Meld Criteria in the Transplant Waiting List: Impact on Mortality Overall and by Diagnostic Groups

Abstract

Abstract:Introduction: The modification of liver graft allocation for selection by severity criteria based on the Model for End-Stage Liver Disease (Meld) has not yet been properly analyzed in Brazil regarding the distribution of indications for transplant and mortality among enrolled patients. In a context of low organ donation and procurement, this assessment is relevant. Objective:To compare mortality on the liver transplant waiting list in Brazil before and after the adoption of Meld score as a criterion for allocation on the waiting list: overall, by diagnostic group, and by Meld range at enrollment. Methods:We retrospectively studied 899 patients (median age = 52.8 years, body mass index, BMI = 25.2 and Meld = 18) divided into the pre- (n = 320, 35.6%) and post-Meld (n = 579, 64.4%) periods and into groups: 1 (n = 480, 53.4%): ethanolic, cryptogenic and autoimmune cirrhosis; 2 (n = 80, 8.9%): biliary diseases; 3 (n = 93, 10.3%): metabolic and other diseases; and 4 (n = 246, 27.4%): post-viral B and C cirrhosis. Special scoring was assigned to 19.5% of patients, according to legislation criteria. The sample was also divided by Meld ranges at enrollment (< 18; 18–24; and > 24). Waitlist mortalities of the pre- and post-Meld groups were compared in the total sample, in each diagnostic group, and in each Meld range. Results:The incidence of referrals to transplantation was different in the pre- and post-Meld eras (p = 0.049), increasing in group 3 (from 8.1 to 11.6%) and decreasing in group 4 (from 32.5 to 24.5%). Of the enrollees, 32.9% died before transplantation. Mean Meld increased from 16 to 20 (p < 0.001), and mean time between enrollment and outcome (transplant or death) decreased from 102 days to 58 (p = 0.028). Waiting list mortality dropped from 105.7% (patient-years) to 54.9% in the post-Meld group (p = 0.001). There was a reduction from 104.2% (patient-years) to 51.1% (p = 0.034) in group 1, and the proportion fell from 160.3% (patient-years) to 52% (p = 0.019) in group 2. On the other hand, there was no statistically significant variation in the groups 3 and 4. In Meld range 1 (< 18), mortality ranged from 87.2% per patient-year to 24.1% per patient-year (p = 0.005). In Meld range 2 (18–24), it ranged from 109.8 to 72.4% per patient-year (p = 0.019). In the Meld > 24 range, there was no significant change in waitlist mortality. Finally, survival at 1, 3 and 12 months after transplantation did not vary significantly between the pre-Meld and post-Meld era. Conclusion:Comparing the pre- and post-Meld groups, patients were enrolled when they were most severely ill, and there was a reduction in mean time on the list for the outcome and a decrease in waiting list mortality with no change in post-transplant survival. Diagnosis groups 1 and 2 have benefited. In addition, the decrease in waiting list mortality was observed among patients with Meld < 24 at the time of enrollment. This reduction was not observed in the group of patients with Meld > 24.

Liver Transplantation in Brazil between 2010 and 2021: 30-day Survival

“…Although a significant achievement, organ replacement treatment has not yet met the growing demand, resulting in a shortage of available livers. As a result, predictive strategies have been developed, such as MELD (Model for End-Stage Liver Disease), which is widely used worldwide to help manage the fair and efficient allocation of organs for patients needing liver transplantation 4,5 .…”

Transplante de Fígado no Brasil entre 2010 e 2021: Sobrevida de 30 Dias

“…Embora tenha sido uma conquista importante, o tratamento de substituição do órgão ainda não foi capaz de atender a crescente demanda, resultando em uma carência de fígados disponíveis. Como resultado, foram desenvolvidas estratégias preditivas, como o MELD (Model for End-Stage Liver Diesease), que são amplamente utilizadas em todo o mundo para ajudar a gerenciar a alocação justa e eficiente de órgãos para pacientes que precisam de transplante hepático 4,5 .…”