Criteria for Liver Transplant Should Include Quality of Life Measures: Study

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Criteria for Liver Transplant Should Include Quality of Life Measures: Study

by John C. Martin

Article 02-02-05

 

People selected as candidates for a liver transplant are prioritized on the

waiting list based on the severity of their liver disease. But doctors in a

recent study point out that the evaluation of a patient's liver disease doesn't

take his or her quality of life into account.1

 

Their research is published in the February issue of the journal Liver

Transplantation.

 

How Waiting List Criteria are Decided

Decisions on allocating livers for transplant is currently based on a particular

patient's score on the Model for End-Stage Liver Disease, or MELD, experts say.

The MELD score uses results of three laboratory tests to predict the short-term

prognosis of a patient's liver disease. The higher the score, the more severe a

person's liver disease.

 

Because the MELD score is based on clinical findings, it is believed to be an

accurate model of liver disease severity, according to experts. But it doesn't

take into account complications such as hepatic encephalopathy, which is

associated with cognitive dysfunction, personality changes, and learning

problems; and ascites, an accumulation of excess fluid in the abdomen that can

accompany liver disease. These complications can directly affect a patient's

quality of life, say the authors of the study.

 

Quality of Life Considerations

To determine whether or not the MELD score directly corresponds to a patient's

quality of life, doctors at UCLA included 150 patients in their study awaiting a

liver transplant. The research project included two types of assessments of

liver disease severity for each patient, including the MELD score, as well as

two quality-of-life questionnaires.

 

Liver disease complications among the patients included ascites, hepatic

encephalopathy, and bleeding gastrointestinal varices. Eight patients had a

history of spontaneous bacterial peritonitis, another potential complication of

liver disease.

 

The study team found that while most patients with end-stage liver disease

reported that their quality of life was impaired, there was little connection

between quality of life measurements and liver disease severity as measured by

MELD. " The MELD score itself does not correlate well with severity of hepatic

encephalopathy or ascites, " wrote Sammy Saab, MD, of the David Geffen School of

Medicine at UCLA, and his colleagues. " In our model, encephalopathy and ascites

were found to be important factors to consider in measuring quality of life. "

 

Quality of Life Considerations are 'Essential'

" Patients consider quality of life in addition to survival when making health

care decisions, " the researchers added. " In liver disease in particular, it is

essential to understand the impact of their disease on their quality of life

because of the prolonged wait for transplantation. "

 

They point out doctors should not assume that the clinical measurement of a

person's liver disease doesn't always reflect his or her quality of life. Thus,

future research that focuses on information about people waiting for liver

transplants should include quality of life assessments as well as liver disease

evaluations and survival odds, the researchers maintain.

 

The long-term goal is that a person's quality of life should be included when

prioritizing a patient on the liver-transplant waiting list.

 

Expert: Keep it in Context

In an editorial accompanying the study,2 Richard Freeman, MD, of the Division of

Transplant Surgery at Tufts-New England Medical Center in Boston has a slightly

different view. Freeman wrote that while quality of life is a significant

consideration in health care decision-making, decisions about allocating organs

for transplants must be considered within the context of the severe organ

shortage.

 

" In the current extremely constrained donor supply, the quality is not whether

an individual patient's [health-related quality of life] is poor enough to

warrant intervention with transplantation, but more directly, to whom, among all

of the potential recipients of a given donor liver, should that donor liver be

offered, " he wrote.

 

Freeman maintains that a person's quality of life should not outweigh risk of

death when decisions are being made about where patients should be placed on the

transplant waiting list. " Would we ever want to direct an organ to a patient

with a poorer quality life … who has a low MELD score ahead of a patient with a

possibly higher or equally low health-related quality of life score, but a much

higher MELD score? " he questioned. " In other words, would the chance to improve

the quality of life ever be prioritized before the chance to save a life? "

 

" One might visualize a system in which, among candidates with equal waiting

mortality risks, we might prioritize the one with the poor health-related

quality of life, " Freeman wrote. " But it is difficult to imagine ever ranking

health-related quality of life ahead of mortality risk. "

 

1. Saab S, Ibrahim AB, Shpaner A et al. MELD fails to measure quality of life in

liver transplant candidates. Liver Transpl 2005 Feb;11(2):218-23.

2. Freeman RB. MELD and the quality of life. Liver Transpl 2005

Feb;11(2):134-136.

 

John Martin is a long-time health journalist and an editor for Priority

Healthcare. His credits include coverage of health news for the website of Fox

Television's The Health Network, and articles for the New York Post and other

consumer and trade publications.

 

 

 

 

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