Balancing Donor and Recipient Risk Factors in Liver Transplantation: The Value of D-MELD With Particular Reference to HCV Recipients

Avolio, Alfonso Wolfango; Cillo, Umberto; Salizzoni, Mauro; Carlis, Luciano De; Colledan, M.; Gerunda, G.E.; Mazzaferro, Vincenzo; Tisone, Giuseppe; Romagnoli, Renato; Caccamo, L.; Rossi, Massimo; Vitale, Alessandro; Cucchetti, Alessandro; Lupo, L.; Gruttadauria, Salvatore; Nicolotti, Nicola; Burra, Patrizia; Gasbarrini, Antonio; Agnes, Salvatore

doi:10.1111/j.1600-6143.2011.03732.x

Cited by 85 publications

(75 citation statements)

References 49 publications

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“…Although contradictory results have been reported, 30 it is widely recognized as an important predictor of poor outcomes after liver transplant. 31,32 However, the novel finding of the present study was that the negative effects of higher D-MELD scores on patient and graft survival were present and interestingly rather similar throughout all quantiles. Accordingly, this result supports its use as the potential confounder for the adjustment of the impact of surgeon experience in the present study.…”

Section: Discussionsupporting

confidence: 46%

Untitled

Grąt

Lewandowski²,

Patkowski³

et al. 2018

Exp Clin Transplant

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Objectives: Data on the relevance of surgeon experience in liver transplant procedures are scarce. In this study, we evaluated the effects of individual surgeon experience on survival outcomes after deceased-donor liver transplant. Materials and Methods:In this retrospective analysis of 1193 liver transplant procedures, quantile regression for survival data was performed to assess the effects of surgeon experience. Conditional quantiles of mortality and graft loss were set as primary and secondary outcome measures, respectively, which were categorized as early, midterm, and late. Results: Greater experience of a surgeon performing hepatectomy increased the risk of early mortality (P = .005) and graft loss (P = .025) when the recipient Model for End-Stage Liver Disease was ≤ 25 and the donor Model for End-Stage Liver Disease was ≤ 1600. In conventional transplant procedures, greater experience of surgeon performing hepatectomy additionally increased the risk of midterm mortality (P = .027) and graft loss (P = .046). Conversely, a graft implant procedure performed by a more experienced surgeon was associated with better early, midterm, and late outcomes after conventional transplants (all P < .037) and reduced the risk of early graft loss when the donor Model for End-Stage Liver Disease score was > 1600 (P = .027). Conclusions: Unexpectedly, individual surgeon experience yields bimodal effects on posttransplant outcomes, dependent on the stage of operation, operative technique, severity of recipient status, and transplant risk profile. Key words: Center volume, Donor model for end-stage liver disease score, Mortality, Risk profile IntroductionLiver transplant is one of the most complex surgical procedures, with postoperative mortality rates ranging from 3% to 12% and 5-year survival rates ranging from 70% to 75%. [1][2][3][4][5] Numerous studies available in the transplant literature have reported risk factors for poor outcomes. Those of most relevance have reported outcomes attributable to recipients, donors, and operative procedural characteristics. 1,4,6,7 In addition, the role of combined factors, such as the donor Model for End-Stage Liver Disease (D-MELD) score introduced by Halldorson and associates and derived from recipient MELD score and donor age, has been recently advocated. 8,9 However, data on the association between the individual experience of the surgeon and patient outcomes after deceased-donor liver transplant are scarce. Notably, surgeon experience has been previously reported as a factor significantly related to postoperative outcomes in other transplant procedures and in procedures in the field of general surgery. [10][11][12][13] Given the worldwide shortage of donors, the optimal utilization of the scarce resources is of basic importance. Previously, much attention has been given to the association between case volume at a particular transplant center and posttransplant outcomes. Several groups who studied related topics have found that outcomes of liver transplants performed at hig...

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Section: Discussionsupporting

confidence: 46%

Untitled

Grąt

Lewandowski²,

Patkowski³

et al. 2018

Exp Clin Transplant

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“…Several proposed models focusing on urgency, utility or benefit principles, or combinations thereof, involve adjusting scores, matching donors and recipients, and other optimizations, assuming that access to LT is not the only goal; delisting criteria, long-term transplantation outcomes, and organ availability must be considered, as well as the expected results of alternative therapies (6)(7)(8)(9)(10)(11)(12). The issue's complexity, the number of variables and different medical, social and political figures involved, and the huge differences in local and regional scenarios have all contributed to hindering the development of a consensual allocation/ priority system that considers all the above elements.…”

Section: Introductionmentioning

confidence: 99%

A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a “Blended Principle Model”

Cillo

Burra

Mazzaferro

et al. 2015

American Journal of Transplantation

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184

129

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“…Being the product of two continuous variables, donor age and MELD, D-MELD produces a continuous riskgradient predicting both increased postoperative mortality and length of stay. The original D-MELD model (3) has been further refined in the Italian study (4,5) analyzing the risk in combination with recipient age, primary indication, portal vein status, retransplant status and center volume. Similar to D-MELD a novel score, BAR (BAlance of Risk) score (6), has been developed.…”

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confidence: 99%

“…Intending to decrease the frequency of unsustainable donor-to-recipient matches, D-MELD was developed to account for the two dominant variables in the prediction of outcome, patient condition at transplant, as measured by MELD score, and donor quality, as measured by age (3,4). Being the product of two continuous variables, donor age and MELD, D-MELD produces a continuous riskgradient predicting both increased postoperative mortality and length of stay.…”

mentioning

confidence: 99%

“…The strength of currently developed D2Rm scores (SOFT [7], D-MELD [3,4] and BAR [6]) lies in the improved predictive ability analyzing the combination between donorrecipient factors. Furthermore, D-MELD and BAR, developed from the UNOS database, have been validated in Europe demonstrating superiority to other scores which include only donor or recipient factors (DRI, MELD).…”

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confidence: 99%

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Balancing Utility and Need by Means of Donor-to-Recipient Matching: A Challenging Problem

Avolio

Halldorson

Burra

et al. 2013

American Journal of Transplantation

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We read with interest the article of Braat et al. (1) The authors developed, using the Euro-Transplant database, a novel donor risk index (ET-DRI) in order to predict and stratify the outcome after liver transplantation. Like Feng and coauthors did for to the American DRI (2), the authors postulated that donor quality is the strongest determinant of recipient outcome. However, while DRI and ET-DRI are helpful in recognizing grafts with expected higher risk, both fail to provide information whether to accept or not a liver for a certain recipient. We feel that such a suggestion requires deeper investigation and discussion. The authors suggest that ET-DRI should be used in the allocation. 1Although several recipient parameters were tested (age, indication, MELD, urgency), established studies (3-7) on donor-to-recipient match (D2Rm) were not considered by the authors. The merits of the current MELD system are simplicity, objectivity and accuracy in predicting waiting list mortality, as well as equity, since disease severity is the only prioritizing factor. Disadvantages of the current system include a pressure toward poorer outcomes as the sickest (highest MELD) recipients often match with higher risk donors, resulting increased frequency of futile transplantations. Yet, the desire for a balance between utility and need in organ allocation has not been completely realized. Scientific efforts to improve utility by improving D2Rm (LYFT, life years from transplant) have been difficult to implement as allocation policy due to concerns about policy complexity and limiting of access for some recipient subgroups.Intending to decrease the frequency of unsustainable donor-to-recipient matches, D-MELD was developed to account for the two dominant variables in the prediction of outcome, patient condition at transplant, as measured by MELD score, and donor quality, as measured by age (3,4). Being the product of two continuous variables, donor age and MELD, D-MELD produces a continuous riskgradient predicting both increased postoperative mortality and length of stay. The original D-MELD model (3) has been further refined in the Italian study (4,5) analyzing the risk in combination with recipient age, primary indication, portal vein status, retransplant status and center volume. Similar to D-MELD a novel score, BAR (BAlance of Risk) score (6), has been developed. Differently from the ET-DRI, the BAR score adds to donor age recipient age, MELD, retransplant status, need of mechanical ventilation and cold ischemia time (CIT).

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Balancing Donor and Recipient Risk Factors in Liver Transplantation: The Value of D-MELD With Particular Reference to HCV Recipients

Cited by 85 publications

References 49 publications

Untitled

Untitled

A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a “Blended Principle Model”

Balancing Utility and Need by Means of Donor-to-Recipient Matching: A Challenging Problem

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