Optimising the management of patients awaiting liver transplantation
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Liver transplantation is a highly successful treatment for selected patients with end-stage liver disease, hepatocellular carcinoma, metabolic disease and fulminant hepatic failure. However, the demand for transplantation outstips the supply of deceased donor livers. There are a number of approaches that can attempt to address this issue, including optimising the selection of potential candidates for liver transplantation and the allocation of donor organs.
Accurate prediction of the risk of death on the liver transplant waiting list is important in prioritising patients for transplantation. We have shown that the Child-Turcotte-Pugh (CTP) score, the model for end-stage liver disease (MELD) score and United Network for Organ Sharing -derived medical status are independent predictors of waiting list death.
Accurate prediction of the outcome at the time of listing patients, which includes both the time on the waiting list and the post-transplantation course for transplanted patients, would help to determine which patients are appropriate for listing and would help to counsel potential transplant candidates. We have developed a novel scoring system which accurately predicts the outcome after listing and performs better than the CTP and MELD scores.
Prioritisation of patients waiting for transplantation is important in attempting to rescue those at greatest risk of waiting list death. We compared prioritisation decisions based on clinical judgement with MELD score and showed that patients who subsequently died waiting were three times as likely to be prioritised by MELD as clinical judgement. Half of the patients who died waiting would have been allocated a donor liver on the basis of MELD.
Allocation of deceased donor livers in Australia and New Zealand was analysed using a survey of liver transplant units the Australian and New Zealand Liver Transplant Registry. Deceased donor liver allocation was shown to be based on an assessment of clinical acuity informed by MELD. Allocation of whole livers from standard and extended criteria donors and split and reduced left lobes was to patients of high acuity, whilst allocation of split right lobes was to more stable recipients.
A model of allocation of deceased donor livers on the basis of survival benefit (that is, predicted survival after transplantation with a particular donor liver minus predicted survival if the patient remained on the waiting list) has been proposed. The model was validated using data from the Liver Transplant Unit Victoria (based at the Austin and Royal Children's Hospitals). The waiting list model stratified patient survival on the waiting list and predicted the survival of low risk patients well, although it did not differentiate well between higher risk patients. The donor risk model stratified post transplantation survival well. The recipient risk model stratified post transplantation survival, although the patients predicted to be at greatest risk in fact had a low risk of post-transplantation graft loss.
Sharing of deceased donor livers between donor regions might rescue patients who are at greatest risk of death on the waiting list. Prospective collection of data on patients on liver transplant waiting lists in Australia and New Zealand who had MELD scores of at least 25 was undertaken and simulation of inter-regional sharing of deceased donor livers for high MELD patients was performed. Simulation of models of inter-regional sharing for patients with high MELD and PELD scores has demonstrated that this approach has the potential to rescue patient at a high risk of waiting list death. A trial of voluntary inter-regional sharing of deceased donor livers for patients with a MELD score of at least 35 has begun in Australia and New Zealand.
- Michael Fink, Senior Lecturer
- Robert Jones, Professor
- Christopher Christophi, Professor
- Vijayaragavan Muralidharan, Associate Professor
- Paul Gow, Associate Professor
- Peter Angus, Professor
- Wang Bao-Zhong, Associate Professor
- Graham Starkey, Honorary
- Fink MA, Angus PW, Gow PJ, Berry SR, Wang BZ, Muralidharan V, Christophi C, Jones RM. Liver transplant recipient selection – MELD versus clinical judgement. Liver Transplantation 2005; 11 (6): 621-26 26.
- Fink MA, Berry SR, Gow PJ, Angus PW, Wang B-Z, Muralidharan V, Christophi C, Jones RM. Risk factors for liver transplantation waiting list mortality. Journal of Gastroenterology and Hepatology 2007; 22(1): 119-24
- Gory I, Fink M, Bell S, Gow P, Nicoll A, Knight V, Dev A, Rode A, Bailey M, Cheung W, Kemp W, Roberts SK - On behalf of the Melbourne Liver Group. Radiofrequency ablation versus resection for the treatment of early stage hepatocellular carcinoma: a multicenter Australian study. Scandinavian Journal of Gastroenterology 2015, 50(5): 567-576 3.
- Perini MV, Starkey G, Fink MA, Bhandari R, Muralidharan V, Jones R, Christophi C. From minimal to maximal surgery in the treatment of hepatocarcinoma: A review. World J Hepatol 2015; 7(1): 93-100
- Bellomo R, Marino B, Starkey G, Fink M, Wang BZ, Eastwood GM, Peck L, Young H, Houston S, Skene A, Opdam H, Jones R. Extended normothermic extracorporeal perfusion of isolated human liver after warm ischaemia: a preliminary report. Crit Care Resusc. 2014; 16: 197-201
- Nikfarjam M, Weinberg L, Fink MA, Muralidharan V, Starkey G, Jones RM, Staveley-O’Carroll K, Christophi C. Pressurized pulse irrigation with saline reduces surgical-site infections following major hepatobiliary and pancreatic surgery: Randomized controlled trial. World Journal of Surgery 2014; 38: 447-55
- Verran D, Mulhearn M, Dilworth P, Balderson G, Munn S, Chen J, Fink M, Crawford M, Mccaughan G. Nature and outcomes of the increased incidence of colorectal malignancy post liver transplantation in Australasia. The Medical Journal of Australia 2013; 199(9): 610-12
- Bellomo R, Marino B, Starkey G, Wang BZ, Fink MA, Zhu N, Suzuki S, Houston S, Eastwood G, Calzavacca P, Glassford N, Chambers N, Skene A, Schneider AG, Jones D, Hilton A, Opdam H, Warrillow S, Gauthier N, Johnson L, Jones R. Normothermic extracorporeal human liver perfusion following donation after cardiac death. Critical Care and Resuscitation 2013; 15: 78-82
- Mayur G, Jones RM, Mirza D, Wang BZ, Fink MA, Starkey G, Vaughan RB, Testro AG. Australia's first liver-intestinal transplant. The Medical Journal of Australia 2012; 197(8): 463-65
- Story DA, Leslie K, Myles PS, Fink M, Poustie SJ, Forbes A, Yap S, Beavis V, Kerridge R, on behalf of the REASON Investigators, Australian and New Zealand College of Anaesthetists Trials Group. Complications and mortality in older surgical patients in Australia and New Zealand (the REASON Study): Multicentre, prospective, observational study. Anaesthesia 2010; 65(10): 1022-30
- Story DA, Fink MA, Leslie K, Myles PS, Yap SJ , Beavis V, Kerridge RK, McNicol L. Perioperative mortality risk score using pre- and postoperative risk factors in older patients. Anaesthesia and Intensive Care 2009; 3 (3): 392-98
- McNicol L, Story DA, Leslie K, Myles PS, Fink MA, Shelton AC, Clavisi O, Poustie SJ. Postoperative complications and mortality in older patients having non-cardiac surgery at three Melbourne teaching hospitals. Medical Journal of Australia 2007; 186(9): 447-52
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