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Chang CH, Bryce CL, Shneider BL, et al. Accuracy of the Pediatric End-stage Liver Disease Score in Estimating Pretransplant Mortality Among Pediatric Liver Transplant Candidates. JAMA Pediatr. 2018;172(11):1070–1077. doi:10.1001/jamapediatrics.2018.2541
Do Pediatric End-stage Liver Disease scores adequately estimate 90-day pretransplant mortality among pediatric patients?
In this study of 4298 patients with chronic liver disease identified using the United Network for Organ Sharing pediatric waiting list, Pediatric End-stage Liver Disease scores and mortality were concordant; however, the estimated risk using the Pediatric End-stage Liver Disease score significantly underestimated actual 90-day mortality.
The Pediatric End-stage Liver Disease system may be flawed and may disadvantage children awaiting liver transplant when used to adjudicate organ allocation decisions; a new system that reflects actual 90-day mortality should be developed.
Fair allocation of livers between pediatric and adult recipients is critically dependent on the accuracy of mortality estimates afforded by the Pediatric End-stage Liver Disease (PELD) and Model for End-stage Liver Disease, respectively. Widespread reliance on exceptions for pediatric recipients suggests that the 2 systems may not be comparable.
To evaluate the accuracy of the PELD score in estimating 90-day pretransplant mortality among pediatric patients on the United Network for Organ Sharing (UNOS) waiting list.
Design, Setting, and Participants
Patients who were listed from February 27, 2002, to March 31, 2014, for primary liver transplant were included in this retrospective analysis and were followed up for at least 2 years through June 17, 2016. The study analyzed 2 cohorts using the UNOS Standard Transplant Analysis and Research data files. The full cohort comprised 4298 patients (<18 years of age) who had chronic liver disease (excluding cancer). The reduced cohort (n = 2421) excluded patients receiving living donor transplantation or PELD exception points.
Main Outcomes and Measures
Observed and expected 90-day pretransplant mortality rates evaluated at 10-point interval PELD levels.
Among the 4298 patients in the full cohort (mean [SD] age, 2.5 [4.2] years; 2251 [52.4%] female; 2201 [51.2%] white), PELD scores and mortality were concordant (C statistic, 0.8387 [95% CI, 0.8191-0.8584] for the full cohort and 0.8123 [95% CI, 0.7919-0.8327] for the reduced cohort). However, the estimated 90-day mortality using the PELD score underestimated the actual probability of death by as much as 17%.
Conclusions and Relevance
With use of the PELD score, the ranking of risk among children was preserved, but direct comparisons between adult and pediatric candidates were not accurate. Children with chronic liver disease who are in need of transplant may be at a disadvantage compared with adults in a similar situation.
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