Retrospective Study
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Transplant. Jun 18, 2023; 13(4): 169-182
Published online Jun 18, 2023. doi: 10.5500/wjt.v13.i4.169
Delayed referral for liver transplant evaluation worsens outcomes in chronic liver disease patients requiring inpatient transplant evaluation
Katherine M Cooper, Alessandro Colletta, Nicholas J Hathaway, Diana Liu, Daniella Gonzalez, Arslan Talat, Curtis Barry, Anita Krishnarao, Savant Mehta, Babak Movahedi, Paulo N Martins, Deepika Devuni
Katherine M Cooper, Alessandro Colletta, Nicholas J Hathaway, Diana Liu, Daniella Gonzalez, Department of Medicine, UMass Chan Medical School, Worcester, MA 01605, United States
Arslan Talat, Curtis Barry, Anita Krishnarao, Savant Mehta, Deepika Devuni, Department of Medicine, Division of Gastroenterology, UMass Chan Medical School, Worcester, MA 01605, United States
Babak Movahedi, Paulo N Martins, Department of Surgery, Transplant Division, UMass Chan Medical School, Worcester, MA 01605, United States
Author contributions: Cooper KM, Colletta A, Hathaway NJ, and Devuni D contributed to analysis and interpretation of data; Cooper KM, Talat A, and Devuni D contributed to study concept and design; Cooper KM, Colletta A, Liu D, Gonzalez D, Barry C, Krishnarao A, Mehta S, Movahedi B, and Martins PN contributed to acquisition of data; Cooper KM and Colletta A contributed to drafting of the manuscript; Cooper KM, Martins PN, and Devuni D contributed to critical revision of the manuscript for important intellectual content; Cooper KM and Hathaway NJ contributed to statistical analysis; Barry C, Krishnarao A, Mehta S, Movahedi B, and Martins PN contributed to material support; Devuni D contributed to study supervision.
Institutional review board statement: This study was reviewed and approved by the institutional review board at our medical center (IRB Docket: Study00000016, approved 10/24/21).
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous clinical data that were obtained after each patient agreed care with informed consent. This study received a Health Insurance Portability and Accountability Act (HIPAA) waiver for informed consent at our institution through the IRB review process.
Conflict-of-interest statement: All authors have no conflicts of interest related to this study to report.
Data sharing statement: This study was reviewed and approved by the institutional review board at our medical center with a waiver of consent due to the retrospective nature of this study.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Katherine M Cooper, MD, Doctor, Department of Medicine, UMass Chan Medical School, 55 Lave Ave North, Worcester, MA 01605, United States. katherine.cooper@umassmed.edu
Received: April 25, 2023
Peer-review started: April 25, 2023
First decision: May 18, 2023
Revised: May 21, 2023
Accepted: June 6, 2023
Article in press: June 6, 2023
Published online: June 18, 2023
Abstract
BACKGROUND

Indications to refer patients with cirrhosis for liver transplant evaluation (LTE) include hepatic decompensation or a model for end stage liver disease (MELD-Na) score ≥ 15. Few studies have evaluated how delaying referral beyond these criteria affects patient outcomes.

AIM

To evaluate clinical characteristics of patients undergoing inpatient LTE and to assess the effects of delayed LTE on patient outcomes (death, transplantation).

METHODS

This is a single center retrospective cohort study assessing all patients undergoing inpatient LTE (n = 159) at a large quaternary care and liver transplant center between 10/23/2017-7/31/2021. Delayed referral was defined as having prior indication (decompensation, MELD-Na ≥ 15) for LTE without referral. Early referral was defined as referrals made within 3 mo of having an indication based on practice guidelines. Logistic regression and Cox Hazard Regression were used to evaluate the relationship between delayed referral and patient outcomes.

RESULTS

Many patients who require expedited inpatient LTE had delayed referrals. Misconceptions regarding transplant candidacy were a leading cause of delayed referral. Ultimately, delayed referrals negatively affected overall patient outcome and an independent predictor of both death and not receiving a transplant. Delayed referral was associated with a 2.5 hazard risk of death.

CONCLUSION

Beyond initial access to an liver transplant (LT) center, delaying LTE increases risk of death and reduces risk of LT in patients with chronic liver disease. There is substantial opportunity to increase the percentage of patients undergoing LTE when first clinically indicated. It is crucial for providers to remain informed about the latest guidelines on liver transplant candidacy and the transplant referral process.

Keywords: Liver transplantation, Liver transplant evaluation, Liver transplant referral, Patient access, Equity, Patient outcomes

Core Tip: There are many system and provider-level barriers to liver transplant evaluation. However, the effect of late transplant evaluations remains unclear. We demonstrate delayed liver transplant evaluation is independently associated with death prior to transplant in patients undergoing liver transplant evaluation.