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Transplant center experience influences spontaneous survival and waitlist mortality in acute liver failure: An analysis of the UNOS database
Author(s) -
Wong Natalie Z.,
Schaubel Douglas E.,
Reddy K. Rajender,
Bittermann Therese
Publication year - 2021
Publication title -
american journal of transplantation
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 2.89
H-Index - 188
eISSN - 1600-6143
pISSN - 1600-6135
DOI - 10.1111/ajt.16234
Subject(s) - medicine , retrospective cohort study , cohort , single center , liver failure , surgery , emergency medicine
Transplant centers coordinate complex care in acute liver failure (ALF), for which liver transplant (LT) can be lifesaving. We studied associations between waitlist outcomes and center (1) ALF waitlist volume (low: <20; medium: 20‐39; high: 40+ listings) and (2) total LT volume (<600, 600‐1199, 1200+ LTs) in a retrospective cohort of 3248 adults with ALF listed for LT at 92 centers nationally from 2002 to 2019. Predicted outcome probabilities (LT, died/too sick, spontaneous survival [SS]) were obtained with multinomial regression, and observed‐to‐expected ratios were calculated. Median center outcome rates were 72.6% LT, 18.2% died/too sick, and 6.1% SS. SS was significantly higher with greater center ALF volume (median 0% for low‐, 5.9% for medium‐, and 8.6% for high‐volume centers; P = .039), while waitlist mortality was highest at low‐volume centers (median 21.4%, IQR: 16.1%‐26.7%; P = .042). Significant heterogeneity in center performance was observed for waitlist mortality (observed‐to‐expected ratio range: 0‐4.1) and particularly for SS (0‐6.4), which persisted despite accounting for recipient case mix. This novel study demonstrates that increased center experience is associated with greater SS and reduced waitlist mortality for ALF. More‐focused management pathways are needed to improve ALF outcomes at less‐experienced centers and to identify opportunities for improvement at large.