The introduction of MELD-based organ allocation impacts 3-month survival after liver transplantation by influencing pretransplant patient characteristics

Abstract

Summary Introduction of the model of end‐stage liver disease (MELD) for organ allocation has changed the waiting‐list management. Despite reports of unaffected survival after orthotopic liver transplantation (OLT) in the MELD era, survival rates have decreased in our center. The aim of this study was to identify factors contributing to reduced survival. Three‐month survival, recipient and graft parameters of all 323 OLT between 2004 and 2008, which fall into a pre‐ (N = 220) and a post‐MELD (n = 103) era, were analysed by Kaplan–Meier‐, Mann–Whitney‐ and Fisher tests. After the introduction of MELD, mean scores at OLT increased (14.8 vs. 18.6, P = 0.002). The main indications for OLT were not statistically different between eras. Post‐MELD recipients were older (47.9 vs. 50.9 years, P = 0.025), donors younger (NS), cold ischemia time shorter (696 vs. 635 min., P = 0.001), and duration of surgery longer (218 vs. 245 min., P = 0.001). Procedure time significantly correlated with MELD and international normalized ratio (INR). Three‐month survival dropped (from 88.6% to 79.6%, P = 0.03). Independent variables of survival were creatinine, urea and duration of surgery. Reduced 3‐month survival was associated with longer surgery duration, higher creatinine and urea likely reflecting higher recipient morbidity. Survival probability should be incorporated into MELD‐based graft allocation.

Predictive factors of early graft loss in living donor liver transplantation

“…The present study evaluated 78 consecutive patients submitted to living donor liver transplantation divided into two groups according to graft survival. Statistical analysis demonstrated the importance of MELD score and GRBW ratio for the prediction of post-transplant outcomes (5,6,27,31,36) . An increase in survival and improved outcomes of living donor liver transplantation were obtained in different series conducted in Europe and the United States when rigorous selection criteria were applied to donors and recipients (9,26,28) .…”

“…Weismüller et al (36) compared the outcomes of cadaveric liver transplantation after organ allocation based on MELD score, in which patients with a higher score were transplanted resulting in a decrease of survival from 88.6% to 76.9% in the first 3 months after the procedure. A retrospective study conducted by Brandão et al (6) associated MELD score and Child classification with survival in 436 cadaveric transplant recipients.…”

Intravenous immunoglobulins in liver transplant patients: Perspectives of clinical immune modulation

“…However, the problems were rather shifted from the pre-to the posttransplant period. It was a consequence of the escalating organ shortage that final pre-LT MELD scores were significantly increasing in recent years [11][12][13][14] . Therefore, liver transplant patients became more complex with considerably higher perioperative risk profiles.…”

“…Therefore, liver transplant patients became more complex with considerably higher perioperative risk profiles. Rates of early posttransplant immunologic and infectious complications have markedly increased and survival rates were, thus, significantly deteriorating in recent years [10][11][12][13][14] . There is evidence that the immune systems of high-MELD patients are per se compromised, which in turn, may lead to an increased risk of septical disorders.…”

“…To respond to this challenging situation, the model of end-stage liver disease (MELD) score was implemented to give priority to the most urgent patients on the waiting lists. The "sickest first" approach based on serum creatinine, bilirubin, and the international normalized ratio contributed to reduction of waiting list mortality [7][8][9][10][11][12][13] . However, the problems were rather shifted from the pre-to the posttransplant period.…”