Change in model for end-stage liver disease score on the transplant waiting list predicts survival in patients undergoing liver transplantation

Allocation of donor livers through the model for end-stage liver disease (MELD) score has resulted in a fall in waiting list deaths in the United States. Change in MELD score (DeltaMELD) whilst awaiting transplant has been suggested as a method of refining organ allocation. Our aims were to analyse the effect of DeltaMELD between listing and transplant, and examine its impact on patient survival, intensive care stay and hospital stay in 402 patients transplanted for chronic liver disease at a single centre. Patients who had a DeltaMELD score of >+1 point were more likely to die in hospital following transplant (P < 0.05) and had a significantly worse 12- and 36-month survival post transplant (P < 0.0001) when compared with patients with DeltaMELD 相似文献   

Value of the MELD score for the assessment of pre- and post-liver transplantation survival

The MELD score has now been implemented in the United States for liver allocation, but it has not been validated in Europe. Its association with posttransplant outcome is unclear. Optimal cutoff values of MELD and Child-Pugh scores to predict death on the liver waiting list were defined in a series of 137 cirrhotic patients listed for liver transplantation. Six-month actuarial survival while on the waiting list was 90% with a Child-Pugh <11 and MELD <17, whereas it decreased progressively to 40% at 6 months after listing for those having a Child-Pugh and MELD score >10 and >16. Analysis of a series of 112 patients (85 chronic liver disease and 27 hepatocellular carcinoma) revealed no change in MELD value at the time of transplantation compared to the score at the time of listing (mean +/- SD: 15.5 +/- 7.7 vs 15 +/- 5.8) with a mean waiting time of 118 days. Using either the optimal cutoff for MELD score (<17 or >16) or seven different strata (3 to 7, 8 to 10, 11 to 13, 14 to 16, 17 to 19, 20 to 22, 23 to 39), whether measured at listing or just before liver transplantation, there was no significant difference (chi(2) 4.97, P = .58) in survival: 82.7% and 63% at 6 and 60 months, overall. Our data confirm that the MELD score with only three parameters is as good as the Child-Pugh score to predict mortality on the Eurotransplant waiting list. The optimal cutoff to assess higher priority for the bad category is >16. There was no negative impact on short- or long-term prognosis of the bad categories of MELD.     

Clinical epidemiological analysis of the mortality rate of liver transplant candidates living in rural areas

MELD score has been used to predict 90‐day mortality of subjects listed for liver transplantation (OLT). Validation of MELD score for patients on the waiting list in transplant programmes serving rural areas in North America is lacking. A retrospective cohort of patients affected by end‐stage liver disease was studied to assess the mortality rate within 90 days after being listed at our transplant centre. Secondary aims were to identify differences between predicted and observed 90‐days mortality using MELD and MELDNa scores at the time of listing. Among 126 patients included in this study, waiting list mortality was 35.0%. Ninety‐day mortality was 21.1%, which was significantly greater than the mortality estimated by the MELD (9.1%, 95% CI: 6.6–11.5) and MELDNa (9.3%, 95%CI: 6.0–12.5). Despite this underestimation, AUC for MELD and MELDNa was 0.80 and 0.78 respectively. In our study, independent predictors of waiting list mortality were age, diagnosis of cholestatic disease and residence over 500 km from our transplant centre. MELD and MELDNa underestimated the 90‐day mortality in patients with liver failure living in rural areas. Validation of these models should be performed in other transplant centres serving patients with limited access to specialized services.     

Does the meld system provide equal access to liver transplantation for patients with different ABO blood groups?

This study investigates the relationship between blood group and waiting time until transplantation or death on the waiting list. All patients listed for liver transplantation in the Netherlands between 15 December 2006 and 31 December 2012, were included. Study variables were gender, age, year of listing, diagnosis, previous transplantations, blood group, urgency, and MELD score. Using a competing risks analysis, separate cumulative incidence curves were constructed for death on the waiting list and transplantation and used to evaluate outcomes.In 517 listings, the mean death rate per 100 patient‐years was 10.4. A total of 375 (72.5% of all listings) were transplanted. Of all transplantations, 352 (93.9%) were ABO‐identical and 23 (6.1%) ABO‐compatible. The 5‐year cumulative incidence of death was 11.2% (SE 1.4%), and of transplantation 72.5% (SE 2.0%). Patient blood group had no multivariate significant impact on the hazard of dying on the waiting list nor on transplantation. Age, MELD score, and urgency status were significantly related to the death on the waiting list and transplantation. More recent listing had higher probability of being transplanted. In the MELD era, patient blood group status does not have a significant impact on liver transplant waiting list mortality nor on waiting time for transplantation.     

A systematic review of the performance of the model for end-stage liver disease (MELD) in the setting of liver transplantation.

The Model for End-Stage Liver Disease (MELD) score is now used for allocation in liver transplantation (LT) waiting lists, replacing the Child-Turcotte-Pugh (CTP) score. However, there is debate as whether it is superior to CTP score to predict mortality in patients with cirrhosis on the LT waiting list and after LT. We reviewed studies comparing the accuracy of MELD vs. CTP score in transplantation settings. We found that in studies of the LT waiting list (12,532 patients with cirrhosis), only 4 of 11 showed MELD to be superior to CTP in predicting short-term (3-month) mortality. In addition, 2 of 3 studies (n = 1,679) evaluating the changes in MELD score (DeltaMELD) showed that DeltaMELD had better prediction for mortality than the baseline MELD score. The impact of MELD on post-LT mortality was assessed in 15 studies (20,456 patients); only 6 (9,522 patients) evaluated the discriminative ability of MELD score using the concordance (c) statistic (the MELD score had always a c-statistic < 0.70). In 11 studies (19,311 patients), high MELD score indicated poor post-LT mortality for cutoff values of 24-40 points. In re-LT patients, 2 of 4 studies evaluated the discriminative ability of MELD score on post-LT mortality. Finally, several studies have shown that the predictive ability of MELD score increases by adding clinical variables (hepatic encephalopathy, ascites) or laboratory (sodium) parameters. On the basis of the current literature, MELD score does not perform better than the CTP score for patients with cirrhosis on the waiting list and cannot predict post-LT mortality.     

Impact of Adult Living Donor Liver Transplantation on Waiting Time Survival in Candidates Listed for Liver Transplantation

Studies comparing adult living donor liver transplantation to deceased donor liver transplantation have focused on post-transplant survival. Our aim was to focus on the impact of living donor liver transplant on waiting time mortality and overall mortality. We analyzed the affect of living donor liver transplantation on waiting time mortality and overall mortality (from listing until last follow up) in a cohort of 116 transplant candidates. Fifty-eight candidates who had individuals present as potential living donors (volunteer group) were matched by MELD score to 58 liver transplant candidates who did not have individuals present as a potential living donor (no volunteer group). Twenty-seven percent of candidates in the no volunteer group and 62% of candidates in the volunteer group underwent liver transplantation, p = 0.0003. One-year waiting list mortality for the volunteer group and no volunteer group was 10% and 20%, respectively, p = 0.03. Patient survival from the time of listing to last follow up was similar between the two groups. In our study group, living donor liver transplantation is associated with a higher rate of liver transplantation and lower waiting time mortality. In the era of living donor liver transplantation, estimates of patient survival should incorporate waiting time mortality.     

Characteristics of liver transplant candidates delisted following recompensation and predictors of such delisting in alcohol‐related liver disease: a case–control study

Whether and when recovery beyond the need for transplant may occur in patients listed for decompensation remains unclear. This study aimed to investigate the characteristics of patients delisted following recompensation. Seventy‐seven patients who were listed between 2005 and 2015 for decompensation, but later delisted following recompensation were included. Alcohol‐related liver disease (ALD) was the underlying etiology in the majority (n = 47, 61%). Listing characteristics of these patients were compared with those of decompensated ALD patients who either underwent deceased donor liver transplantation or died on the waiting list. The model for end‐stage liver disease (MELD) score <20 and serum albumin ≥32 g/l at listing were the only independent predictors of recompensation/delisting in ALD. The probability of recompensation was 70% when both factors were present at listing. Interestingly, about a tenth of decompensated ALD patients who died on the waiting list (median duration on waiting list 11 months) and a quarter of decompensated ALD patients who underwent living donor liver transplantation (median duration on waiting list 2 months) also had both factors at listing. In conclusion, ALD seems to be the most favorable etiology for recompensation beyond the need for transplantation. Both MELD and serum albumin at listing independently predict recompensation/delisting in ALD. It seems advisable to implement a period of observation for ALD patients with both favorable factors, before embarking on living donor liver transplantation.     

Is MELD score sufficient to predict not only death on waiting list,but also post‐transplant survival?

Model for end-stage liver disease (MELD) score has emerged as a useful tool in predicting mortality in patients awaiting liver transplantation. There is still, however, discussion as to whether further parameters could improve the sensitivity and specificity of the MELD score. From 1997 to 2003, 621 adult patients with end-stage liver disease were listed for orthotopic liver transplantation (OLT). Patients suffering from hepatoma were excluded from analysis (113 patients). The MELD score was investigated at the time of listing (MELD ON) and of coming off the list (MELD OFF). Patients who died while on the waiting list showed a significant increase in their MELD score during the waiting time (MELD ON: 21 +/- 7 vs. MELD OFF: 28 +/- 9) as well as a significantly higher MELD ON compared with patients who were transplanted (MELD ON: 16 +/- 5 vs. MELD OFF: 17 +/- 7) or removed from the waiting list (MELD ON: 16 +/- 6 vs. MELD OFF: 12 +/- 3). Multivariate analysis identified MELD ON, ascites and recurrent infection as independent risk factors for death on the waiting list (P < 0.01). MELD score was not identified as a predictor for the post-transplant survival rate. MELD score is a strong predictor for death on the waiting list, but refractory ascites and recurrent infection are independent risk factors, too.     

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.     

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.     

Could metabolic liver function tests predict mortality on waiting list for liver transplantation? A study on 560 patients

Ecochard M, Boillot O, Guillaud O, Roman S, Adham M, Mion F, Dumortier J. Could metabolic liver function tests predict mortality on waiting list for liver transplantation? A study on 560 patients.
Clin Transplant 2011: 25: 755–765. © 2010 John Wiley & Sons A/S. Abstract: Background: Allocation of graft in liver transplantation (LT) depends mainly on Model for End Stage Liver Disease (MELD) score. We studied the prognostic ability of three metabolic liver function tests in 560 cirrhotic patients listed for transplantation, in comparison with MELD and Child–Turcotte–Pugh (CTP) scores. Methods: Indocyanine green retention rate (ICG), aminopyrine breath test (ABT), and galactose elimination capacity were performed at the time of listing in addition to standard biological parameters. Seventy‐three patients died on waiting list, 438 were transplanted, and 73 died after LT. Cox regression analysis and receiver operating characteristic curves with c‐statistics were calculated after stratification according to CTP and MELD score. Results: For the mortality before transplantation, c‐statistics showed that ICG and ABT had a slightly better prognostic ability (0.73 and 0.68, respectively) than MELD score (0.66), and similar to CTP score (0.70). ABT’s prognostic ability remained significant once the MELD score (below and above 20) had already been taken into account. Only ICG had a prognostic ability to predict the survival after LT, even after stratification according to MELD and CTP score. Conclusions: Our results strongly support that ABT and ICG may be useful in the ranking of the patients in LT list, adding prognosis information in association with MELD score.     

Is estimated glomerular filtration rate superior to serum creatinine in predicting mortality on the waiting list for liver transplantation?

Serum creatinine is an important prognostic indicator in patients on the liver transplant waiting‐list, being a component of the Model for End Stage Liver Disease (MELD) score. However, creatinine is influenced by age, gender and race, and in this role may disadvantage some individuals. The Modification of Diet in Renal Disease (MDRD) estimated glomerular filtration rate (eGFR) takes into account these variables and may be a superior measure of renal function. Our aim was to examine whether the MDRD 4‐variable, 5‐variable and 6‐variable eGFRs are superior to serum creatinine in predicting 3‐month waiting‐list mortality in patients with end‐stage liver disease. This was a retrospective single‐centre study of 427 adults listed for first liver transplantation. The median listing MDRD 4‐variable, 5‐variable and 6‐variable eGFR was 69, 71 and 73 ml/min/1.73 m², respectively. The median listing serum creatinine was 89 μm . MDRD 4‐variable (P = 0.002), 5‐variable (P < 0.001) and 6‐variable eGFR (P < 0.001), and serum creatinine (P < 0.001), were all predictors of mortality on the transplant waiting‐list. Of the three MDRD equations, the 6‐variable eGFR was the better prognostic indicator. The substitution of 6‐variable eGFR for serum creatinine did not improve the prognostic accuracy of the MELD (P = 0.825) and UK score for Patients with End‐Stage Liver Disease (P = 0.781) scores. In conclusion the MDRD eGFR is comparable, but not superior to serum creatinine, in predicting death within 3 months of listing for liver transplantation.     

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.     

Developments in pediatric liver transplantation since implementation of the new allocation rules in Eurotransplant

Liver allocation in the Eurotransplant (ET) region has changed from a waiting time to an urgency‐based system using the model of end‐stage liver disease (MELD) score in 2006. To allow timely transplantation, pediatric recipients are allocated by an assigned pediatric MELD independent of severity of illness. Consequences for children listed at our center were evaluated by retrospective analysis of all primary pediatric liver transplantation (LTX) from deceased donors between 2002 and 2010 (110 LTX before/50 LTX after new allocation). Of 50 children transplanted in the MELD era, 17 (34%) underwent LTX with a high‐urgent status that was real in five patients (median lab MELD 22, waiting time five d) and assigned in 12 patients (lab MELD 7, waiting time 35 d). Thirty‐three children received a liver by their assigned pediatric MELD (lab MELD 15, waiting time 255 d). Waiting time in the two periods was similar, whereas the wait‐list mortality decreased (from about four children/yr to about one child/yr). One‐ and three‐yr patient survival showed no significant difference (94.5/97.7%; p = 0.385) as did one‐ and three‐yr graft survival (80.7/75.2%; and 86.5/82%; p = 0.436 before/after). Introduction of a MELD‐based allocation system in ET with assignment of a granted score for pediatric recipients has led to a clear priorization of children resulting in a low wait‐list mortality and good clinical outcome.     

Survival Benefit-Based Deceased-Donor Liver Allocation

Currently, patients awaiting deceased-donor liver transplantation are prioritized by medical urgency. Specifically, wait-listed chronic liver failure patients are sequenced in decreasing order of Model for End-stage Liver Disease (MELD) score. To maximize lifetime gained through liver transplantation, posttransplant survival should be considered in prioritizing liver waiting list candidates. We evaluate a survival benefit based system for allocating deceased-donor livers to chronic liver failure patients. Under the proposed system, at the time of offer, the transplant survival benefit score would be computed for each patient active on the waiting list. The proposed score is based on the difference in 5-year mean lifetime (with vs. without a liver transplant) and accounts for patient and donor characteristics. The rank correlation between benefit score and MELD score is 0.67. There is great overlap in the distribution of benefit scores across MELD categories, since waiting list mortality is significantly affected by several factors. Simulation results indicate that over 2000 life-years would be saved per year if benefit-based allocation was implemented. The shortage of donor livers increases the need to maximize the life-saving capacity of procured livers. Allocation of deceased-donor livers to chronic liver failure patients would be improved by prioritizing patients by transplant survival benefit.     

The MELD score may help to determine optimum time for liver transplantation

BACKGROUND: The model for end-stage liver disease (MELD) score is a good predictor of mortality on the waiting list and short-term survival post liver transplantation. Aim: Our aim was to determine if there is a pretransplant MELD score beyond which liver transplantation is prohibitive. PATIENTS AND METHODS: Forty-six adult patients underwent primary liver transplantation from January 1996 to December 2002. Patients followed to the most recent visit or death underwent survival analysis using Cox regression and Kaplan Meier methods. RESULTS: There was a significant correlation between the pretransplant MELD score and survival at 6 months posttransplant (P=.037 95% CI: 1.004-1.13). Patients with pretransplant MELD score greater than or equal to 32 showed significantly greater mortality compared with those less than 32 (HR 9.18, 95%CI=1.16-72.44). CONCLUSION: Pretransplant MELD may help to determine the optimum time for liver transplantation.     

MELD and other predictors of survival after liver transplantation

Abstract: Background: This study examined how reliable is the pre‐transplant model for end‐stage liver disease (MELD) score in predicting post‐transplantation survival and analyzed variables associated with patient survival. Methods: A cohort study was conducted. Receiver operating characteristic curve c‐statistics were used to determine the ability of MELD score to predict mortality. The Kaplan–Meier (KM) method was used to analyze survival as a function of time regarding the MELD score and Child‐Turcotte‐Pugh (CTP) category. The Cox model was employed to assess the association between baseline risk factors and mortality. Results: Recipients and donors were mostly male, with a mean age of 51.6 and 38.5 yr, respectively (n = 436 transplants). The c‐statistic values for three‐month patient mortality were 0.60 and 0.61 for MELD score and CTP category, respectively. KM survival at three, six and 12 months were lower in those who had a MELD score ≥21 or were CTP category C. Multivariate analysis revealed that recipient age ≥65 yr, MELD ≥ 21, CTP C category, bilirubin ≥ 7 mg/dL, creatinine ≥ 1.5 mg/dL, platelet transfusion, hepatocellular carcinoma, and non‐white color donor skin were predictors of mortality. Conclusions: Severe pre‐transplant liver disease, age ≥ 65, non‐white skin donor, and hepatocellular carcinoma are associated with poor outcome.     

The Survival Benefit of Liver Transplantation

Demand for liver transplantation continues to exceed donor organ supply. Comparing recipient survival to that of comparable candidates without a transplant can improve understanding of transplant survival benefit. Waiting list and post-transplant mortality was studied among a cohort of 12 996 adult patients placed on the waiting list between 2001 and 2003. Time-dependent Cox regression models were fitted to determine relative mortality rates for candidates and recipients. Overall, deceased donor transplant recipients had a 79% lower mortality risk than candidates (HR = 0.21; p < 0.001). At Model for End-stage Liver Disease (MELD) 18-20, mortality risk was 38% lower (p < 0.01) among recipients compared to candidates. Survival benefit increased with increasing MELD score; at the maximum score of 40, recipient mortality risk was 96% lower than that for candidates (p < 0.001). In contrast, at lower MELD scores, recipient mortality risk during the first post-transplant year was much higher than for candidates (HR = 3.64 at MELD 6-11, HR = 2.35 at MELD 12-14; both p < 0.001). Liver transplant survival benefit at 1 year is concentrated among patients at higher risk of pre-transplant death. Futile transplants among severely ill patients are not identified under current practice. With 1 year post-transplant follow-up, patients at lower risk of pre-transplant death do not have a demonstrable survival benefit from liver transplant.     

Can the Dropout Risk of Candidates with Hepatocellular Carcinoma Predict Survival after Liver Transplantation?

In the last US national conference on liver transplantation for hepatocellular carcinoma (HCC), a continuous priority score, that incorporates model for end‐stage liver disease (MELD), alpha‐fetoprotein and tumor size, was recommended to ensure a more equitable liver allocation. However, prioritizing highest alpha‐fetoprotein levels or largest tumors may select lesions at a higher risk for recurrence; similarly, patients with higher degree of liver failure could have lower postoperative survival. Data from 300 adult HCC recipients were reviewed and the proposed HCC‐MELD equation was applied to verify if it can predict post‐transplantation survival. The 5‐year survival and recurrence rates after transplantation were 72.8 and 13.5%, respectively. Cox regression analysis confirmed HCC‐MELD as predictive of both postoperative survival and recurrence (p < 0.001). The 5‐year predicted survival and recurrence rates were plotted against the HCC‐MELD‐based dropout probability: the higher the dropout probability while on waiting list, the lower the predicted survival after transplantation, that is worsened by hepatitis C positivity; similarly, the higher the predicted HCC recurrence rate after transplantation. The HCC priority score could predict the postoperative survival of HCC recipients and could be useful in selecting patients with greater possibilities of survival, resulting in higher post‐transplantation survival rates of HCC populations.     

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.