Background. Access to liver transplantation (LT) remains prioritized by patient acuity. Retrospective studies have demonstrated that patients with lower acuity still experience significant survival benefit with transplant; however, these results have yet to be confirmed by a randomized controlled trial. Methods. We simulated a randomized controlled trial using the novel trial emulation method. Adults listed for liver-only transplant 2016–2019 were paired using a time-dependent 1:1 propensity score and randomized to transplant (TXP) versus waitlist-only (WL) arms. All patients randomized to TXP had undergone transplant during the study period, whereas the WL arm included both patients who underwent transplant (WL-TXP) and did not (WL-only). Follow-up was measured from the date of transplantation of the TXP patients until removal from the waitlist, loss to follow-up, retransplantation, or the end of our follow-up period (December 31, 2019), whichever occurred first for the WL patients. Results. Of 23 672 total prematched patients, 8834 (37.3%) underwent transplant and 9460 had a lower Model for End-Stage Liver Disease (MELD) score of 6–14 (40.0%). 18.9% of MELD score 6–14 patients were transplanted compared with 49.6% of MELD score 15–24 patients. Nine thousand five hundred six patients were successfully matched. WL patients had a 73% increased risk of death compared with TXP patients (hazard ratio HR, 1.73; 95% confidence interval CI, 1.48-2.04). WL-only patients had a 2.83-fold greater mortality risk during follow-up compared with TXP or WL-TXP patients (HR, 2.83; 95% CI, 2.35-3.43). Trends were similar in MELD score 15–24 (HR, 3.74; 95% CI, 2.90-4.82) and MELD score 6–14 (HR, 1.52; 95% CI, 1.04-2.23) cohorts. Conclusions. Patients with a low MELD score experience a significant survival advantage with transplantation, despite their lower-acuity disease.
Hill et al. (Mon,) studied this question.