Preliminary results of a liver allocation plan using a continuous medical severity score that de-emphasizes waiting time

Abstract

Liver allocation remains problematic because current policy prioritizes status 2B or 3 patients by waiting time rather than medical urgency. On February 21, 2000, we implemented a variance to the United Network for Organ Sharing liver allocation policy that redefined status 2A by much more rigid, definable criteria and prioritized status 2B patients by using a continuous medical urgency score based on the Child-Turcotte-Pugh score and other medical conditions. In this system, waiting time is used only to differentiate status 2B candidates with equal medical urgency scores. Comparing the 6-month period (period 1; n ‫؍‬ 67) before implementation of this system to the 6-month period after implementation (period 2; n ‫؍‬ 75), there was a significant reduction in the number of transplantations performed for patients listed as status 2A (46.3% to 14.7%; P ‫؍‬ .002) and an increase in the number of patients listed as status 2B who received transplants (44.8% to 70.7%; P ‫؍‬ .10). Most dramatically, there was a 37.1% reduction in overall deaths on the waiting list from 94 deaths in period 1 to 62 deaths in period 2 (P ‫؍‬ .005), with the most significant reduction for patients removed from this list at status 2B (52 v 18 patients; P ‫؍‬ .04). There were 3 postoperative deaths in each period, with only 1 graft lost in period 2. Status 2B patients with the greatest degree of medical urgency received transplants without multiple peer reviews requesting elevation to 2A status. We conclude that a continuous medical urgency score system allocates donor livers much more fairly to those in medical need and reduces waiting list mortality without sacrificing efficacy. (Liver Transpl 2001;7: 173-178.)

MELD score predicts 1-year patient survival post-orthotopic liver transplantation

“…Use of a continuous score has been shown to decrease mortality in patients waiting for OLT. 8 However, it is not clear if the improvement of pretransplant survival comes at risk of reducing posttransplant survival. Preliminary studies have shown that in the short term, MELD does not impact patient survival after OLT.…”

“…The application of a continuous scale that de-emphasizes waiting time for status 2B candidates resulted in a significant reduction of overall deaths on the wait list. 8 The Model for End-Stage Liver Disease (MELD) is a similar continuous scale that has been adopted by the United Network for Organ Sharing (UNOS) to stratify patients on the liver transplant wait list. 1 The MELD scale originally was designed to assess short-term prognosis in patients with hepatic cirrhosis who underwent transjugular intrahepatic portosystemic shunt (TIPS).…”

Donor and recipient outcomes in right lobe adult living donor liver transplantation

“…Reduced-size liver transplantation7 was the wellspring for this effort followed by cadaveric split liver transplantation,*-1° adult-to-pediatric living related, and more recently adult living donor liver transplantation (ALDLT). "-'* In Europe and the United States, right hepatic lobes (segments [5][6][7][8] are by far the most common grafts u~ed,l5-~* because they represent the logical balance of providing the recipient with sufficient liver mass to overcome the small-for-size syndrome that is observed following left lobe graftingl5 without compromising donor ~afety.~5 However, it is exceedingly difficult to accurately determine recipient outcomes in the Untied States, because only a few centers have published comprehensive reports. l5-l9 Furthermore, fewer reports have provided comparisons to whole organ …”

Child comes of age

“…We must wait and see if MELD, prospectively applied to the transplant waiting list, will give the better outcomes we seek. A modification of the CTP and UNOS status system that de-emphasizes waiting time 13 improves both donor organ utilization and patient survival, as recently reported. Will "Child," recently come of age have to retire soon or can we meld the 40 years of experience of CTP with the emerging new index of severity of liver disease and allow Child a few more years of productive existence?…”