OPTIMAL TIMING OF LIVER-TRANSPLANTATION FOR PRIMARY BILIARY-CIRRHOSIS

In 1989, we reported on the efficacy of liver transplantation in prima ry biliary cirrhosis (PBC) by demonstrating that the actual patient su rvival following transplantation was significantly better than without transplantation as predicted by a mathematical survival model (''Mayo natural history model''). Our aim in this investigation was to determ ine an optimal time to perform liver transplantation in PBC. One hundr ed forty-three patients with PEC undergoing liver transplantation were followed prospectively. Disease severity was measured immediately bef ore transplantation by a summary score (''risk score'') used in the Ma yo natural history model, namely age, bilirubin, albumin, prothrombin time, and the presence or absence of edema. Proportional hazards analy ses were performed assessing patient survival following transplantatio n. The influence of disease severity immediately pretransplantation on resource utilization for liver transplantation was assessed. Compared with our report in 1989, liver transplantation was performed at an ea rlier stage of disease (e.g., median risk score: 7.5 vs. 8.3; P < .01) . Following transplantation, patient survival probabilities at 1, 2, a nd 5 years were 93%, 90%, and 88%, respectively. In the proportional h azards analysis, the risk of death following transplantation remained low until reaching a risk score of 7.8. In contrast, risk scores great er than 7.8 were associated with a progressively increased mortality. Resource utilization measured by the days in the intensive care unit ( ICU) and hospital and the requirement for intraoperative blood transfu sions was significantly greater in recipients who had higher risk scor es before transplantation. Our data suggest that an optimal timing for liver transplantation, as determined by patient survival and resource utilization, appears to be at a risk score around 7.8 in patients wit h PBC.