Frequency of and reasons behind non-listing in adult patients referred for liver transplantation: Results from a retrospective study

Table 1 Adult patients evaluated for liver transplantation by year

	2015	2016	2017	2015-2017
Non listed	29	60	80	169 (53.8%)
On waitlist (on 31/12)1	17	28	21	21 (6.7%)
Drop-out from waitlist	5	5	6	16 (5.1%)
Transplanted	30	36	42	108 (34.4%)
Total (column)	81	129	149	314

¹These data were provided only to illustrate the distribution of patients in the individual years of the study. For the final calculation of the three-year study period, only those patients who were on the active waitlist as of 31 December 2017 were considered.

Table 2 Clinical features of patients

	All patients (n = 314)	Listed (n = 145)	Non-listed (n = 169)	P value
Age (yr)	54.6 ± 11.5	54.4 ± 10.1	54.7 ± 12.6	NS
Male sex	236 (75.1%)	118 (81.4%)	118 (69.8%)	0.018
Alcohol	130 (41.4%)	61 (42.1%)	69 (40.8%)	NS
HCC	112 (35.7%)	63 (43.4%)	49 (29%)	0.008
Active HBV	35 (11.1%)	19 (13.1%)	16 (9.5%)	NS
Past HBV	32 (10.2%)	22 (15.2%)	10 (5.9%)	0.007
HCV	70 (22.3%)	36 (24.8%)	34 (20.1%)	NS
PBC/PSC	23 (7.3%)	15 (10.3%)	8 (4.7%)	NS
Autoimmune	9 (2.9%)	3 (2.1%)	6 (3.6%)	NS
Non-Alcoholic Steatohepatitis	43 (13.7%)	25 (17.2%)	18 (10.6%)	NS
Other indications1	27 (8.6%)	14 (9.6%)	13 (7.7%)	NS
Confirmed or suspected ALF2	34 (10.8%)	8 (5.5%)	26 (15.3%)	0.011
Portal vein thrombosis	52 (16.6%)	28 (19.3%)	24 (14.2%)	NS
TIPS	20 (6.4%)	14 (9.7%)	6 (3.6%)	0.027
Referred from another hospital	102 (32.5%)	33 (22.8%)	69 (40.8%)	0.001

¹Include 6 hepatitis D virus coinfection, 5 polycystic liver disease, 3 re-transplantation, 3 iron overload, 2 secondary biliary cirrhosis, 2 Budd-Chiari Syndrome, 2 Alagille Syndrome, 1 Caroli Syndrome, 1 Wilson disease, 1 drug-induced liver disease, 1 portal hypertensive biliopathy.

²Include: 10 drug-related, 6 indeterminate, 5 hepatitis B virus, 4 hepatitis A virus, 2 hepatitis E virus, 2 iatrogenic, 1 autoimmune, 1 malignant infiltration, 1 amanita phalloides, 1 Hemolysis Elevated Liver enzymes and Low Platelet count syndrome, 1 acute hepatic artery thrombosis.

Data has been presented as the number of patients (%) or mean ± SD. Analysis has been conducted by either a χ² test or independent samples student’s t-test. HCC: Hepatocellular carcinoma; HBV: Hepatitis B virus; HCV: Hepatitis C virus; PBC: Primary biliary cholangitis; PSC: Primary sclerosing cholangitis; ALF: Acute liver failure; TIPS: Transjugular intrahepatic portosystemic shun; NS: Not significant.

Table 3 Reasons behind non-listing for liver transplantation

Non-listing categories	Non-listing motivations	N°
Contraindications	Psychological1	19	9.3%	91	44.4%
	Cardiovascular2	14	6.8%
	Surgical3	12	5.9%
	Ongoing alcohol abuse4	10	4.9%
	Infectious5	10	4.9%
	Obesity (BMI > 35)	9	4.4%
	Respiratory6	7	3.4%
	Extrahepatic malignancy7	6	2.9%
	Malnutrition8	4	1.9%
Incorrect indication	MELD Na < 159	33	16.1%	76	37.1%
	Recovery after conservative management for confirmed or suspected ALF	21	10.2%
	HCC beyond up-to-7 criteria and not amenable to downstaging	16	7.8%
	Low Mayo Risk Score	4	2.0%
	HCC successfully treated (T0)	2	1.0%
Patient decision	Refused transplantation	16	7.8%	25	12.2%
	Chose another center	6	2.9%
	Lost to follow-up	3	1.5%
Complications during evaluation		13	6.3%	13	6.3%
Total		205	100%	205	100%

¹6 cases of psychiatric comorbidities, 5 cases of neurological comorbidities, 3 cases of persistent non-compliance, 5 cases of the lack of an adequate support system.

²8 cases of ischemic heart disease, 4 cases of valvular heart disease, 1 case of arrhythmia, 1 case of pulmonary hypertension.

³5 cases of portal vein thrombosis Yerdel III-IV, 6 cases of previous gastrointestinal surgery with arterial axil alteration, 1 case of high-risk re-transplantation.

⁴abstinence period < 6 months and negative evaluation by alcohol-disorders specialist.

⁵4 cases of pneumonia, 2 cases of sepsis, 2 cases of HIV infection, 1 case of active tuberculosis, 1 case of osteomyelitis.

⁶5 cases of severe chronic obstructive pulmonary disease, 1 case of severe restrictive pattern, 1 case of interstitial lung disease.

⁷2 cases of breast cancer, 1 case of ovarian cancer, 1 case of lung cancer, 1 case of pancreatic cancer, 1 case of lymphoma.

⁸Based on the opinions of the nutritional consultant and the subsequent multidisciplinary (transplant hepatologist, transplant surgeon, and anesthesist) decision.

⁹After the antiviral treatment or alcoholic abstinence.

MELD-Na: Model for end-stage liver disease-sodium; ALF: Acute liver failure; HCC: Hepatocellular carcinoma; BMI: Body mass index.

Table 4 Multivariate analysis of predictors for listing

Variable	P value	OR (95%CI)
Referred from another hospital	0.005	2.113 (1.259–3.548)
Past HBV infection	0.019	0.373 (0.164–0.852)
HCC	0.068	0.623 (0.374–1.037)
Male sex	0.067	1.699 (0.964-2.994)
TIPS	0.116	0.439 (0.157–1.226)
ALF/Severe acute hepatitis	0.310	1.584 (0.651–3.852)

Analysis has been conducted by using multivariate logistic regression. HBV: Hepatitis B virus; HCC: Hepatocellular carcinoma; TIPS: Transjugular intrahepatic portosystemic shunt; ALF: Acute liver failure.