Improved Waiting-List Outcomes in Argentina After the Adoption of a Model for End-Stage Liver Disease-Based Liver Allocation Policy

Abstract

In July 2005, Argentina became the first country after the United States to introduce the Model for End-Stage Liver Disease (MELD) for organ allocation. In this study, we investigated waiting-list (WL) outcomes (n 5 3272) and post-liver transplantation (LT) survival in 2 consecutive periods of 5 years before and after the implementation of a MELD-based allocation policy. Data were obtained from the database of the national institute for organ allocation in Argentina. After the adoption of the MELD system, there were significant reductions in WL mortality [28.5% versus 21.9%, P < 0.001, hazard ratio (HR) 5 1.57, 95% confidence interval (CI) 5 1.37-1.81] and total dropout rates (38.6% versus 29.1%, P < 0.001, HR 5 1.31, 95% CI 5 1.16-1.48) despite significantly less LT accessibility (57.4% versus 50.7%, P < 0.001, HR 5 1.53, 95% CI 5 1.39-1.68). The annual number of deaths per 1000 patient-years at risk decreased from 273 in 2005 to 173 in 2010, and the number of LT procedures per 1000 patient-years at risk decreased from 564 to 422. MELD and Model for End-Stage Liver DiseaseSodium scores were excellent predictors of 3-month WL mortality with c statistics of 0.828 and 0.857, respectively (P < 0.001). No difference was observed in 1-year posttransplant survival between the 2 periods (81.1% versus 81.3%). Although patients with a MELD score > 30 had lower posttransplant survival, the global accuracy of the score for predicting outcomes was poor, as indicated by a c statistic of only 0.523. Patients with granted MELD exceptions (158 for hepatocellular carcinoma and 52 for other reasons) had significantly higher access to LT (80.4%) in comparison with nonexception patients with equivalent listing priority (MELD score 5 18-25; 54.6%, P < 0.001, HR 5 0.49, 95% CI 5 0.40-0.61). In conclusion, the adoption of the MELD model in Argentina has resulted in improved liver organ allocation without compromising posttransplant survival.

Liver Transplantation in Latin America

“…Argentina has led the region in issues related to liver allocation (22,27). Five hospitals in Buenos Aires respond to more than 80% of the transplant activity in the country, including adult, pediatric, split, and living-related liver transplantation.…”

Hepatitis C virus infection in Argentina: Burden of chronic disease

“…To estimate HCV genotype distribution, data from over 200 treated patients was used [16] . Genotype 1 (G1) subtypes distribution was calculated using data from another study [5] .…”

“…Data from the national organ registry for the years 1999 to 2013 showed that the percentage of liver transplant in HCV patients was 22.0% before adoption of model for end stage liver disease (MELD) based allocation and 22.4% after MELD implementation [15,16] . Database from the Pan American Health Organization allow us to estimate the diagnosed population based upon data for HCV positive blood donors [7] .…”

Meeting report of the 19th Annual International Congress of the International Liver Transplantation Society (Sydney Convention and Exhibition Centre, Sydney, Australia, June 12‐15, 2013)

“…Cejas et al (O‐37) presented Argentinean Transplant Society data that identified a competitive advantage for candidates who received wait‐list prioritization through MELD exception points. Argentina was the first country to follow the United States in implementing a MELD‐based LAS . In their study of all transplant candidates from 2005 to 2011, patients who received MELD allocation priority exceptions had increased access to transplantation, decreased wait‐list mortality, and better posttransplant survival than patients who underwent transplantation with an equivalent physiological MELD score or had been denied prioritization.…”