Inaccuracies found in UNOS categorization of ACLF in LT patients, reform needed

January 31, 2022

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Source/Disclosures


Disclosures: The authors report no relevant financial information.


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The United Network for Organ Sharing database on categorizing acute or chronic liver failure in liver transplant patients disagrees with manual chart review and demonstrates the need for policy reform, according to findings from the study.

“The ACLF studies that have relied on [United Network for Organ Sharing (UNOS)] and led discussions to change liver transplant policies around the world may provide inaccurate and biased estimates,” Brian P. Lee, MD, MAS, assistant professor at the Keck School of Medicine at the University of Southern California, Healio told. “Policymakers should ask themselves if they relied too heavily on this data and acted too quickly. UNOS should reform its data collection to more accurately capture ACLF and better inform liver transplant allocation policies.

Lee and colleagues conducted stratified random sampling among three LT centers between 2013 and 2019 and collected 481 samples of LT recipients aged 18 and older (median age 55). Of these, 250 had no ACLF, 75 had ACLF grade 1, 79 had ACLF grade 2, and 77 had ACLF grade 3, according to UNOS classification. The investigators compared the concordance of the ACLF classifications by UNOS with the blinded manual chart review.

According to the results of the study, the concordance of ACLF grade by UNOS compared to the chart review was 72% for no ACLF, 64% for grade 1, 56% for grade 2 and 64 % for grade 3. The investigators also determined that Cohen’s overall kappa coefficient was 0.48 (95% CI, 0.42-0.54), suggesting poor agreement with manual chart review . The most common reason for overestimation of ACLF by UNOS was the absence of acute decompensation, with discordant categorization of cerebral and respiratory failure being the most common reason for underestimation.

“We found that UNOS did not categorize ACLF consistently or accurately when compared to the chart review, which points to the need for UNOS reform and non-UNOS studies to inform appropriate transplant policies with the ACLF,” Lee and colleagues wrote in Journal of Hepatology.

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