Aktuelle Entwicklungen der Lebertransplantation in Deutschland: MELD-basierte Organallokation und „incentives” für Transplantationszentren

Abstract

Liver transplantation represents a successful and well-established therapeutic concept for patients with advanced liver diseases. Organ donor shortage continues to pose a significant problem. To ensure fair and transparent allocation of too few post-mortem grafts, the model of end-stage liver disease (MELD)-based allocation was implemented in December 2006. This has decreased waiting list mortality from 20 to 10 % but at the same time has reduced post OLT survival (1-year survival from almost 90% to below 80%), which is largely due to patients with a labMELD score > 30. Following MELD introduction the regular allocation threshold has increased from a matchMELD of initially 25 to meanwhile 34. At the same time the quality of donor organs has seen a continuous deterioration over the last 10 - 15 years: 63% of organs are "suboptimal" with a donor risk index of > 1.5. Moreover, the numbers of living-related liver transplantations have decreased. In Germany incentives for transplant centres are inappropriate: patients with decompensated cirrhosis, high MELD scores and high post-transplant mortality as well as marginal liver grafts are accepted for transplantation without the necessary consideration of outcomes, and against a background of the still absent publication and transparency of outcome results. The outlined development calls for measures for improvement: (i) the increase of donor grafts (e. g., living donation, opt-out solutions, non-heart beating donors), (ii) the elimination of inappropriate incentives for transplant centres, (iii) changes of allocation guidelines, that take the current situation and suboptimal donor grafts into account, and (iv) the systematic and complete collection of transplant-related data in order to allow for the development of improved prognostic scores.

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

“…Direct clinical implications of the organ shortage, like pre-LT rising transfusion need, prolonged waiting times and increasing MELD scores, have shown to promote the risk of immunologic imbalance [127,134,148] . This could be one explanation for the reported outcome deterioration in the MELD era [5,[10][11][12][13][14] . As a consequence, pre-LT immunologic screening has been recently recommended, particularly in high-risk liver patients [137,138,149] .…”

“…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.…”

“…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.…”

“…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. Almost 85% of patients become afflicted with early infections, which is nowadays the most common cause of death soon following LT [10][11][12][13][14] . To realize LT at an earlier stage of disease progression, an increasing number of so-called extended criteria donor organs (ECD; based on donor age, liver steatosis, allograft infections, living-related or non-heart beating donors) are nowadays accepted [15,16] .…”