Simulation of Deceased-donor Liver Graft Allocation as UNOS Status I or IIa on the Current Korean Setting for Patients with Hepatitis B Virus-induced Fulminant Hepatic Failure

Hwang, Shin; Lee, Sung Gyu; Jung, Dong Hwan; Kim, Ki Hun; Ha, Tae Yong; Song, Gi Won

Abstract

Hepatitis B virus (HBV)-induced FHF fulminant hepatic failure (FHF) has been a main indication for urgent liver transplantation (LT), and these patients with hepatitis B virus (HBV)-induced FHF have a UNOS status of I. However, HBV-associated FHF has been downgraded to status IIa since late 2007 to eliminate the possibility of confusion between FHF and subacute / acute-orchronic liver failure. This current study evaluated the influence of this change of the UNOS status on organ allocation by using 4 sets of data (a single-institution study without LT cases, a singleinstitution study that included LT cases, a single-institution LT study and the nation-wide LT data). During the 12-year experience at Severance Hospital, HBV infection made up 30% of the 60 FHF patients. For the FHF patients, only 28.3% survived without LT. During the 6-year experience at Asan Medical Center, HBV infection made up 15.8% of the 114 FHF patients. Fifteen percent survived without LT, but 86% survived after LT. Only 1 out of the 14 cases of LT was deceased-donor LT. During the 2-year study on urgent LT at Asan Medical Center, there were 578 LT cases, including 520 living-donor LT and 58 deceased-donor LT. Of them, 120 patients (21.7%) had a UNOS status of I or IIa. The patients with HBV made up 17.8% of the status I patients and 80.3% of the status IIa patients. The one-year patient survival was 83.2% following living-donor LT and this was 71.1% following deceased-donor LT. For the nation-wide data for 8 years, 245 patients were allocated for a deceased-donor liver graft as status I (n=85) or IIa (n=160). Of them, 231 grafts were actually implanted. It was estimated that there is a 2.9-times difference in the probability for organ allocation between UNOS status I and IIa. In conclusion, down-grading of HBV-associated FHF from UNOS status I to status IIa would result in a significantly decreased probability to receive deceased-donor liver grafts. Therefore, it is concluded that such down-grading seems to involve unreasonable discrimination, leading to a disadvantage for patients with HBV-associated FHF. To avoid such dilemma for deceased organ allocation, Korea should consider adopting the model for end-stage liver disease (MELD).