Liver transplant advisory group, clinical centers, and transplant unit surgical and medical supervisors (see the list of participants attached in Acknowledgements).
SUMMARYConcerns related to equity and efficacy of our previous center-based allocation system have led us to introduce a patient-based allocation system called the "Liver Score" that incorporates the model for end-stage liver disease (MELD) score. The main objective of this study was to compare waitlist and post-transplant survivals before and after implementation of the "Liver Score" using the French transplant registry (period before: 2004-2006 and period after: 2007-2012). Patients transplanted during the second period were sicker and had a higher MELD. One-year waitlist survival (74% vs. 76%; P = 0.8) and 1-year post-transplant survival (86.3% vs. 85.7%; P = 0.5) were similar between the 2 periods. Cirrhotic recipients with MELD >35 had lower 1-year post-transplant survival compared to those with MELD <35 (74.8% vs. 86.3%; P < 0.01), mainly explained by their higher intubation and renal failure rates. The MELD showed a poor discriminative capacity. In cirrhotic recipients with MELD >35, patients presenting 2 or 3 risk factors (dialysis, intubation, or infection) had a lower 1-year survival compared to those with none of these risk factors (61.2% vs. 92%; P < 0.01). The implementation of the MELD-based allocation system has led to transplant sicker patients with no impact on waitlist and post-transplant survivals. Nevertheless, selection of patients with MELD >35 should be completed to allow safe transplantation.
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