Evaluation Within Thirty Days of Referral for Liver Transplantation is Associated with Reduced Mortality: A Multi-Center Analysis of Patients Referred Within the VA Health System

BACKGROUND AND AIMS Successful liver transplantation offers the possibility of improved survival among patients with decompensated cirrhosis. However, there is wide variability in access to care and promptness of the transplant evaluation process in the United States. METHODS We performed a multi-center retrospective study of 1,118 patients who underwent evaluation for liver transplantation at the six Veterans Affairs' transplant centers from 2013-2018. Of these, 832 patients were evaluated within 30 days and 286, more than 30 days after referral. We studied the differential effects of the time from referral to evaluation on pre and post-transplant mortality and transplant list drop out and explored predictors of early transplant evaluation. RESULTS Patients in the early evaluation group had a shorter adjusted time from referral to listing by 29.5 days (95% CI -50.4, -8.5, p<0.006), and referral to transplantation by 115.1 days (95% CI -179.5, -50.7, p<0.0001). On a multivariable Cox hazard model, evaluation within 30 days of referral was associated with a significantly lower pre-transplant mortality (adjusted Hazard Ratio aHR 0.70, 95% CI 0.54-0.91, p-value<0.01), but not associated with transplant list dropout (aHR 0.95, 95% CI 0.65-1.39, p=0.79) or post-transplant death (aHR 1.88, 95% CI 0.72-4.9, p=0.20). An early evaluation within 30 days was positively associated with a higher MELD at referral (aHR 1.03, 95% CI 1.01-1.06, p=0.006) and negatively associated with distance from the transplant center (aHR 0.99, 95% CI 0.99-0.99, p=0.045). CONCLUSION Evaluation of patients referred for liver transplantation within 30 days is associated with a reduction in pre-transplant mortality.