Algorithm for prioritization of patients on the waiting list for liver transplantation

Prioritization of patients on the waiting list (WL) for OLT is still a critical issue. Numerous models have been developed to predict mortality before and after OLT. AIM: The aim of the study was to prospectively evaluate cirrhotics with and without hepatocellular carcinoma (HCC) undergoing orthotopic liver transplantation (OLT) severity of liver disease on the WL and at transplant, mortality on the WL and after OLT, and their correlations. MATERIALS AND METHODS: An algorithm based on seven patient variables (MELD, CTP, UNOS, HCC, BMI, waiting time, age) was created by software dedicated to prioritize patients on the waiting list. RESULTS: We evaluated 118 patients including 75 men and 43 women of age range 19 to 66 years, who underwent OLT from July 2004 to June 2006. Mean CTP and MELD at listing were 8.44 (range 6-12) and 13 (range 2-24), respectively. Overall mortality on the WL at 24 months was 13%, which was significantly higher among patients with MELD > 25 compared to patients with MELD 0 to 15 (P < .0001) or MELD 16 to 25 (P = .0007) at listing. Mean MELD at OLT was 15 (range 7-36), which was significantly lower in patients with than without HCC (MELD 12 vs 16; P = .0003). Six hundred-day patient survival was significantly lower among patients with MELD > 25 compared to patients with MELD < 25 at OLT (P = .017), whereas no difference in survival was observed between patients with and without HCC. CONCLUSIONS: The sickest patients are characterized by high mortality both on the waiting list and after liver transplantation. Patients with HCC are transplanted in better condition compared to patients without HCC with the same survival.     

Reduced Priority MELD Score for Hepatocellular Carcinoma Does Not Adversely Impact Candidate Survival Awaiting Liver Transplantation

The liver organ allocation policy of the United Network for Organ Sharing (UNOS) is based on the model for end-stage liver disease (MELD). The policy provides additional priority for candidates with hepatocellular carcinoma (HCC) who are awaiting deceased donor liver transplantation (DDLT). However, this priority was reduced on February 27, 2003 to a MELD of 20 for stage T1 and of 24 for stage T2 HCC. The aim of this study was to determine the impact of reduced priority on HCC candidate survival while on the waiting list. The UNOS database was reviewed for all HCC candidates listed after February 27, 2002, The HCC candidates were grouped into two time periods: MELD 1 (listed between February 27, 2002, and February 26, 2003) and MELD 2 (listed between February 27, 2003 and February 26, 2004). For the two time periods, the national DDLT incidence rates for HCC patients were 1.44 versus 1.53 DDLT per person-year (p = NS) and the waiting times were similar for the two periods (138.0 +/- 196.8 vs. 129.0 +/- 133.8 days; p = NS). Furthermore, the 3-, 6- and 12-month candidate, patient survival and dropout rates were also similar nationally. Regional differences in rates of DDLT for HCC were observed during both MELD periods. Consequently, the reduced MELD score for stage T1 and T2 HCC candidates awaiting DDLT has not had an impact nationally either on their survival on the waiting list or on their ability to obtain a liver transplant within a reasonable time frame. However, regional variations point to the need for reform in how organs are allocated for HCC at the regional level.     

Model for End-Stage Liver Disease (MELD) score and organ allocation from cadaveric donors for 198 liver transplantation procedures performed in a single center

Since February 2002, the United Network for Organ Sharing (UNOS) proposed to adopt a modified version of the Model for End-Stage Liver Disease (MELD) to assign priority on the waiting list for orthotopic liver transplantation (OLT). In this study, we evaluated the impact of MELD score on liver allocation in a single center series of 198 liver recipients (mean age of patients, 52.21+/-8.92 years), considering the relationship between clinical urgency derived from MELD score (overall MELD, 18.7+/-6.83; MELD <15 in 69 patients, MELD >or=15 in 129 patients) and geographical distribution of cadaveric donors (inside/outside Liguria Region, 125/73). The waiting time for OLT was 230+/-248 days, whereas the 3-month and 1-year patient survivals were 87.37% and 79.79%, respectively. No difference was observed for MELD score retrospectively calculated for patients who underwent OLT before February 2002 (n=71) compared with MELD score calculated for patients who received a liver thereafter (18.26+/-6.68 vs 18.94+/-6.92; P= .504). No significant difference was found in waiting time before and after adoption of MELD score (213+/-183 vs 238+/-278 days; P= .500), or by stratifying patients for MELD <15/>or=15 (225+/-234 vs 232+/-256 days; P= .851). Using the geographical distribution of donors as a grouping variable (outside vs inside Liguria Region), no significance occurred for MELD score (19.68+/-7.42 vs 18.17+/-6.42; P= .135) or waiting time (211+/-226 vs 242+/-261 days; P= .394). In our series, more OLTs were performed among sicker patients and no differences were found in the management of livers procured from cadaveric donors outside or inside Liguria Region. However, further efforts are needed to reduce the waiting time among patients with higher MELD scores.     

Consequences of the Implementation of the Model for End-stage Liver Disease System for Liver Allocation in Brazil

Background

In July 2006, the system for liver allocation in Brazil started to rely on the Model for End-stage Liver Disease (MELD) scale, replacing the previous chronological criteria. Under the new system, the score for listing pediatric patients is obtained by multiplication of the calculated PELD score by 3. The current criteria also features extra points for diseases such as hepatocellular carcinoma (HCC). This study sought to analyze the consequences of implementation of the MELD system on waiting list mortality, posttransplant survival rates and characteristics of the transplanted patients.

Methods

We retrospectively studied data from the State Health Secretariat of São Paulo, regarding all patients registered on the waiting list for liver transplantation in the State of São Paulo, in two periods: July 2005 to July 2006 (pre-MELD era) and July 2006 to July 2010 (MELD era). Patient survival rates calculated using the Kaplan-Meier method were compared by the log-rank test. P values <.05 were considered statistically relevant.

Results

After implementation of the MELD, waiting list registrations decreased by 39.8%; the percentage of transplants in HCC recipients increased from 2.4% to 23.7%; pediatric transplants increased from 6.5% to 9.3%; deaths on the list fell from 599 in the pre-MELD era to 359 in the last year analyzed; recipients with higher MELD displayed significantly lower posttransplant survival rates; HCC patients, better survival after transplantation (P = .002); No difference was observed comparing survival rates between pre-MELD and MELD eras (P = 474) or between adults and children (P = .867).

Conclusion

Under the MELD system for liver allocation in Brazil, there was a reduction in waiting list mortality and an increased number of transplantations in pediatric and HCC recipients. Survival rates of patients with higher MELD score were inferior. However, this result was offset by the greater survival in HCC recipients, with no difference in patient survival rates between the pre-MELD and MELD eras.     

Mortality while awaiting liver retransplantation: predictability of MELD scores

INTRODUCTION: Model for End-stage Liver Disease (MELD) scores at the time of listing on the transplant waiting list have been shown to accurately predict 3-month mortality in adults. There is no data assessing the accuracy of the MELD scores in predicting mortality of patients awaiting liver retransplantation. We sought to determine the outcome of patients listed for retransplantation at a single center and the accuracy of MELD scores in predicting mortality on the transplant waiting list. METHODS: A retrospective review of adult patients at a single center listed for a second liver transplantation during the years 1993 to 2000. MELD scores and a concordance statistic were calculated at the time of initial listing and initial transplant as well as the time of relisting for a second transplant and at 2, 4, 6, 8, 12, and 24 weeks after relisting. RESULTS: Of the 63 patients in the study, 43 (68%) received a second transplant, and 20 (32%) died while awaiting retransplantation. Of the patients receiving a second transplant, 13 (30%) died within 1 year of receiving the transplant. The most common cause of death on the waiting list was sepsis (50%), hepatorenal syndrome (20%), and multiorgan failure (10%), whereas the majority of deaths posttransplantation were sepsis-related (69%). At the time of relisting the c-statistic for MELD scores predicting death after 1 week on the waiting list was 0.78 (P = .007). After 3 months on the waiting list, the c-stat was largely unchanged (0.76, P = .04). CONCLUSIONS: We have shown that MELD scores may predict mortality on the transplant waiting list for patients listed for a second transplant.     

Potential predictive value of the MELD score for short-term mortality after liver transplantation

In the last years, a model for end-stage liver disease (MELD) was suggested as a disease severity score for patients with end-stage liver disease awaiting liver transplantation. In the early 2002, United Network for Organ Sharing (UNOS) has proposed to replace the current status 2A, 2B, and 3 by a modified version of the original MELD score based upon patient risk for 3-month mortality on the waiting list. In this study UNOS status and MELD score were evaluated retrospectively for postoperative 3-month mortality in patients who underwent liver transplantation from 2000 to 2001. Liver recipients were stratified for UNOS status 2A, 2B, and 3, and the corresponding MELD score was calculated for each patient. A receiver operating characteristic (ROC) analysis was performed for both conventional UNOS status and MELD score by fitting patient deaths within 3 months after liver transplantation. The MELD score revealed a better prediction rate for 3-month mortality after the first LT than conventional UNOS status, although no statistical significance was evident by ROC curve comparison. This preliminary study seems to suggest a potentially better predictive rate for the MELD score than conventional UNOS status concerning short-term mortality after liver transplantation.     

Validation of the HCC-MELD for dropout probability in patients with small hepatocellular carcinoma undergoing locoregional therapy

Abstract: Background:  The model for end-stage liver disease (MELD) is used in prioritizing cirrhotic patients awaiting liver transplantation. Patients with small hepatocellular carcinoma (HCC) are eligible candidates. An HCC-MELD equation was recently proposed to predict the dropout rate of HCC patients on the waiting list. This study aimed to validate the accuracy of this equation.
Methods:  We investigated 390 patients with small HCC who were candidates for liver transplantation and underwent locoregional therapy.
Results:  The estimated probability of dropout according to the equation was 8.2% for T1 stage and 13.5% for T2 stage HCC (p < 0.0001). The actual disease progression rate at three months was 2.1% for T1 and 3.0% for T2 stage HCC. At six months, the progression rate was 5.3% for T1 stage and 6.8% for T2 stage. The area under receiver operating characteristic curve of the HCC-MELD equation was 0.81 at three months and 0.80 at six months. Patients undergoing radiofrequency ablation (RFA) had significantly lower dropout rates compared with other treatment groups according to the equation (p = 0.0007). The actual tumor progression rate was also the lowest for the RFA group at both three and six months.
Conclusion:  The HCC-MELD equation is a feasible predictive model for patients with small HCC undergoing locoregional therapy.     

Analysis of Model for End-Stage Liver Disease (MELD) score in a liver transplantation waiting list

BACKGROUND: The Model for End-Stage Liver Disease (MELD) was introduced in 1999 to quantify the 3-month prognosis of cirrhotic patients after a transjugular intrahepatic portosystemic shunt (TIPS). Because of the imbalance between organ donors and patients on the waiting list, the MELD was adopted by the United States in 2002 to allocate liver grafts for transplantation. Preliminary results have indicated a reduction in waiting list deaths and an increase in transplantation rates for candidates. Seeking to find a new model to predict death on the waiting list and after liver transplantation, retrospective studies have examined MELD scores in waiting list patients. The aim of this study was to analyze the MELD scores of patients on the liver waiting list for comparisons between transplanted patients. PATIENTS AND METHODS: A retrospective study was performed analyzing 131 registrations of 127 orthotopic liver transplant (OLT) patients (4 underwent retransplantation) grafted between November 2000 and January 2006, excluding 24 patients: 2 had urgent retransplantations due to hepatic artery thrombosis and 22 had incomplete data. These patients were divided into 3 groups: group I (transplanted patients)-53 patients underwent 55 OLT; group II-29 patients who died on the waiting list; group III-patients on the waiting list including 23 patients still waiting as of the date of the study. RESULTS: The main indication for OLT was hepatitis C virus cirrhosis (50.50%), followed by alcoholic liver cirrhosis (23.30%), cryptogenic cirrhosis (12.60%), autoimmune hepatitis (5.80%), hepatitis B virus cirrhosis (4.85%), and primary biliary cirrhosis (2.91%). Group I: MELD score 15.62 (range, 6-39) on admission to the list, and 18.87 (range, 7-39) at transplantation. The mean waiting time for OLT was 478.39 days (range, 2-1270 days). The 38 patients who survived underwent 39 OLT (1 retransplantation). The MELD score at entrance to the list was 14.62 (range, 7-30) and at transplantation, 17.70 (range, 7-39). The mean time between admission to the list and transplantation was 505.37 days (range, 6-1270 days). The 15 patients who died had received 16 OLT (1 retransplantation). Their MELD scores were 17.80 (range, 6-39) and 21.81 (range, 9-39) at admission to the list and at transplantation, respectively, with a mean time on the waiting list of 417.93 days (range, 2-872 days). Group II: 29 patients died before OLT, at a mean age of 52.60 years (range, 22-67 years). Their MELD score was 19.24 (range, 7-45), and the interval between admission to the waiting list and death was 249.55 days (range, 3-1247 days). Group III: 23 patients still active on the OLT waiting list at the time of study displayed a mean MELD score of 13.65 (range, 6-28) and 354.30 days (range, 2-905 days) waiting until the moment. In conclusion, MELD score at the time of admission to the waiting list was higher among those patients who died either awaiting a liver graft (19.24) or after OLT (17.80) compared with those who survived after OLT (14.60) or are still awaiting OLT (13.65).     

Impact of the MELD score on waiting time and disease severity in liver transplantation in United States veterans.

Organ allocation for liver transplantation (LT) in the United States is based on the Model for End-Stage Liver Disease (MELD) score. The MELD score prioritizes organ distribution to sicker patients. There is limited data on the effect of this policy on transplantation in the Veterans Affairs (VA) healthcare system. The aim of this study was to determine the impact of the MELD score on U.S. veteran patients undergoing LT. Comparison of MELD scores and waiting time of LT recipients before and after the introduction of the MELD system was done. A total of 192 LT recipients were analyzed. Blood type, diagnosis, listing MELD score, and Child-Turcotte-Pugh (CTP) score at transplant did not differ although MELD era recipients were older (mean 54.3 vs. 51.3 yr, P = 0.009). Mean waiting time decreased from 461 days (pre-MELD) to 252 days (MELD era) (P = 0.004). Mean MELD score at LT increased from 23.4 (MELD era) compared to 20.3 (pre-MELD) (P = 0.01). In conclusion, waiting time for LT in U.S. veterans has decreased significantly in the MELD era. The MELD score of patients transplanted in the MELD era is significantly higher and patients are still being listed at a high MELD score. The MELD system has lead to sicker veterans being transplanted with shorter waiting times.     

Impact of model for end-stage liver disease (MELD) scoring system on pathological findings at and after liver transplantation.

The Model for End-Stage Liver Disease (MELD) scoring system, a validated objective liver disease severity scale, was adopted in February 2002 to allocate cadaveric organs for liver transplantation (LT). To improve transplantability before succumbing to advanced disease, patients with low-stage hepatocellular carcinoma (HCC) are given extra points in this system commensurate with their predicted mortality. Our aims were to determine 1) any change in the pathological findings at LT following the implementation of this system and 2) the impact of scoring advantage given to early-stage HCC. Clinicopathologic findings were compared before (pre-MELD, n = 87) and after (MELD, n = 58) the introduction of the MELD system. The findings in the pre-MELD vs. MELD groups were as follows: HCC, 27.5% vs. 48.3% (P = 0.001); portal vein thrombosis (PVT), 13.7% vs. 25.9% (P = 0.08); cholestasis, 16.1% vs. 32.7% (P = 0.026); inflammation grade of 2 or more, 43.7% vs. 48.3% (P = not significant); hepatitis C (HCV), 45.9% vs. 51.7% (P = not significant); HCV with lymphoid aggregates, 25% vs. 60% (P = 0.003); HCV with hyperplastic hilar nodes, 15.0% vs. 36.6% (P = 0.001); and post-LT HCC recurrence, 4.1% vs. 3.4% (P = not significant). Non-HCC-related findings were further compared in the 2 subgroups of pre-MELD (n = 57) and MELD (n = 31) after exclusion of HCC and fulminant hepatic failure (FHF) cases, and only cholestasis was significantly increased in the subgroup MELD. In conclusion, increased incidence of native liver cholestasis in the MELD era may be the histologic correlate of clinically severe liver disease. The scoring advantage given to low-stage HCC did result in a significantly increased incidence of HCC in the MELD group, but it did not adversely affect the post-LT recurrence rate.     

Assessment of short-term survival after liver transplant by the Model for End-Stage Liver Disease

The Model for End-Stage Liver Disease (MELD) score has demonstrated the ability to predict mortality among patients with chronic liver disease on the liver waiting list. The aim of this study was to assess the capability of the MELD score to correctly predict posttransplantation survival in Spain and to determine specific thresholds of MELD above which liver transplantation should be discouraged and the patient removed from the waiting list. METHODS: In this study, we retrospectively applied the MELD score to 168 patients at time of transplantation to estimate 1-month and 3-month posttransplant survivals by stratifying them into four groups: group A, MELD score < 10; group B, MELD score 10-18; group C, MELD score 19-24; group D, MELD score > 24. RESULTS: One-, 2-, and 3-month survivals were 84.3%, 80% and 79.5%, respectively. One-, 2-, and 3-month survivals in group A (18 patients) were identical (77.8%). In group B (80 patients), 1-month survival was 84.8%, and 2- and 3-month survivals were 78.4%. In group C (42 patients) 1-month survival was 90.5% and 2- and 3-month survivals were 88%. One-, 2-, and 3-month survivals in group D (28 patients) were 77.9%, 74%, and 70%, respectively. We defined a new group (group E) formed by patients with MELD score < or =24. When we compared 1-, 2-, and 3-month survival rates in group E (85.6%, 81.25%, and 81.25%, respectively) with survival rates in group D, the difference was not significant (P > .05). CONCLUSIONS: Although overall outcomes of patients whose MELD scores were high at the time of liver transplantation were inferior to those of patients whose MELD scores were lower, there was no significant difference for specific thresholds of MELD above which liver transplantation should be discouraged and the patient removed from the waiting list.     

Analysis of the Liver Transplant Waiting List in Our Center

BackgroundLiver transplantation (LT) is an important treatment for acute liver failure and end-stage liver disease. Due to the limited supply of livers, there are still thousands of candidates waiting for transplantation in Turkey. We aimed to analyze LT waiting list access by demographics and etiology, particularly the diagnosis of hepatocellular carcinoma (HCC), which has been prioritized for LT in recent years.Materials and MethodsBetween 2011 and 2018, all patients listed for LT in our center were retrospectively reviewed. Demographic features, etiology of liver disease, waiting time, Model for End-Stage Liver Disease (MELD) score, and survival data were recorded. Differences between the LT group and deceased patients on the waiting list were evaluated.ResultsDuring this period, 266 patients were included in the LT waiting list. Only 119 patients (44.7%) underwent LT (men, 94; women, 25; mean age, 53 years), whereas 103 (38%) died (men, 60; women, 43; mean age, 53 years) in the waiting period. Seventeen patients were status 1A or 1B and of these, 7 patients died from fulminant hepatic failure. MELD score was significantly higher in deceased group (28 ± 7 vs 25 ± 6; P = .014). The frequency of HCC was significantly higher in LT group (29% vs 11%; P = .002). Overall survival of the patients in the waiting list with and without liver transplantation were 63% and 41%, respectively.ConclusionsHCC is one of the leading etiologies that is considered for cadaveric LT from the waiting list in our center. These patients had slightly lower MELD scores compared to deceased patients with shorter waiting times. We recommend early referral and close monitoring of the patients who are LT candidates.     

Predicting Survival among Patients Listed for Liver Transplantation: An Assessment of Serial MELD Measurements

We examined whether consideration of repeated model for end-stage liver disease (MELD) measurements for patients listed for liver transplantation improves predictive value beyond current MELD alone. Clinical data were extracted for all adult primary liver transplantation candidates from our institution who were listed with the United Network for Organ Sharing (UNOS) between 1990 and 1999. Serum creatinine, bilirubin, and international normalized ratio (INR) were obtained from an institutional laboratory database. Cox models were constructed using current MELD, change in MELD (Delta), and number of MELD scores to predict survival on the waiting list. Eight hundred and sixty-one patients met inclusion criteria, 639 underwent transplantation, and 80 died while waiting. A one-unit increment in current MELD imparted significant hazard ratios ranging from 1.12 to 1.19 in all models. Delta MELD was predictive of mortality univariately, but less predictive when current MELD was included, and not predictive when considered with both current and number of MELD scores. Overall, current MELD is the single most important determinant of mortality risk on the waiting list. Delta MELD is predictive of death only within 4 d of the event; however, part of this correlates with the dying process itself, thus limiting Delta MELD's utility in survival prediction models.     

Comparison of two equivalent model for end‐stage liver disease scores for hepatocellular carcinoma patients using data from the United Network for Organ Sharing liver transplant waiting list registry

Patients with hepatocellular carcinoma (HCC) have been advantaged on the liver transplant waiting list within the United States, and a 6‐month delay and exception point cap have recently been implemented to address this disparity. An alternative approach to prioritization is an HCC‐specific scoring model such as the MELD Equivalent (MELD_EQ) and the mixed new deMELD. Using data on adult patients added to the UNOS waitlist between 30 September 2009 and 30 June 2014, we compared projected dropout and transplant probabilities for patients with HCC under these two models. Both scores matched actual non‐HCC dropout in groups with scores <22 and improved equity with non‐HCC transplant probabilities overall. However, neither score matched non‐HCC dropout accurately for scores of 25–40 and projected dropout increased beyond non‐HCC probabilities for scores <16. The main differences between the two scores were as follows: (i) the MELD_EQ assigns 6.85 more points after 6 months on the waitlist and (ii) the deMELD gives greater weight to tumor size and laboratory MELD. Post‐transplant survival was lower for patients with scores in the 22–30 range compared with those with scores <16 (P = 0.007, MELD_EQ; P = 0.015, deMELD). While both scores result in better equity of waitlist outcomes compared with scheduled progression, continued development and calibration is recommended.     

Expanded criteria donor grafts for deceased donor liver transplantation under the MELD system: a decision analysis.

Expanded criteria donor (ECD) liver grafts have a higher likelihood of primary graft failure (PGF) compared with standard criteria donor (SCD) grafts. Given a choice between an available ECD graft versus waiting for an SCD graft that may not always become available, what should liver transplant candidates do? The study's aim was to estimate 1-year survival comparing immediate ECD liver grafting with waiting for an SCD organ. Using UNOS data, published literature estimates, and expert opinion, we constructed a Markov decision analytic model to estimate survival while waiting for an SCD transplant and survival with immediate ECD transplant. Sensitivity analyses were performed by varying model parameters individually and simultaneously with a second-order Monte Carlo simulation. For all patients with MELD scores >20, survival was higher with immediate ECD transplant despite the additional increased risk for PGF. Survival was better with an immediate ECD transplant unless the probability of PGF exceeded 23%, 72%, and 88% for recipients with MELD scores of 11-20, 21-25, and 26-30 respectively. For patients with MELD scores >30, the survival benefit with the immediate ECD strategy persisted at even higher rates of PGF. In conclusion, our results suggest that, despite the higher risk for PGF, transplantation with an available ECD graft should be preferred over waiting for an SCD organ for patients with advanced MELD scores. At less advanced MELD scores, the survival benefit depends on the risk of PGF associated with the ECD organ.     

Comparison of clinical outcomes in chronic hepatitis B liver transplant candidates with and without hepatocellular carcinoma.

Patients with hepatocellular carcinoma (HCC) receive a higher MELD score and may undergo liver transplantation (OLT) earlier compared to patients with cirrhosis, potentially decreasing waiting list mortality. However, post-OLT survival may be reduced by recurrence of HCC. We compared clinical outcomes between patients with HBV-cirrhosis and no HCC and patients with HBV-HCC. A total of 279 patients (HBV-cirrhosis = 183; HBV-HCC = 96) in the US HBV-OLT study were followed for a median of 30.2 months from listing. Patients with HCC were older, more likely to be Asian, and had less severe liver impairment than patients with HBV-cirrhosis. Despite a higher rate of OLT in patients with HCC (78.1% vs. 51.4%; P < 0.001), intention-to-treat (ITT) survival (73% vs. 78%) and survival without OLT (82% vs. 79%) at 5 years were similar for patients with and without HCC. Cox regression analysis identified higher albumin, lower MELD, no HCC at listing, and being transplanted to be associated with better ITT survival. Ninety-four patients with HCC (including 19 new HCC) and 75 with HBV-cirrhosis underwent OLT. Post-OLT survival (83% vs. 90%) and HBV recurrence (11% vs. 10%) at 3 years were similar, while disease (HBV and/or HCC) recurrence (19% vs. 10%; P = 0.043) was higher in patients with HBV-HCC vs. HBV-cirrhosis. Disease recurrence was the only independent predictor of post-OLT survival. In conclusion, despite more advanced liver disease and a lower rate of transplantation, ITT survival of patients listed for HBV-cirrhosis was comparable to those with HBV-HCC, possibly related to beneficial effects of antiviral therapy.     

Preoperative characteristics and intraoperative transfusion and vasopressor requirements in patients with low vs. high MELD scores.

Recent changes in organ allocation based on the model for end-stage liver disease (MELD) prioritize the most ill patients on the waiting list for liver transplantation. While patients undergoing liver transplantation in the MELD era are more acutely ill, the impact of the policy changes on perioperative management has not been completely assessed. We retrospectively reviewed the records of 124 primary adult liver transplant patients. Patients were divided into low (< or = 30) and high MELD (>30) score groups. Preoperative characteristics and intraoperative management were compared between the 2 groups. Patients with high MELD scores had lower baseline hematocrit and fibrinogen levels and were more likely to require ventilatory and vasopressor support before transplantation. Intraoperative transfusion requirements and use of vasopressors were also significantly increased in patients with high MELD scores compared to patients with low MELD scores. In conclusion, these data suggest that pretransplant MELD scores provide important information for perioperative management of patients undergoing liver transplantation.     

Survival on Waiting List for Liver Transplantation Before and After Introduction of the Model for End-stage Liver Disease Score

Background

Since July 2006, the Model for End-stage Liver Disease (MELD) score has served as the national basis for allocation of donor livers for transplantation in Brazil. Patients with higher MELD scores receive greater priority for allocation regardless of the time on the waiting list.

Purpose

To investigate the impact of MELD score implementation on the survival of waiting list patients.

Methods

A retrospective study of patients registered at the national Organ Procurement Organization (OPO) for the liver transplantation waiting list between January 2004 and June 2006 (pre-MELD) and between July 2006 and December 2008 (post-MELD).

Results

We included listed patients awaiting liver transplantation in the pre-MELD era (n = 250, 48.4%) and in the post-MELD era (n = 266, 51.6%). The times awaiting transplant prior to and after the MELD system were 487.2 ± 384.8 days and 183.9 ± 157.2 days, respectively. Prior to the MELD score, waiting list survivals were greater when compared to rates in the current system. Early posttransplant patient survival rates were significantly reduced in the post-MELD era (83.4%) compared to the period before MELD implementation (93.2%).

Conclusions

MELD score provides a transparent, objective system to drive allocation policy; however, it presents several important limitations. Constant need of changes and reevaluation are needed as an evolutionary process. Future changes in the present system may be addressed by adjusting the MELD system.     

Validation of a dropout assessment model of candidates with/without hepatocellular carcinoma on a common liver transplant waiting list

The model of end‐stage liver disease (MELD) score is often used for liver graft allocation, and patients with hepatocellular carcinoma (HCC) receive exception points (22 in the US). A better model is desirable for patients with HCC as they tend to have a privileged access to transplantation, without taking HCC characteristics into account. A new simpler model designed from a training set of US patients (n = 49 026) was tested on two validation sets (US and UK patient cohorts with, respectively, n = 20 475 and n = 1781). The risk of dropout was between 3.2 and 7.8% at 3 months in patients with HCC, and was captured into a score, including HCC size, HCC number, AFP, and MELD (?37.8 +1.9*MELD+5.9 if HCC Nb ≥ 2 + 5.9 if AFP > 400 + 21.2 if HCC size > 1 cm). This new model could be validated on external US and UK liver candidate cohorts. It provides a dynamic and more accurate assessment of dropout than the use of exception MELD (C‐indices of 66.2–73.7% vs. 52.7–56.6%). In addition, the model shows a similar distribution as MELD for patients with non‐HCC, and both scores could be used in parallel for the management of waiting‐list patients with and without HCC.     

Liver transplantation for hepatocellular carcinoma: lessons from the first year under the Model of End-Stage Liver Disease (MELD) organ allocation policy.

We examined the impact of the Model for End-Stage Liver Disease (MELD) organ allocation scheme on 44 patients with hepatocellular carcinoma (HCC) awaiting orthotopic liver transplantation (OLT) between February 2002 and January 2003, and compared the outcome with 58 patients listed in the 4 years before MELD implementation. Patients undergoing living-donor liver transplantation were excluded. The Kaplan-Meier probabilities for OLT at 3, 6, and up to 8.5 months were 22.5%, 64.0%, and 88.0%, respectively, under MELD versus 17.2%, 24.7%, and 35.8% at 3, 6 and 9 months, respectively, in the pre-MELD group (P =.0006). In Cox regression analysis, non-O blood group (hazard ratio 2.5; P =.047 versus blood group O) and 3 tumor nodules (hazard ratio 5.5; P =.005) were associated with a significantly higher probability for OLT under MELD. The probabilities of dropout were 5.6% at 6 and 8.5 months under MELD versus 7.2% and 37.8% at 6 and 12 months, respectively, in the pre-MELD group (P =.74). The lack of a significant difference in dropout may be due to low dropout rates in the first 6 months in either group. No HCC was found in the explant in 1 patient from each group. In conclusion, the HCC-adjusted MELD system significantly improved the probability of timely OLT, albeit a significant disadvantage for blood group O was evident. Compared with preliminary UNOS data, in which 90% of patients with HCC have received OLT within 3 months, our results reflect the wide regional variation in the impact of MELD.