Journal of Gastroenterology and Hepatology 22 (2007) 119–124 © 2006 The Authors 119 Journal compilation © 2007 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd doi:10.1111/j.1440-1746.2006.04422.x Blackwell Publishing AsiaMelbourne, AustraliaJGHJournal of Gastroenterology and Hepatology0815 93192006 Blackwell Publishing Asia Pty Ltd200722119124Original Article Liver transplant waiting list mortalityMA Fink et al. HEPATOLOGY Risk factors for liver transplantation waiting list mortality Michael A Fink,* ,† S Roger Berry,* ,† Paul J Gow,* Peter W Angus,* Bao-Zhong Wang,* ,† Vijayaragavan Muralidharan,* ,† Christopher Christophi* ,† and Robert M Jones* ,† *Liver Transplant Unit Victoria, and † Department of Surgery, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia Abstract Background and Aim: The gap between the demand for liver transplantation and organ donation rates has a major impact on waiting list mortality. Understanding the risk factors that predict liver transplant waiting list death may help optimize organ allocation policy and reduce waiting list deaths. Methods: We analyzed risk factors associated with waiting list mortality in the Liver Transplant Unit Victoria for the period 1988 through 2004. Results: The mean annual waiting list mortality for the period examined was 10.2% (10.6% for adult and 6.4% for pediatric patients). Factors associated with waiting list death included female sex, fulminant hepatic failure, primary non-function, blood group O, more urgent United Network for Organ Sharing (UNOS)-derived medical status, a Child- Turcotte-Pugh (CTP) score ≥ 11, a model for end-stage liver disease (MELD) score ≥ 20, and a pediatric end-stage liver disease score ≥ 20. UNOS-derived medical status, CTP class, and MELD score were significant at the multivariate level. Conclusions: Disease severity scores, such as MELD, predict the risk of liver transplanta- tion waiting list mortality. Use of such scores in organ allocation in Australian liver transplant units may result in reduced waiting list mortality. Introduction The gap between the demand for liver transplantation and organ donation rates has a major impact on waiting list mortality. 1–6 Understanding the risk factors that predict liver transplant waiting list death may help optimize organ allocation policy and reduce waiting list deaths. Death of liver transplant candidates approxi- mates 1-year post-transplantation mortality in the USA 7 and repre- sents a significant component of failure of liver transplantation on an intention-to-treat basis. Australia, with a land area 78% of that of the USA, but only 7% of the population, 8 has unique challenges in providing liver transplantation services, including transporta- tion and sharing of organs and patient access to transplantation services. In addition, the deceased organ donor rate of 9.0 per mil- lion population per year 9 is one of the lowest in the Western world. However, waiting list outcomes and factors associated with death on the waiting list have not previously been analyzed. The present article evaluates the risk factors for liver transplantation waiting list mortality in the Liver Transplant Unit Victoria (LTUV). Methods The LTUV waiting list was studied by analysis of a prospective database for the period 1988 (the year the unit commenced) through 2004. Patients who were delisted due to deterioration in medical condition or tumor progression and who subsequently died were considered to have died on the waiting list. Waiting list mortality was defined as the number of deaths on the waiting list divided by the sum of the number of patients on the waiting list at the start of the period and the number of patients activated over the period, expressed as a percentage. Groups of patients at greater risk of death on the waiting list were analyzed. Factors analyzed included age, sex, height, weight, girth, primary disease process, blood group, United Network for Organ Sharing (UNOS)-derived medical status, Child-Turcotte- Pugh (CTP) score and class, model for end-stage liver disease (MELD) score and, in patients less than 18 years of age, pediatric end-stage liver disease (PELD) score. These were measured at the time patients were placed on the waiting list. Fulminant hepatic failure was defined as liver failure occurring within 6 weeks of the onset of disease and excluded hepatic arterial thrombosis and primary non-function following previous liver transplantation. Patients were classified by UNOS-derived medical status as ventilated, non-ventilated in the Intensive Care Unit (ICU), hospi- tal-bound or requiring frequent hospital care. The CTP score was calculated according to Pugh’s modification of the Child-Turcotte classification. 10 Patients with a CTP score of 5 or 6 were classified as CTP class A; 7, 8 or 9 as CTP class B; and greater or equal to 10 Key words fatal outcome, liver transplantation, mortality, survival rates, waiting lists. Accepted for publication 15 December 2005. Correspondence Dr Michael A Fink, The University of Melbourne Department of Surgery, Austin Hospital, Melbourne 3084, Australia. Email: mafink@unimelb.edu.au