The Survival Benefit of Liver Transplantation

Demand for liver transplantation continues to exceed donor organ supply. Comparing recipient survival to that of comparable candidates without a transplant can improve understanding of transplant survival benefit. Waiting list and post‐transplant mortality was studied among a cohort of 12 996 adult patients placed on the waiting list between 2001 and 2003. Time‐dependent Cox regression models were fitted to determine relative mortality rates for candidates and recipients. Overall, deceased donor transplant recipients had a 79% lower mortality risk than candidates (HR = 0.21; p < 0.001). At Model for End‐stage Liver Disease (MELD) 18–20, mortality risk was 38% lower (p < 0.01) among recipients compared to candidates. Survival benefit increased with increasing MELD score; at the maximum score of 40, recipient mortality risk was 96% lower than that for candidates (p < 0.001). In contrast, at lower MELD scores, recipient mortality risk during the first post‐transplant year was much higher than for candidates (HR = 3.64 at MELD 6–11, HR = 2.35 at MELD 12–14; both p < 0.001). Liver transplant survival benefit at 1 year is concentrated among patients at higher risk of pre‐transplant death. Futile transplants among severely ill patients are not identified under current practice. With 1 year post‐transplant follow‐up, patients at lower risk of pre‐transplant death do not have a demonstrable survival benefit from liver transplant.