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Research Letter |

The Portrait of an Adult Liver Transplant Recipient in the United States From 1987 to 2013 FREE

Maria Stepanova, PhD1; Homan Wai, MD1; Sammy Saab, MD2; Alita Mishra, MD3; Chapy Venkatesan, MD3; Zobair M. Younossi, MD, MPH3
[+] Author Affiliations
1Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, Virginia
2Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles
3Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, Virginia
JAMA Intern Med. 2014;174(8):1407-1409. doi:10.1001/jamainternmed.2014.2903.
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Published online

Since the first liver transplant, tremendous advances in organ preservation, surgical techniques and postoperative management have occurred. These advances have made liver transplantation the standard of care for patients with end-stage liver disease.13 In this study, we describe how the clinicodemographic portrait of adult liver transplant recipients has changed in the United States over the past 25 years.

This study used the Scientific Registry of Transplant Recipients (SRTR). We included all adult liver transplant recipients from 1987 to June 2013. The study span was split into 4 approximately equally long cycles: 1987 to 1993, 1994 to 2000, 2001 to 2006, and 2007 to 2013. Cochran-Armitage test and Kendall τ-b coefficient were used to assess time trends. The study was granted a nonhuman subject research status by Inova Institutional Review Board.

A total of 108 707 adult liver transplants performed in 153 different transplant centers across the country were included (Table).

Table Graphic Jump LocationTable.  Clinicodemographic Presentation of Liver Transplant Recipients From 1987 to 2013a

Consistent with the changes in the general US population, liver transplant recipients are becoming increasingly older. Nevertheless, the increase in the mean age (7.3 years between cycles 1 and 4) is greater than that for patients with the diagnosis of chronic liver disease (41.1-45.3 years for the same time period4). In contrast, changes in the racial/ethnic profile of transplant recipients were similar to those seen in the US general population.4 Also, the proportion of male transplant recipients increased over time (Table).

Furthermore, patients’ clinical presentation and functional status suggest that transplant recipients are becoming sicker. In particular, the rates of nearly all chronic conditions increased, and the average model for end-stage liver disease (MELD) (currently used for prioritization of wait-listed candidates3) score increased slightly. Of the indications for liver transplantation, the proportion of alcoholic liver disease decreased while that of primary liver cancer increased (Table). Of chronic liver disease etiologies, hepatitis C virus (HCV), alcoholic liver disease, and nonalcoholic fatty liver disease are now the most prevalent, and while alcoholic liver disease decreased, nonalcoholic fatty liver disease has shown a rapid increase (Table).

The results of this descriptive study show how liver transplant recipients have changed over the past 2 decades. In particular, liver transplant recipients in the United States have become older, predominantly male and with more comorbidities. Although the reasons are not entirely clear, one major contributor to this change may be related to the easing of some listing criteria for liver transplant candidates, such as increasing the threshold for age and body mass index. In addition, the increase in age could be related to the aging of the “baby boomer” cohort with high prevalence of HCV, the most common indication for liver transplantation.

The explanation for the observed sex disparity remains unclear. Although sex bias from MELD allocation has been reported,5 it is also important to note that the 2 most common indications for liver transplantation, HCV and hepatocellular carcinoma, have male predominance.6

Our results also suggest that liver transplant recipients are becoming sicker. This may reflect the mandated transition to the “sickest-first” approach by MELD allocation.2,3 We also noted an increase in the rates of comorbidities related to metabolic syndrome, which may be explained by the increasing prevalence of obesity and its complications in the United States. However, a steady rather than abrupt increase in the rates of most of comorbidities (Figure) could also be explained by easing of the criteria for transplant listing and relief of some relative contraindications.

Place holder to copy figure label and caption
Figure.
The Prevalence of Comorbidities in Adult Liver Transplant Recipients by Year

The vertical blue line represents introduction of the model for end-stage liver disease score in 2001. CAD indicates coronary artery disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; PVD, peripheral vascular disease; TX, transplant.

Graphic Jump Location

The clinicodemographic portrait of liver transplant recipients in the United States is changing. The growing proportion of transplant recipients with comorbidities may warrant additional efforts for optimal management of these patients.

Corresponding Author: Zobair M. Younossi, MD, MPH, Betty and Guy Beatty Center for Integrated Research, Claude Moore Health Education and Research Building, 3300 Gallows Rd, Falls Church, VA 22042 (zobair.younossi@inova.org).

Published Online: June 30, 2014. doi:10.1001/jamainternmed.2014.2903.

Author Contributions: Dr Stepanova had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: All authors.

Acquisition, analysis, or interpretation of data: Stepanova, Younossi.

Drafting of the manuscript: Stepanova, Saab, Venkatesan, Younossi,

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Stepanova, Younossi.

Administrative, technical, or material support: Wai.

Study supervision: Saab, Venkatesan.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by the Liver Outcomes Research Fund and The Beatty Liver and Obesity Fund from Inova Health System, Falls Church, Virginia.

Role of the Sponsors: The data reported herein have been supplied by the Minneapolis Medical Research Foundation as the contractor for the Scientific Registry of Transplant Recipients (SRTR). The interpretation and reporting of these data are the responsibility of the authors and in no way should be seen as an official policy of or interpretation by the SRTR or the US Government.

Previous Presentation: The data were partially presented as a poster at 2014 Digestive Disease Week 2014; May 3, 2014; Chicago, Illinois.

Alqahtani  SA, Larson  AM.  Adult liver transplantation in the USA. Curr Opin Gastroenterol. 2011;27(3):240-247.
PubMed   |  Link to Article
Wiesner  RH.  Patient selection in an era of donor liver shortage: current US policy. Nat Clin Pract Gastroenterol Hepatol. 2005;2(1):24-30.
PubMed   |  Link to Article
Wiesner  R, Edwards  E, Freeman  R,  et al; United Network for Organ Sharing Liver Disease Severity Score Committee.  Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91-96.
PubMed   |  Link to Article
Younossi  ZM, Stepanova  M, Afendy  M,  et al.  Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008. Clin Gastroenterol Hepatol. 2011;9(6):524-530.
PubMed   |  Link to Article
Cholongitas  E, Marelli  L, Kerry  A,  et al.  Female liver transplant recipients with the same GFR as male recipients have lower MELD scores: a systematic bias. Am J Transplant. 2007;7(3):685-692.
PubMed   |  Link to Article
Mishra  A, Otgonsuren  M, Venkatesan  C, Afendy  M, Erario  M, Younossi  ZM.  The inpatient economic and mortality impact of hepatocellular carcinoma from 2005 to 2009: analysis of the US nationwide inpatient sample. Liver Int. 2013;33(8):1281-1286.
PubMed   |  Link to Article

Figures

Place holder to copy figure label and caption
Figure.
The Prevalence of Comorbidities in Adult Liver Transplant Recipients by Year

The vertical blue line represents introduction of the model for end-stage liver disease score in 2001. CAD indicates coronary artery disease; COPD, chronic obstructive pulmonary disease; DM, diabetes mellitus; PVD, peripheral vascular disease; TX, transplant.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable.  Clinicodemographic Presentation of Liver Transplant Recipients From 1987 to 2013a

References

Alqahtani  SA, Larson  AM.  Adult liver transplantation in the USA. Curr Opin Gastroenterol. 2011;27(3):240-247.
PubMed   |  Link to Article
Wiesner  RH.  Patient selection in an era of donor liver shortage: current US policy. Nat Clin Pract Gastroenterol Hepatol. 2005;2(1):24-30.
PubMed   |  Link to Article
Wiesner  R, Edwards  E, Freeman  R,  et al; United Network for Organ Sharing Liver Disease Severity Score Committee.  Model for end-stage liver disease (MELD) and allocation of donor livers. Gastroenterology. 2003;124(1):91-96.
PubMed   |  Link to Article
Younossi  ZM, Stepanova  M, Afendy  M,  et al.  Changes in the prevalence of the most common causes of chronic liver diseases in the United States from 1988 to 2008. Clin Gastroenterol Hepatol. 2011;9(6):524-530.
PubMed   |  Link to Article
Cholongitas  E, Marelli  L, Kerry  A,  et al.  Female liver transplant recipients with the same GFR as male recipients have lower MELD scores: a systematic bias. Am J Transplant. 2007;7(3):685-692.
PubMed   |  Link to Article
Mishra  A, Otgonsuren  M, Venkatesan  C, Afendy  M, Erario  M, Younossi  ZM.  The inpatient economic and mortality impact of hepatocellular carcinoma from 2005 to 2009: analysis of the US nationwide inpatient sample. Liver Int. 2013;33(8):1281-1286.
PubMed   |  Link to Article

Correspondence

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