Increased Waitlist Death and Removal in Pediatric Liver Transplant Recipients Denied Exception Requests.
1Pediatrics, UCSF, San Francisco, CA
2Surgery, UCSF, San Francisco, CA
3School of Medicine, UCSF, San Francisco, CA.
Meeting: 2016 American Transplant Congress
Abstract number: 353
Keywords: Pediatric, Waiting lists
Session Information
Session Name: Concurrent Session: Pediatric Liver Transplant
Session Type: Concurrent Session
Date: Monday, June 13, 2016
Session Time: 4:30pm-6:00pm
Presentation Time: 4:30pm-4:42pm
Location: Room 206
Purpose: Over 30% of children listed for liver transplant (LT) have exceptions filed to increase their PELD/MELD. Non-standard exception requests (NSER) are granted by regional review boards. The impact of denial of NSER has not been studied.
Methods: UNOS data 2009-2014 on pediatric waitlist (WL) candidates, 0-18 years, analyzed excluding standard exceptions. Competing-risks regression evaluated WL death/removal for too sick, accounting for LT; backward stepwise selection with variables p<0.1 used to select multivariable (MV) models.
Results: Of 2747 WL candidates, 47%, 28%, and 25% were listed at age <2, 2-11, and 12-18 years, respectively, with 54% female, 22% Hispanic, 43% biliary atresia. Of 1216 with NSER (44%), 6.5% were never approved (n=79). WL death/removal occurred in 14% of those never approved, 5% of those approved (n=1137), and 7% with no NSER (n=1531). Denial was associated with increased risk of WL death/removal in univariate (HR=2.9, 95% CI 1.5-5.5, p=0.001) and MV (HR=2.1, 95% CI 1.0-4.2, p=0.04) analyses compared to NSER approval (Table 1). In MV model, higher MELD/PELD increased WL death/removal (HR 1.06, 95% CI 1.04-1.07, p<0.001). Gender, prior LT, region, list year did not predict WL death/removal.
| Univariate | Multivariate | |||||
| HR | 95%CI | HR | 95%CI | p | ||
| Hispanic | 1.8 | 1.3-2.5 | 1.8 | 1.3-3.9 | 0.001 | |
| Public insurance | 1.7 | 1.2-2.3 | ||||
| Age | <2 yr | – | – | – | – | – |
| 2-11 yr | 0.7 | 0.5-1.0 | 0.6 | 0.4-0.9 | 0.007 | |
| 12-18 yr | 0.7 | 0.5-1.1 | 0.5 | 0.3-0.7 | <0.001 | |
| Diagnosis | Biliary atresia | – | – | – | – | – |
| Other cholestatic | 1.1 | 0.7-1.9 | 1.3 | 0.7-2.2 | 0.4 | |
| Metabolic liver disease | 1.6 | 0.9-2.6 | 2.2 | 1.3-3.9 | 0.01 | |
| Acute liver failure | 1.7 | 0.9-3.2 | 1.8 | 0.9-3.6 | 0.1 | |
| Tumor | 1.5 | 0.7-3.2 | 2.7 | 1.2-6.1 | 0.02 | |
| Other | 2.0 | 1.4-2.9 | 2.5 | 1.6-4.0 | <0.001 | |
| Exception Request | Ever approved | – | – | – | – | – |
| Never approved | 2.9 | 1.5-5.5 | 2.3 | 1.1-4.8 | 0.02 | |
| No exception requests | 1.5 | 1.1-2.0 | 1.1 | 0.8-1.6 | 0.5 | |
| Listing labs, per 1 unit increase | INR | 1.2 | 1.1-1.3 | |||
| Bilirubin (mg/dL) | 1.05 | 1.04-1.06 | 1.04 | 1.03-1.15 | <0.001 | |
| Creatinine (mg/dL) | 1.12 | 1.01-1.24 | 1.2 | 1.04-1.3 | 0.01 | |
| Albumin | 0.7 | 0.6-0.9 |
Conclusion: Patients denied NSER are more likely to die or require removal from the WL for being too sick.
CITATION INFORMATION: Braun H, Dodge J, Rhee S, Roberts J, Perito E. Increased Waitlist Death and Removal in Pediatric Liver Transplant Recipients Denied Exception Requests. Am J Transplant. 2016;16 (suppl 3).
To cite this abstract in AMA style:
Braun H, Dodge J, Rhee S, Roberts J, Perito E. Increased Waitlist Death and Removal in Pediatric Liver Transplant Recipients Denied Exception Requests. [abstract]. Am J Transplant. 2016; 16 (suppl 3). https://atcmeetingabstracts.com/abstract/increased-waitlist-death-and-removal-in-pediatric-liver-transplant-recipients-denied-exception-requests/. Accessed May 21, 2025.« Back to 2016 American Transplant Congress