stage Liver Disease (MELD) score does not incorporate hepatic encephalopathy (HE), an independent predictor of waitlist mortality.


To evaluate the impact of severe HE (grade 3–4) on waitlist outcomes in MELD ≥ 30 patients.


Using the OPTN/UNOS database, we evaluated LT waitlist registrants from 2005–2014. Demographics, comorbidities, and waitlist survival were compared between four cohorts: MELD 30–34 with severe HE, MELD 30–34 without severe HE, MELD ≥ 35 with severe HE, and MELD ≥ 35 without severe HE.


Among 10,003 waitlist registrants studied, 41.6% had MELD score 30–34 and 58.4% had MELD ≥ 35. Patients with severe HE had a higher 90-day waitlist mortality in both MELD 30–34 (severe HE 71.1% vs. no HE 56.6%; p < 0.001) and MELD ≥ 35 subgroups (severe HE 85% versus no HE 74.2%; p < 0.001). MELD 30–34 patients with severe HE had similar 90-day waitlist mortality as MELD ≥ 35 patients without severe HE (71.1 vs. 74.2%, respectively; p = 0.35). On multivariate Cox proportional hazards modeling, MELD ≥ 30 patients had 58% greater risk of 90-day waitlist mortality than those without severe HE (HR 1.58, 95% CI 1.53–1.62; p < 0.001).


Patients awaiting LT with MELD score of 30–34 and severe HE should receive priority status for organ allocation with exception MELD ≥ 35.


Severe hepatic encephalopathy MELD Share 35 policy Waitlist mortality Liver transplantation 



Alcoholic liver disease


Cold ischemia time




Donor Service Area


Hepatic encephalopathy


Hepatitis C virus


Liver transplantation


Model for End-Stage Liver Disease


Nonalcoholic steatohepatitis


Organ Procurement and Network


United Network for Organ Sharing


Author’s contribution

CG and GC were responsible for study concept and design, acquisition of the data, analysis and interpretation of the data, and drafting and approval of the final manuscript. MH was responsible for acquisition of the data, statistical analyses, and drafting and approval of the final manuscript. ERY was responsible for drafting, critical revision, and approval of the final manuscript. RJW and AA were responsible for the interpretation of the data, study supervision, drafting, critical revision, and approval of the final manuscript. All authors were involved in the final approval of the manuscript submitted and have agreed to be accountable for all aspects of the work.

Compliance with ethical standards

Conflict of interest

All authors declare no conflict of interest in the preparation of this manuscript, including financial, consultant, institutional, and other relationships that might lead to bias.

Supplementary material

10620_2018_5032_MOESM1_ESM.docx (91 kb)
Supplementary material 1 (DOCX 90 kb)
10620_2018_5032_MOESM2_ESM.docx (87 kb)
Supplementary material 2 (DOCX 86 kb)


  1. 1.
    Dzebisashvili N, Massie AB, Lentine KL, et al. Following the organ supply: Assessing the benefit of inter-DSA travel in liver transplantation. Transplantation. 2013;95:361–371.CrossRefPubMedGoogle Scholar
  2. 2.
    Roberts JP, Dykstra DM, Goodrich NP, et al. Geographic differences in event rates by Model for End-Stage Liver Disease score. American Journal of Transplantation. 2006;6:2470–2475.CrossRefPubMedGoogle Scholar
  3. 3.
    Massie AB, Chow EK, Wickliffe CE, et al. Early changes in liver distribution following implementation of Share 35. American Journal of Transplantation. 2015;15:659–667.CrossRefPubMedGoogle Scholar
  4. 4.
    Edwards EB, Harper AM, Hirose R, et al. The impact of broader regional sharing of livers: 2-year results of “Share 35”. Liver Transplatation. 2016;22:399–409.CrossRefGoogle Scholar
  5. 5.
    D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. Journal of Hepatology. 2006;44:217–231.CrossRefPubMedGoogle Scholar
  6. 6.
    Gines P, Quintero E, Arroyo V, et al. Compensated cirrhosis: natural history and prognostic factors. Hepatology. 1987;7:122–128.CrossRefPubMedGoogle Scholar
  7. 7.
    Merkel C, Bolognesi M, Angeli P, et al. Prognostic indicators of survival in patients with cirrhosis and esophageal varices, without previous bleeding. American Journal of Gastroenterology. 1989;84:717–722.PubMedGoogle Scholar
  8. 8.
    Milani A, Marra L, Siciliano M, et al. Prognostic significance of clinical and laboratory parameters in liver cirrhosis. A multivariate statistical approach. Hepatogastroenterology. 1985;32:270–272.PubMedGoogle Scholar
  9. 9.
    Stewart CA, Malinchoc M, Kim WR, et al. Hepatic encephalopathy as a predictor of survival in patients with end-stage liver disease. Liver Transplatation. 2007;13:1366–1371.CrossRefGoogle Scholar
  10. 10.
    Wong RJ, Gish RG, Ahmed A. Hepatic encephalopathy is associated with significantly increased mortality among patients awaiting liver transplantation. Liver Transplantation. 2014;20:1454–1461.CrossRefPubMedGoogle Scholar
  11. 11.
    Kim WR, Therneau TM, Benson JT, et al. Deaths on the liver transplant waiting list: an analysis of competing risks. Hepatology. 2006;43:345–351.CrossRefPubMedGoogle Scholar
  12. 12.
    Said A, Williams J, Holden J, et al. Model for end stage liver disease score predicts mortality across a broad spectrum of liver disease. Journal of Hepatology. 2004;40:897–903.CrossRefPubMedGoogle Scholar
  13. 13.
    Yoo HY, Edwin D, Thuluvath PJ. Relationship of the Model for End-Stage Liver Disease (MELD) scale to hepatic encephalopathy, as defined by electroencephalography and neuropsychometric testing, and ascites. American Journal of Gastroenterology. 2003;98:1395–1399.CrossRefPubMedGoogle Scholar
  14. 14.
    Ham J, Gish RG, Mullen K. Model for End-Stage Liver Disease (MELD) exception for hepatic encephalopathy. Liver Transplantation. 2006;12:S102–S104.CrossRefPubMedGoogle Scholar
  15. 15.
    Bajaj JS, Wade JB, Gibson DP, et al. The multi-dimensional burden of cirrhosis and hepatic encephalopathy on patients and caregivers. American Journal of Gastroenterology. 2011;106:1646–1653.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Wong RJ, Aguilar M, Gish RG, et al. The impact of pretransplant hepatic encephalopathy on survival following liver transplantation. Liver Transplantation. 2015;21:873–880.CrossRefPubMedGoogle Scholar
  17. 17.
    Gotthardt D, Weiss KH, Baumgartner M, et al. Limitations of the MELD score in predicting mortality or need for removal from waiting list in patients awaiting liver transplantation. BMC Gastroenterology. 2009;9:72.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Tapper EB. Challenge accepted: Confronting readmissions for our patients with cirrhosis. Hepatology. 2016;64:26–28.CrossRefPubMedGoogle Scholar
  19. 19.
    Bajaj JS, Reddy KR, Tandon P, et al. The 3-month readmission rate remains unacceptably high in a large North American cohort of patients with cirrhosis. Hepatology. 2016;64:200–208.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Cordoba J, Ventura-Cots M, Simon-Talero M, et al. Characteristics, risk factors, and mortality of cirrhotic patients hospitalized for hepatic encephalopathy with and without acute-on-chronic liver failure (ACLF). Journal of Hepatology. 2014;60:275–281.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Chiranjeevi Gadiparthi
    • 1
  • George Cholankeril
    • 2
  • Eric R. Yoo
    • 3
  • Menghan Hu
    • 4
  • Robert J. Wong
    • 5
  • Aijaz Ahmed
    • 2
    • 6
  1. 1.Division of Gastroenterology and HepatologyUniversity of Tennessee Health Science CenterMemphisUSA
  2. 2.Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordUSA
  3. 3.Department of MedicineSanta Clara Valley Medical CenterSan JoseUSA
  4. 4.Department of BiostatisticsBrown University School of Public HealthProvidenceUSA
  5. 5.Division of Gastroenterology and HepatologyAlameda Health System, Highland HospitalOaklandUSA
  6. 6.Division of Gastroenterology and HepatologyStanford University School of MedicineStanfordUSA

Personalised recommendations