Model for End-Stage Liver Disease Score-Based Allocation of Donors for Liver Transplantation: A Spanish Multicenter Experience

Superiority of the new sex-adjusted models to remove the female disadvantage restoring equity in liver transplant allocation

BACKGROUND AND AIMS

Model for End-stage Liver Disease (MELD) and MELDNa are used worldwide to guide graft allocation in liver transplantation (LT). Evidence exists that females are penalized in the present allocation systems. Recently, new sex-adjusted scores have been proposed with improved performance respect to MELD and MELDNa. GEMA-Na, MELD 3.0, and sex-adjusted MELDNa were developed to improve the 90-day dropout prediction from the list. The present study aimed at evaluating the accuracy and calibration of these scores in an Italian setting.

METHODS

The primary outcome of the present study was the dropout from the list up to 90 days because of death or clinical deterioration. We retrospectively analysed data from 855 adults enlisted for liver transplantation in the Lazio region (Italy) (2012-2018). Ninety-day prediction of GEMA-Na, MELD 3.0 and sex-adjusted MELDNa with respect to MELD and MELDNa was analysed. Brier score and Brier Skill score were used for accuracy, and the Greenwood-Nam-D'Agostino test was used to evaluate the calibration of the models.

RESULTS

GEMA-Na (concordance = .82, 95% CI = .75-.89), MELD 3.0 (concordance = .81, 95% CI = .74-.87) and sex-adjusted MELDNa (concordance = .81, 95% CI = .74-.88) showed the best 90-day dropout prediction. GEMA-Na showed a higher increase in accuracy with respect to MELD (p = .03). No superiority was shown with respect to MELDNa. All the tested scores showed a good calibration of the models. Using GEMA-Na instead of MELD would potentially save one in nine dropouts and could save one dropout per 285 patients listed.

CONCLUSIONS

Validation and reclassification of the sex-adjusted score GEMA-Na confirm its superiority in predicting short-term dropout also in an Italian setting when compared with MELD.

Early postoperative mortality in liver transplant recipients involving indications other than hepatocellular carcinoma. A retrospective cohort study

AIMS

To analyze the perioperative differences in a consecutive cohort of liver transplant recipients (LTRs) classified according to the indication of transplantation, and assess their impact upon early mortality 90 days after transplantation.

DESIGN

A retrospective cohort study was carried out.

SCOPE

A single university hospital.

PATIENTS

A total of 892 consecutive adult LTRs were included from January 1995 to December 2017. Recipients with acute liver failure, retransplantation or with grafts from non-brain death donors were excluded. Two cohorts were analyzed according to transplant indication: hepatocellular carcinoma (HCC-LTR) versus non-carcinoma (non-HCC-LTR).

MAIN VARIABLES OF INTEREST

Recipient early mortality was the primary endpoint. The pretransplant recipient and donor characteristics, surgical time data and postoperative complications were analyzed as independent predictors.

RESULTS

The crude early postoperative mortality rate related to transplant indication was 13.3% in non-HCC-LTR and 6.6% in HCC-LTR (non-adjusted HR=2.12, 95%CI=1.25-3.60; p=0.005). Comparison of the perioperative features between the cohorts revealed multiple differences. Multivariate analysis showed postoperative shock (HR=2.02, 95%CI=1.26-3.24; p=0.003), early graft vascular complications (HR=4.01, 95%CI=2.45-6.56; p<0.001) and multiorgan dysfunction syndrome (HR=18.09, 95%CI=10.70-30.58; p<0.001) to be independent predictors of mortality. There were no differences in early mortality related to transplant indication (adjusted HR=1.60, 95%CI=0.93-2.76; p=0.086).

CONCLUSIONS

The crude early postoperative mortality rate in non-HCC-LTR was higher than in HCC-LTR, due to a greater incidence of postoperative complications with an impact upon mortality (shock at admission to intensive care and the development of multiorgan dysfunction syndrome).

The Effects of MELD-Based Liver Allocation on Patient Survival and Waiting List Mortality in a Country with a Low Donation Rate

The Model for End-Stage Liver Disease (MELD)-based allocation system was implemented in Germany in 2006 in order to reduce waiting list mortality. The purpose of this study was to evaluate post-transplant results and waiting list mortality since the introduction of MELD-based allocation in our center and in Germany. Adult liver transplantation at the Charité—Universitätsmedizin Berlin was assessed retrospectively between 2005 and 2012. In addition, open access data from Eurotransplant (ET) and the German Organ Transplantation Foundation (DSO) were evaluated. In our department, 861 liver transplantations were performed from 2005 to 2012. The mean MELD score calculated with the laboratory values last transmitted to ET before organ offer (labMELD) at time of transplantation increased to 20.1 from 15.8 (Pearson’s R = 0.121, p < 0.001, confidence interval (CI) = 0.053–0.187). Simultaneously, the number of transplantations per year decreased from 139 in 2005 to 68 in 2012. In order to overcome this organ shortage the relative number of utilized liver donors in Germany has increased (85% versus 75% in non-German ET countries). Concomitantly, 5-year patient survival decreased from 79.9% in 2005 to 60.3% in 2012 (p = 0.048). At the same time, the ratio of waiting list mortality vs. active-listed patients nearly doubled in Germany (Spearman’s rho = 0.903, p < 0.001, CI = 0.634–0.977). In low-donation areas, MELD-based liver allocation may require reconsideration and inclusion of prognostic outcome factors.

Impact of Model for End-stage Liver Disease Score-based Allocation System in Korea: A Nationwide Study

BACKGROUND

In June 2016, the Korean Network for Organ Sharing implemented a Model for End-stage Liver Disease (MELD) score-based allocation system to better prioritize deceased-donor liver transplant (DDLT) candidates. The aim of this study was to assess the impact of this allocation system.

METHODS

We compared waiting list and posttransplant outcomes during the first year of operation of the MELD allocation system (from June 2016 to May 2017) with an equivalent period before its implementation (from June 2015 to May 2016).

RESULTS

A total of 3041 candidates were listed for DDLT (1464 pre-MELD, 1577 post-MELD era) and 892 patients received DDLT during the study period. A decrease in waiting list mortality and an increase in DDLT rate were observed after MELD implementation. However, the number of living donor liver transplants did not differ significantly pre- to post-MELD. As was expected, introduction of the MELD allocation system increased mean MELD scores at DDLT (24.1 ± 8.3 pre-MELD, 34.5 ± 7.0 post-MELD era, P < 0.001). Posttransplant patient survival rates at 1-year were 79.9% in pre-MELD era and 76.2% in post-MELD era (P = 0.184). The proportion of interregional organ transfer increased from 25.1% to 40.5%. Furthermore, transplant benefits increased with MELD scores.

CONCLUSIONS

The MELD system was found to address the goal of fairness well. Implementation of the MELD system improved equity in terms of access to DDLT regardless of regions. Although a greater proportion of more severely ill patients received DDLT after MELD implementation, posttransplant survivals remained unchanged.

Development of a Korean Liver Allocation System using Model for End Stage Liver Disease Scores: A Nationwide, Multicenter study

The previous Korean liver allocation system was based on Child-Turcotte-Pugh scores, but increasing numbers of deceased donors created a pressing need to develop an equitable, objective allocation system based on model for end-stage liver disease scores (MELD scores). A nationwide, multicenter, retrospective cohort study of candidates registered for liver transplantation from January 2009 to December 2011 was conducted at 11 transplant centers. Classification and regression tree (CART) analysis was used to stratify MELD score ranges according to waitlist survival. Of the 2702 patients that registered for liver transplantation, 2248 chronic liver disease patients were eligible. CART analysis indicated several MELD scores significantly predicted waitlist survival. The 90-day waitlist survival rates of patients with MELD scores of 31-40, 21-30, and ≤20 were 16.2%, 64.1%, and 95.9%, respectively (P < 0.001). Furthermore, the 14-day waitlist survival rates of severely ill patients (MELD 31-40, n = 240) with MELD scores of 31-37 (n = 140) and 38-40 (n = 100) were 64% and 43.4%, respectively (P = 0.001). Among patients with MELD > 20, presence of HCC did not affect waitlist survival (P = 0.405). Considering the lack of donor organs and geographic disparities in Korea, we proposed the use of a national broader sharing of liver for the sickest patients (MELD ≥ 38) to reduce waitlist mortality. HCC patients with MELD ≤ 20 need additional MELD points to allow them equitable access to transplantation. Based on these results, the Korean Network for Organ Sharing implemented the MELD allocation system in 2016.

D-MELD, the Product of Donor Age and Preoperative MELD, Predicts Surgical Outcomes After Living Donor Liver Transplantation, Especially in the Recipients With HCV-positive and Smaller Grafts

BACKGROUND

Appropriate donor-recipient match has not been explored well in living-donor liver transplantation (LDLT) unlike deceased-donor liver transplantation. In this study, we evaluate the donor-recipient match using D-MELD (donor age × recipient Modified for End-stage Liver Disease [MELD] score) as a predictor of surgical outcomes in LDLT, paying attention to graft size and hepatitis C virus (HCV) status.

PATIENT AND METHODS

The 120 consecutive recipients who received adult-to-adult LDLT from March 2002 to December 2014 were divided into the two groups according to D-MELD score: D-MELD <1000 (low-D-MELD: n = 101) and D-MELD ≥1000 (high-D-MELD: n = 19).

RESULTS

The 90-day mortality rate was significantly higher in the high-DM group than in low-DM group: 36.8% versus 14.9% (P = .046). In the HCV-positive recipients, the 90-day mortality rate was significantly higher in high-DM group (n = 6) than in low-DM group (n = 37): 66.7% versus 13.5% (P = .012), and the 3-year survival rate was significantly lower in high-DM group than in the low-DM group: 33.3% versus 56.8% (P = .01). In the recipients with left graft, the 90-day mortality rate was significantly higher in the high-DM group (n = 8) than in the low-DM group (n = 41): 50% versus 14.6% (P = .044), and total bilirubin level on postoperative day 14 was significantly higher in the high-DM group than in the low-DM group: 17.4 mg/dL versus 9.2 mg/dL (P = .018).

CONCLUSIONS

It was clarified that D-MELD could predict early and long-term surgical outcomes in the recipients who were HCV-positive and who had smaller grafts.

Impact of MELD Allocation System on Waiting List and Early Post-Liver Transplant Mortality

Background and aims

MELD allocation system has changed the clinical consequences on waiting list (WL) for LT, but its impact on mortality has been seldom studied. We aimed to assess the ability of MELD and other prognostic scores to predict mortality after LT.

Methods

301 consecutive patients enlisted for LT were included, and prioritized within WL by using the MELD-score according to: hepatic insufficiency (HI), refractory ascites (RA) and hepatocellular carcinoma (HCC). The analysis was performed to predict early mortality after LT (8 weeks).

Results

Patients were enlisted as HI (44.9%), RA (19.3%) and HCC (35.9%). The major aetiologies of liver disease were HCV (45.5%). Ninety-four patients (31.3%) were excluded from WL, with no differences among the three groups (p = 0.23). The remaining 207 patients (68.7%) underwent LT, being HI the most frequent indication (42.5%). HI patients had the shortest length within WL (113.6 days vs 215.8 and 308.9 respectively; p<0.001), but the highest early post-LT mortality rates (18.2% vs 6.8% and 6.7% respectively; p<0.001). The independent predictors of early post-LT mortality in the HI group were higher bilirubin (OR = 1.08; p = 0.038), increased iMELD (OR = 1.06; p = 0.046) and non-alcoholic cirrhosis (OR = 4.13; p = 0.017). Among the prognostic scores the iMELD had the best predictive accuracy (AUC = 0.66), which was strengthened in non-alcoholic cirrhosis (AUC = 0.77).

Conclusion

Patients enlisted due to HI had the highest early post-LT mortality rates despite of the shortest length within WL. The iMELD had the best accuracy to predict early post-LT mortality in patients with HI, and thus it may benefit the WL management.

MELD-Na: effective in predicting rebleeding in cirrhosis after cessation of esophageal variceal hemorrhage by endoscopic therapy

BACKGROUND AND AIMS

There is no study verifying the predictive value of model for end-stage liver disease and sodium (MELD-Na) for rebleeding and its associated mortality in cirrhotic patients after cessation of acute esophageal variceal hemorrhage (AVH) by endoscopic therapy. This study aimed to determine the predictive value of MELD-Na by comparing with MELD or Child-Turcotte-Pugh (CTP) scores.

PATIENTS AND METHODS

Consecutive adult cirrhotic patients after cessation of AVH by endoscopic therapy (endoscopic variceal ligation or sclerotherapy injections) within 48 hours of admission admitted from 2003 to 2012 were analyzed. The clinical characteristics and laboratory data at admission were documented, based on which MELD-Na, MELD, and CTP scores were calculated.

RESULTS

Among 429 patients who had complete control of AVH, 97 patients (22.6%) suffered esophageal variceal rebleeding within 3 months and 206 patients (48.0%) within 1 year. Fifty-three patients (12.4%) died within 3 months and 98 patients (22.8%) within 1 year from rebleeding. The area under receiver operator characteristics curve of the MELD-Na score for predicting rebleeding and its associated mortality was significantly higher than that of the MELD and the CTP score (rebleeding: 0.83 vs. 0.77 vs. 0.69 for 3 months and 0.85 vs. 0.80 vs. 0.65 for 1 year, P<0.05; mortality: 0.81 vs. 0.75 vs. 0.66 for 3 months and 0.82 vs. 0.78 vs. 0.68 for 1 year, P<0.05).

CONCLUSIONS

The MELD-Na score is clinically useful in predicting 3-month and 1-year rebleeding and its associated mortality in cirrhotic patients after cessation of AVH by endoscopic therapy.

Donor-recipient matching: myths and realities

Liver transplant outcomes keep improving, with refinements of surgical technique, immunosuppression and post-transplant care. However, these excellent results and the limited number of organs available have led to an increasing number of potential recipients with end-stage liver disease worldwide. Deaths on waiting lists have led liver transplant teams maximize every organ offered and used in terms of pre and post-transplant benefit. Donor-recipient (D-R) matching could be defined as the technique to check D-R pairs adequately associated by the presence of the constituents of some patterns from donor and patient variables. D-R matching has been strongly analysed and policies in donor allocation have tried to maximize organ utilization whilst still protecting individual interests. However, D-R matching has been written through trial and error and the development of each new score has been followed by strong discrepancies and controversies. Current allocation systems are based on isolated or combined donor or recipient characteristics. This review intends to analyze current knowledge about D-R matching methods, focusing on three main categories: patient-based policies, donor-based policies and combined donor-recipient systems. All of them lay on three mainstays that support three different concepts of D-R matching: prioritarianism (favouring the worst-off), utilitarianism (maximising total benefit) and social benefit (cost-effectiveness). All of them, with their pros and cons, offer an exciting controversial topic to be discussed. All of them together define D-R matching today, turning into myth what we considered a reality in the past.

Pulmonary complications after elective liver transplantation-incidence, risk factors, and outcome

After liver transplantation (LT), postoperative pulmonary complications (PPC) occur in approximately 35% to 50% of the recipients. Among these PPC, pneumonia is the most frequently encountered. Pulmonary dysfunction has also been widely reported among patients awaiting LT. The links between this dysfunction and PPC have not been clearly established. In this present cohort study, we evaluated the incidence and profile of post-LT pneumonia and identified potential preoperative risk factors.

METHODS

The postoperative clinical course of 212 liver transplant recipients between January 2008 and April 2010 was analyzed. These patients were treated in a single intensive care unit and received standardized postoperative care.

RESULTS

During the postoperative period, 47 (22%) patients developed pneumonia, of whom 20 (43%) developed respiratory failure requiring mechanical ventilation. Univariate analysis showed that several preoperative factors (age of recipient, model for end-stage liver disease score, indication for LT, platelet count, and restrictive lung pattern revealed by preoperative pulmonary function tests) and the transfusion (blood units and fresh frozen plasma units) during the operative period were associated with pneumonia. Using multivariate analysis by logistic regression, only a restrictive lung pattern (odds ratio=3.14; 95% confidence interval, 1.51-6.51; P=0.002) and the international normalized ratio measured prior LT (OR=4.95; 95% confidence interval, 1.86-8.59; P=0.0004) were independent predictors of pneumonia after LT.

CONCLUSION

Pneumonia is common among patients undergoing LT and is a major cause of morbidity. A restrictive pattern on preoperative pulmonary testing and a higher international normalized ratio measured prior LT were associated with more risk of postoperative pneumonia.

MELD-based graft allocation system fails to improve liver transplantation efficacy in a single-center intent-to-treat analysis

BACKGROUND

Since March 2007, priority access to liver transplantation in France has been given to patients with the highest MELD scores.

OBJECTIVE

To undertake an intent-to-treat comparison of center-based vs. MELD-based liver graft allocation.

METHODS

Retrospective cohort analysis (patients listed 6th March 2007 to 5th March 2009; MELD period) with a matched historical cohort (patients listed 6th March 2005 to 5th March 2007; pre-MELD period) in a single high-volume center. Analysis was on an intent-to-treat basis, i.e. starting on the day of wait listing.

RESULTS

Compared to pre-MELD, fewer patients with a MELD score less or equal to 14 (P=0.002), and more patients with a MELD greater or equal to 24 (P<0.05) were transplanted during the MELD period. For HCC candidates, median waiting time increased (121 vs. 54 days, P=0.01), transplantation rate halved (35% vs. 73.5%, P<0.001) and dropouts due to tumor progression increased (16% vs. 0%, P<0.001). Moreover, postoperative course did not change significantly except for infectious complications (35% vs. 24%, P=0.02); overall patient survival was 69.8 ± 3.1% vs. 76 ± 2.9% (P=0.29) and overall graft survival was 77.6 ± 3.4% vs. 82.8 ± 2.9% (P=0.29). Transplant failures were mainly due to deaths on the waiting list in the previous system, but to dropouts related to disease progression in the new system. Cirrhotic patient survival rate did not change (78.1 ± 4.4% vs. 73.5 ± 4.5%, P=0.42), while that of HCC patients decreased (65.3 ± 5.3% vs. 86.8 ± 4.4%, P=0.01). Post-transplant survival worsened significantly according to pre-transplant MELD score (P=0.009).

CONCLUSION

The MELD-based graft allocation system introduced discrimination against HCC patients, whose incidence has increased dramatically, and should be reevaluated.

Are there better guidelines for allocation in liver transplantation? A novel score targeting justice and utility in the model for end-stage liver disease era

OBJECTIVES

To design a new score on risk assessment for orthotopic liver transplantation (OLT) based on both donor and recipient parameters.

BACKGROUND

The balance of waiting list mortality and posttransplant outcome remains a difficult task in the era of the model for end-stage liver disease (MELD).

METHODS

Using the United Network for Organ Sharing database, a risk analysis was performed in adult recipients of OLT in the United States of America between 2002 and 2010 (n = 37,255). Living donor-, partial-, or combined-, and donation after cardiac death liver transplants were excluded. Next, a risk score was calculated (balance of risk score, BAR score) on the basis of logistic regression factors, and validated using our own OLT database (n = 233). Finally, the new score was compared with other prediction systems including donor risk index, survival outcome following liver transplantation, donor-age combined with MELD, and MELD score alone.

RESULTS

Six strongest predictors of posttransplant survival were identified: recipient MELD score, cold ischemia time, recipient age, donor age, previous OLT, and life support dependence prior to transplant. The new balance of risk score stratified recipients best in terms of patient survival in the United Network for Organ Sharing data, as in our European population.

CONCLUSIONS

The BAR system provides a new, simple and reliable tool to detect unfavorable combinations of donor and recipient factors, and is readily available before decision making of accepting or not an organ for a specific recipient. This score may offer great potential for better justice and utility, as it revealed to be superior to recent developed other prediction scores.

Mortality on the waiting list for liver transplantation: management and prioritization criteria

The excellent outcomes of liver transplantation (OLT) have increased its demand and the size of the waiting list, resulting in a substantial mortality rate before OLT, which is a treatment failure owing to disease development. We have reviewed the medical literature on this theme, focusing on prioritization methods.

Impact of the MELD allocation after its implementation in liver transplantation

OBJECTIVE

On 16 December 2006, most Eurotransplant countries changed waiting time oriented liver allocation policy to the urgency oriented Model for End-stage Liver Disease (MELD) system. There are limited data on the effects of this policy change within the Eurotransplant community.

PATIENTS AND METHODS

A total of 154 patients who had undergone deceased donor liver transplantation (LT) were retrospectively analyzed in three time periods: period A (1-year pre-MELD, n = 42) versus period B (1-year post-MELD, n = 52) versus period C (2 years after MELD implementation, n = 60).

RESULTS

The median MELD score at the time of LT increased from 16.3 points in period A to 22.4 and 20.4 in periods B and C, respectively (p = 0.007). Waitlist mortality decreased from 18.4% in period A to 10.4% and 9.4% in periods B and C, respectively (p = 0.015). Three-month mortality did not change significantly (10% each for periods A, B and C). One-year survival was 84% for the MELD 6-19 group compared with 81% in the MELD 20-29 group and 74% in the MELD ≥30 group (p = 0.823). Analyzing MELD score and previously described prognostic scores [i.e. survival after liver transplantation (SALT) score and donor-MELD (D-MELD) score] with regard to 1-year survival, only a high risk SALT score was predictive (p = 0.038). In our center, 2 years after implementation of the MELD system, waitlist mortality decreased, while 90-day mortality did not change significantly.

CONCLUSION

Up to now, only the SALT score proved to be of prognostic relevance post-transplant.

Clinical epidemiological analysis of the mortality rate of liver transplant candidates living in rural areas

MELD score has been used to predict 90-day mortality of subjects listed for liver transplantation (OLT). Validation of MELD score for patients on the waiting list in transplant programmes serving rural areas in North America is lacking. A retrospective cohort of patients affected by end-stage liver disease was studied to assess the mortality rate within 90 days after being listed at our transplant centre. Secondary aims were to identify differences between predicted and observed 90-days mortality using MELD and MELDNa scores at the time of listing. Among 126 patients included in this study, waiting list mortality was 35.0%. Ninety-day mortality was 21.1%, which was significantly greater than the mortality estimated by the MELD (9.1%, 95% CI: 6.6-11.5) and MELDNa (9.3%, 95%CI: 6.0-12.5). Despite this underestimation, AUC for MELD and MELDNa was 0.80 and 0.78 respectively. In our study, independent predictors of waiting list mortality were age, diagnosis of cholestatic disease and residence over 500 km from our transplant centre. MELD and MELDNa underestimated the 90-day mortality in patients with liver failure living in rural areas. Validation of these models should be performed in other transplant centres serving patients with limited access to specialized services.

Prediction of graft dysfunction based on extended criteria donors in the model for end-stage liver disease score era

BACKGROUND

To explain the influence of recipient status combined with the accumulation of extended criteria donor (ECD) variables on the appearance of severe ischemia-reperfusion injury and graft survival in a model for end-stage liver disease (MELD)-based system, we analyzed our most recent consecutive liver transplantations (LTs), dividing them into two periods: 400 LTs (1992-2002; pre-MELD era) and 275 LTs (2002-2007; post-MELD era).

METHODS

Primary dysfunction (PD) was defined as primary graft failure that required emergency retransplantation or as initial poor function. Donor variables were included in a regression model to assess the probability of PD.

RESULTS

Donor age, macrovesicular steatosis more than 30%, and cold ischemia time were associated with allograft dysfunction. Mean probability of PD was 14.8%, 19.2%, 27.5%, and 37.4% for ECD 0, 1, 2, and more than or equal to 3, respectively (P=0.003). Distribution of no-mild, moderate, and severe ischemia-reperfusion injuries among MELD categories was 72.53%, 24.17%, and 3.30% (MELD group=12-19); 56.52%, 36.96%, and 6.5% (MELD group=20-28); and 23.91%, 54.35%, and 21.74% (MELD group >or=29), respectively (P=0.043). The development of PD according to ECD variables was 18.8%, 18.1%, 28.0%, and 35.3% for ECD 0, 1, 2, and more than or equal to 3, respectively (P=0.047). These variables were independent predictors of PD (Cox proportional regression model): ECD 2 (relative risk [RR]=1.59; 95% confidence interval [CI]=1.25-1.62), ECD 3 (RR=2.74; 95% CI=2.38-3.13), MELD 21 to 30 (RR=1.89; 95% CI=1.32-2.06), and MELD more than or equal to 30 (RR=3.38; 95% CI=2.43-3.86). Graft survival decreased, whereas MELD and the number of ECD variables increased.

CONCLUSION

The combination of three or more ECD variables and an MELD more than or equal to 29 is the worst scenario for graft success after LT.

Multicentric evaluation of model for end-stage liver disease-based allocation and survival after liver transplantation in Germany--limitations of the 'sickest first'-concept

Since the introduction of model for end-stage liver disease (MELD) in 2006, post-orthotopic liver transplantation (OLT) survival in Germany has declined. The aim of this study was to evaluate risk factors and prognostic scores for outcome. All adult OLT recipients in seven German transplant centers after MELD implementation (December 2006-December 2007) were included. Recipient data were analyzed for their influence on 1-year outcome. A total of 462 patients (mean calculated MELD = 20.5, follow-up: 1 year) were transplanted for alcoholic cirrhosis (33.1%), hepatocellular carcinoma (26.6%), Hepatitis-C (17.1%), Hepatitis-B (9.5%), primary sclerosing cholangitis (5.6%) and late graft-failure after first OLT before December 2006 (8.7%). 1-year patient survival was 75.8% (graft survival 71.2%) correlating with MELD parameters and serum choline esterase. MELD score >30 [odds ratio (OR) = 4.17, confidence interval: 2.57-6.78, 12-month survival = 52.6%, c-statistic = 0.669], hyponatremia (OR = 2.07), and pre-OLT hemodialysis (OR = 2.35) were the main death risk factors. In alcoholic cirrhosis (n = 153, mean MELD = 21.1) and hepatocellular carcinoma (n = 123, mean MELD = 13.5), serum bilirubin and the survival after liver transplantation score were independent outcome parameters, respectively. MELD >30 currently represents a major risk factor for outcome. Risk factors differ in individual patient subgroups. In the current German practice of organ allocation to sicker patients, outcome prediction should be considered to prevent results below acceptable standards.

The future of liver transplantation

Liver transplantation has been a positive impact on both the survival and the quality of life of patients with advanced liver diseases. Progressive, spectacular improvements in the results of liver transplantation have been observed since the preliminary studies by Thomas Starzl in the United States and Roy Calne in Europe. This improvement is related to better knowledge of the natural history of liver diseases, allowing more adequate recipient selection, improvement of surgical techniques, progress in postoperative management, availability of potent antibacterial, antiviral, and antifungal drugs, as well as introduction of new immunosuppressive agents and protocols. These advances have occurred in the short interval of 45 years, suggesting future improvements in the liver transplantation field. The main investigative efforts in liver transplantation have been directed as follows: First attenuation of disproprortion between the numbers of available liver grafts versus waiting list recipients, by increasing the donor pool applying bioartificial support systems, or rendering grafts compatible by the use of stem cells. Second, improved knowledge about the biology of primary liver tumors establishes indications for and optimal moments of transplantation. Third, application of individualized immunosuppressive protocols, adapted to clinical status of the recipient, as well as the development of more selective, less toxic new immunosuppressive agents.

Comparison of the model for end-stage liver disease (MELD), MELD-Na and MELDNa for outcome prediction in patients with acute decompensated hepatitis

BACKGROUND AND AIM

The model for end-stage liver disease (MELD) is used to predict the outcome of patients with cirrhosis. Incorporation of serum sodium (Na) into MELD may further increase its prognostic ability. Two Na-containing MELD models, MELD-Na and MELDNa, were proposed to enhance the prognostic ability. This study compared the predictive accuracy of these models for acute decompensated hepatitis.

METHODS

We investigated the outcome of 182 patients with acute decompensated hepatitis.

RESULTS

Twenty (11%) patients died at 3 months. The MELD-Na and MELDNa both had significantly higher area under the receiver operating characteristic curve (AUC) in comparison to MELD (MELD-Na: 0.908, MELDNa: 0.895, MELD: 0.823, p=0.004 and 0.001, respectively). Among 96 patients without specific antiviral treatment, the MELD-Na and MELDNa consistently had significantly higher AUC than the MELD (MELD-Na: 0.901, MELDNa: 0.882, MELD: 0.810, p=0.008 and 0.004, respectively). Three independent indicators, pre-existing cirrhosis (odds ratio [OR]: 5.67, 95% confidence interval [CI]: 1.72-18.7), serum albumin<3.7 g/dL (OR: 5.68, 95% CI: 1.18-27.03) and serum sodium (Na)<138 mequiv./L (OR: 10.0, 95% CI: 2.08-47.62), were associated with 3-month mortality.

CONCLUSION

MELD-Na and MELDNa provide better prognostic accuracy than the MELD for patients with acute decompensated hepatitis. The adequacy of liver reserve determines the outcome of these patients.

[The value of MELD in the allocation of priority for liver transplantation candidates]

Liver transplantation is the most effective treatment for many patients with chronic end-stage liver disease. The discrepancy between the number of donor organs and potential recipients causes marked pre-transplantation mortality and consequently optimal rationalization of organ allocation is essential. The Model for End-Stage Liver Disease (MELD) is an objective and easily reproducible prognostic index of mortality based on three simple analytical variables: bilirubin and serum creatinine and the prothrombin time/International Normalized Ratio (INR) of protrombine time. The implementation of MELD as an organ allocation system has reduced mortality on the waiting list without affecting post-transplantation survival. Nevertheless, this model has some limitations and consequently further investigations should be performed to improve the organ allocation policy in liver transplantation.

Prediction of the prognosis of patients with acute-on-chronic hepatitis B liver failure using the model for end-stage liver disease scoring system and a novel logistic regression model

The objective of this study was to determine the predictive value of the model for end-stage liver disease (MELD) scoring system in patients with acute-on-chronic hepatitis B liver failure (ACLF-HBV), and to establish a new model for predicting the prognosis of ACLF-HBV. A total of 204 adult patients with ACLF-HBV were retrospectively recruited between July 1, 2002 and December 31, 2004. The MELD scores were calculated according to the widely accepted formula. The 3-month mortality was calculated. The validity of the MELD model was determined by means of the concordance (c) statistic. Clinical data and biochemical values were included in the multivariate logistic regression analysis based on which the regression model for predicting prognosis was established. The receiver-operating characteristic curves were drawn for the MELD scoring system and the new regression model and the areas under the curves (AUC) were compared by the z-test. The 3-month mortality rate was 57.8%. The mean MELD score for the patients who died was significantly greater than those who survived beyond 3 months (28.7 vs 22.4, P = 0.003). The concordance (c) statistic (equivalent to the AUC) for the MELD scoring system predicting 3-month mortality was 0.709 (SE = 0.036, P < 0.001, 95% confidence interval 0.638-0.780). The independent factors predicting prognosis were hepatorenal syndrome (P < 0.001), liver cirrhosis (P = 0.009), HBeAg (P = 0.013), albumin (P = 0.028) and prothrombin activity (P = 0.011) as identified in multivariate logistic regression analysis. The regression model that was constructed by the logistic regression analysis produced a greater prognostic value (c = 0.891) than the MELD scoring system (z = 4.333, P < 0.001). The MELD scoring system is a promising and useful predictor for 3-month mortality of ACLF-HBV patients. Hepatorenal syndrome, liver cirrhosis, HBeAg, albumin and prothrombin activity are independent factors affecting the 3-month mortality. The newly established logistic regression model appears to be superior to the MELD scoring system in predicting 3-month mortality in patients with ACLF-HBV.

Model for end-stage liver disease can predict very early outcome after liver transplantation

Postoperative Model for End-stage Liver Disease (MELD) values have never been assessed to predict very early (<1 week) death after liver transplantation (OLT). We retrospectively reviewed 275 consecutive OLTs performed in 252 recipients reported in a prospective database. We calculated the MELD score (pre-MELD) and consecutive postoperative MELD (post-MELD) scores computed daily during the first postoperative week and on days 15 and 30 after OLT. Post-MELD scores from nonsurviving recipients displayed on a scatterplot of immediate probability of death were adjusted to the best goodness-of-fit curve, and, finally, depicted graphically as a receiver operating characteristic (ROC) curve. Nonsurviving recipients showed higher post-MELD scores: day 1: 23.5 versus 16.6 (P = .05); day 3: 25.1 versus 12.5 (P = .000); day 5: 25.7 versus 11.8 (P = .000); and day 7: 22.1 versus 10.2 (P = .000). Overall comparisons were performed using a time-dependent general linear regression model, revealing higher post-MELD scores for nonsurviving recipients, irrespective of postoperative time (P = .002). The best goodness-of-fit curve was displayed when adjusting to a theoretical exponential regression curve calculated as follows: Probability of dying within the first week (%) = 3.36 x e(0.079 x (post-MELD)) (r = .89; P = .000). The area under the ROC curve was 0.783 (95% confidence interval, 0.630-0.935; P = .001). The model had a positive predictive value of 82.3%, a negative predictive value of 33.1%, and an accuracy of 79.2%. In conclusion, this study corroborated the suggestion that the MELD score may serve as a reliable tool to assess very early death after OLT.

Comparison of four model for end-stage liver disease-based prognostic systems for cirrhosis

Serum sodium (Na) has been suggested for incorporation into the Model for End-Stage Liver Disease (MELD) to enhance its prognostic ability for patients with cirrhosis. Three Na-containing models--the Model for End-Stage Liver Disease with the incorporation of serum sodium (MELD-Na), the integrated Model for End-Stage Liver Disease (iMELD), and the Model for End-Stage Liver Disease to sodium (MESO) index--were independently proposed for this purpose. This study investigated the accuracy of these 4 MELD-based models for outcome prediction. The c-statistic equivalent to the area under the receiver operating characteristic curve (AUC), used to predict 3- and 6-month mortality, was calculated and compared in 825 patients with cirrhosis. The MELD score tended to be lower with increasing Na level. At 3 months of enrollment, the iMELD had the highest AUC (0.807) and was followed by the MELD-Na (0.801), MESO (0.784), and MELD (0.773); the difference between the MESO and MELD was statistically significant (P = 0.013). At 6 months, the iMELD still had the highest AUC (0.797) and was followed by the MELD-Na (0.778), MESO (0.747), and MELD (0.735); all comparisons showed significant differences between each other (all P < 0.01), with the exception of iMELD and MELD-Na (P = 0.18). With the most discriminative cutoffs, the specificity and negative predictive value were 70%-85% and 89%-97%, respectively, at 3 and 6 months for the 4 models. Patients with spontaneous bacterial peritonitis (SBP) consistently had significantly higher MELD-derived scores in all 4 models compared to patients without SBP (all P < 0.01). Patients with hepatic encephalopathy also had higher scores in all 4 models, although the statistical significance was established only for the iMELD (41.0 +/- 11.5 versus 37.6 +/- 9.1, P = 0.037). In conclusion, the incorporation of Na into the MELD may enhance prognostic accuracy. Both the iMELD and MELD-Na are better prognostic models for outcome prediction in patients with cirrhosis. Patients with SBP have a higher MELD-derived score. Future studies are warranted to define the optimal MELD-based prognostic model for cirrhosis.

Validation of the HCC-MELD for dropout probability in patients with small hepatocellular carcinoma undergoing locoregional therapy

BACKGROUND

The model for end-stage liver disease (MELD) is used in prioritizing cirrhotic patients awaiting liver transplantation. Patients with small hepatocellular carcinoma (HCC) are eligible candidates. An HCC-MELD equation was recently proposed to predict the dropout rate of HCC patients on the waiting list. This study aimed to validate the accuracy of this equation.

METHODS

We investigated 390 patients with small HCC who were candidates for liver transplantation and underwent locoregional therapy.

RESULTS

The estimated probability of dropout according to the equation was 8.2% for T1 stage and 13.5% for T2 stage HCC (p < 0.0001). The actual disease progression rate at three months was 2.1% for T1 and 3.0% for T2 stage HCC. At six months, the progression rate was 5.3% for T1 stage and 6.8% for T2 stage. The area under receiver operating characteristic curve of the HCC-MELD equation was 0.81 at three months and 0.80 at six months. Patients undergoing radiofrequency ablation (RFA) had significantly lower dropout rates compared with other treatment groups according to the equation (p = 0.0007). The actual tumor progression rate was also the lowest for the RFA group at both three and six months.

CONCLUSION

The HCC-MELD equation is a feasible predictive model for patients with small HCC undergoing locoregional therapy.

Is the corrected-creatinine model for end-stage liver disease a feasible strategy to adjust gender difference in organ allocation for liver transplantation?

BACKGROUND

The Model for End-stage Liver Disease (MELD) scoring system is used for organ allocation in liver transplantation. Female cirrhotic patients have lower glomerular filtration rates (GFR) than males for the same creatinine (Cr) level. Correcting the Cr in females for the same GFR as in males shows that females have lower MELD scores and therefore a lower priority for liver transplantation; however, there has been no outcome data that justifies this modification.

METHODS

We investigated 472 cirrhotic patients, comparing the mortality rate between males and females in relation to MELD and corrected-Cr MELD.

RESULTS

Compared to females, male patients had a higher MELD (14.5+/-5.5 vs. 13.8+/-5.7) and significantly higher GFR (61.7+/-21.4 vs. 54.7+/-25.6 mlLmin/1.73 m, P=0.0002) because their Cr value was higher (1.4+/-0.4 vs. 1.3+/-0.5 mg/dL, P=0.0002). The corrected-Cr MELD score in females was higher (15.7+/-6.3) compared to the MELD in their original counterpart (P<0.0001) and the males (P=0.060). Female and male patients had a similar 3-month mortality rate (6.7% vs. 6.3%) and MELD (21.9+/-8.6 vs. 21.7+/-8.9) among deceased patients. At 6 months, female patients tended to have a lower mortality (12.5% vs. 14.7%) and a lower MELD (18.9+/-7.7 vs. 19.4+/-8.5) in deceased patients. However, at 9 and 12 months, females had a consistently higher mortality (25% vs. 21.2% and 37.5% vs. 31.3%, respectively) but lower MELD scores than males by 0.3-1 point.

CONCLUSIONS

Using corrected-Cr MELD, which would prioritize female patients for liver transplantation, may only be justified in predicting intermediate-term (9- and 12-month), but not short-term (3- and 6-month) mortality.