Low Model for End-Stage Liver Disease Score Patients Experience Significant Survival Advantage With Liver Transplantation

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.