Who should get a liver graft?

Freeman, Richard B.; Jamieson, Neville V.; Schaubel, Douglas E.; Porte, Robert J.; Villamil, Federico

doi:10.1016/j.jhep.2009.01.013

Cited by 22 publications

(33 citation statements)

References 58 publications

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“…Interestingly, in this study [10], gender and ethnicity in both donor and recipient were significant for predicting outcome after LT. We believe that disease-specific models (along with donor characteristics) need to be developed, since recurrence of primary liver disease affects long-term post-LT survival [8]. Thus, we agree with Schaubel et al [1], who stated that a ''transplant benefit" system is needed for allocation and prioritization of recipients, taking into account donor and/or operative factors and matching donor to recipient characteristics for optimal outcomes. ''Matching" has been shown to have a great impact on survival benefit from LT [11].…”

Section: Bert Wolterssupporting

confidence: 52%

“…We read with great interest the Twelfth Forum on Liver Transplantation published in Journal of Hepatology [1]. Although we agree that the MELD score is basically a ''justice system" which allocates patients according to severity of liver disease however it is not necessarily the best system [2] and indeed some limitations of the MELD score were totally ignored in the forum mentioned above.…”

Section: Bert Woltersmentioning

confidence: 98%

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Towards a better liver allocation system

Germani

Tsochatzis

Burroughs

2009

Journal of Hepatology

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failures because primary HB-vaccination failures occur in over 5% of adult vaccinees. Not only awareness that vaccine-induced immunity against HBV can wane over time, but also awareness of which factors are associated with waning immunity is important for preventing HBV infection in general and in the healthcare setting in particular. References[1] Boot HJ, van der Waaij LA, Schirm J, Kallenberg CGM, van Steenbergen J, Wolters B. Acute hepatitis B in a healthcare worker: A case report of genuine vaccination failure. J Hepatol 2009;50:426-431. [2] Wiersma ST. Hepatitis B vaccine continues to provide long-term protection to healthcare workers. Journal of Hepatology [1]. Although we agree that the MELD score is basically a ''justice system" which allocates patients according to severity of liver disease however it is not necessarily the best system [2] and indeed some limitations of the MELD score were totally ignored in the forum mentioned above. For example, significant variations of the MELD score have been found using different laboratory methodologies for INR measurement [3], as well as creatinine (Cr) as we have published [4], and recently MELD-Na [5]. These variations, which may be cumulative when summated, lead to inequalities in prioritization of candidates, especially in those with the highest priority for LT (more jaundiced, greater renal dysfunction and lower serum sodium). A system of allocation that inherently does not have standardized measurements cannot reflect true justice for individuals on waiting lists -this needs to be addressed. Moreover, there is an issue of potential gender bias, highlighted by us [6] and reported by Moylan et al. [7]. In the UNOS database, women were more likely to die on the waiting list in the post-MELD era, compared to the pre-MELD era, although women were listed with lower median MELD scores, compared to men (14 vs. 15, p < 0.001). These findings are likely to be the result of not considering lower Cr in women for the same renal function (GFR), as in men [8], as we documented in our paper [6]. Interestingly, we found that correcting Cr by equalising the GFR between men and women resulted in an increase in MELD score by 2 or 3 points in 65% of female LT candidates [6]. Our findings with Cr are also pertinent to ethnicity differences. South Asian candidates have worse GFR for the same Cr values than Caucasians, and the opposite is true for black Africans, whether Americans or otherwise. A correction factor for gender and ethnicity could be introduced [6].Regarding post-LT survival, it is true that the MELD score is a weak predictor of mortality after LT, so it cannot be used as a predictor. In order to assess likelihood of a good outcome, we have proposed a MELDD score -a second D for donor [2,8]. This would allow a utilitarian approach to allocation on top of the ''solely justice approach" of MELD and would lead to a transplant benefit model for allocation. A recent evaluation of the European Liver Transplant Registry data [9], demonstrated that donor age, total ischaemi...

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Section: Bert Wolterssupporting

confidence: 52%

Section: Bert Woltersmentioning

confidence: 98%

Towards a better liver allocation system

Germani

Tsochatzis

Burroughs

2009

Journal of Hepatology

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“…One of them is a limited functional reserve of hepatocytes. On the other hand, liver transplantation from older donors should be possible because of the great regenerative potential of hepatocytes [1].…”

Section: Discussionmentioning

confidence: 99%

Results of Liver Transplantation From Old Donors

Dudek

Kornasiewicz

Remiszewski

et al. 2014

Transplantation Proceedings

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“…This way, the original idea was to produce a similar waiting list mortality for HCC and non-neoplastic patients. Exception points are (re-)assigned every 3 months [34,35] based on the estimation that progression of HCC can produce a 15% increase in mortality [65]. The initially suspected disadvantage of HCC patients on the waiting list was later found to represent an advantage for this patient group, and the probability of LT was higher for HCC candidates than for other patients [66], leading to a concrete disadvantage for all other LT indications [67].…”

Section: Allocation Principles For Hccmentioning

confidence: 99%

HCC-Associated Liver Transplantation - Where Are the Limits and What Are the New Regulations?

Strassburg

2016

Visc Med

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Background: Hepatocellular carcinoma (HCC) represents an increasing health burden worldwide and a challenging disease both in terms of diagnosis and treatment. Methods: The literature available on PubMed for the period of 1990-2016 was reviewed with reference to liver allocation, HCC, liver transplantation (LT), and prediction, and the allocation rules of the German Transplant Act were reviewed. Results: Due to etiological and geographical diversity, HCC is not a homogeneous disease. In the vast majority of patients, HCC develops as a complication of chronic liver disease and cirrhosis. While most patients present with advanced HCC for which palliative strategies are the only available option, LT is the best treatment approach as it not only eliminates the diseased liver and the underlying hepatocarcinogenic mechanisms but also the cancer. The decision for LT is not an easy one to make, because outcome prediction, staging, bridging therapy, and recurrence prevention are difficult and are estimated against the background of the scarce resource of donor organs which are also competitively sought after by patients suffering from non-neoplastic terminal liver diseases, raising the issue of equality of chances in a rationed therapeutic modality. Currently, the Milan criteria are the best evaluated decision tool for LT, but many issues such as down-staging, favorable biological behavior during treatment, expansion of the morphological classification, molecular predictors, and individualized approaches are not yet satisfactorily addressed. Conclusion: In order to provide a fair and effective approach to LT in HCC, the employed allocation rules require continuous development and scientific evaluation. Recently, the allocation rules for standard exception priority according to the German Transplant Act have been revised to improve patient selection for LT in HCC.

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Who should get a liver graft?

Cited by 22 publications

References 58 publications

Towards a better liver allocation system

Towards a better liver allocation system

Results of Liver Transplantation From Old Donors

HCC-Associated Liver Transplantation - Where Are the Limits and What Are the New Regulations?

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