Mortality in patients with end‐stage liver disease above model for end‐stage liver disease 3.0 of 40

Abstract

Background and Aims: Since the implementation of the model for endstage liver disease (MELD) score to determine waitlist priority for liver transplant (LT) in 2002, the score has been capped at 40. Recently, the MELD 3.0 score was proposed to improve upon MELD-Na. Here, we examine waitlist mortality and LT outcomes in patients with MELD 3.0 ≥ 40 to assess the potential impact of uncapping the score. Approach and Results: Adult waitlist registrations for LT from January 2016 to December 2021 were identified in the registry data from the Organ Procurement and Transplant Network. All MELD 3.0 scores were calculated at registration and thereafter. Waitlist mortality for up to 30 days was calculated as well as post-LT survival. There were 54,060 new waitlist registrations during the study period, of whom 2820 (5.2%) had MELD 3.0 ≥ 40 at listing. The 30-day waitlist mortality was high in these patients, yet it increased further in proportion with MELD 3.0 up to a score of 55 with 30-day mortality of 58.3% for MELD 3.0 of 40-44 and 82.4% for ≥ 50. The multivariable hazard ratio was 1.13 for each point of MELD 3.0, adjusting for several variables including acute-on-chronic liver failure. The number of LT recipients with MELD 40 at transplant increased from 155 in 2002 to 752 in 2021. Posttransplant survival was comparable across MELD strata including MELD of 35-39. Conclusion: MELD 3.0 scores beyond 40 are associated with increasing waitlist mortality without adversely affecting posttransplant outcome. Uncapping the MELD score in waitlist candidates may lead to greater survival benefit from LT.

Reply: Validation of MELD 3.0 scoring system in East Asian patients with cirrhosis awaiting liver transplantation

“…[4] Patients with alcohol-associated liver disease tended to have higher MELD scores than those with other viral hepatitis, [5] and therefore, they benefited greatly from the MELD allocation system. [6,7] Therefore, we believe that the extent to which MELD 3.0 can improve the existing MELD original system will vary depending on the situation in different countries.Regarding the study that attempted uncapping on patients with a score of 40 or higher on MELD 3.0, [5] additional validation is necessary in Asia. Clinically, patients with a high MELD score are more likely to experience high mortality or complications after transplantation, which may be due to the fact that alcoholic liver disease often progresses to acute-on-chronic liver failure.Our study indicates that the current efforts to improve the allocation system should be continuously implemented for different ethnicities in various regions.…”

“…Regarding the study that attempted uncapping on patients with a score of 40 or higher on MELD 3.0, [5] additional validation is necessary in Asia. Clinically, patients with a high MELD score are more likely to experience high mortality or complications after transplantation, which may be due to the fact that alcoholic liver disease often progresses to acute-on-chronic liver failure.…”

Mind the gaps: reframing patient selection and organ allocation in liver transplantation

“…For example, the current MELD cap of 40 disadvantages the sickest patients with end-stage liver disease whose MELD scores exceed 40, despite data showing favorable posttransplant survival [7]. Uncapping the MELD may be an easy first step towards a more equitable liver allocation system aligned with the principle of prioritizing the patients most in need [8].…”

Letter to the Editor: Validation of MELD 3.0 scoring system in East Asian patients with cirrhosis awaiting liver transplantation

“…However, with the maturity of liver transplantation technology and improvement of perioperative management, will this restriction deprive people with scores above 40 of the chance to survive? To solve this problem, Kim et al [4] examined waitlist mortality and liver transplantation outcomes in patients with MELD 3.0 ≥ 40 and found that uncapping MELD 3.0 improves mortality risk stratification and better represents urgency for liver transplantation for the sickest patients.…”

“…However, with the maturity of liver transplantation technology and improvement of perioperative management, will this restriction deprive people with scores above 40 of the chance to survive? To solve this problem, Kim et al [4] examined waitlist mortality and liver transplantation outcomes in patients with MELD 3.0 ≥ 40 and found that uncapping MELD 3.0 improves mortality risk stratification and better represents urgency for liver transplantation for the sickest patients.Overall, so far, except for calculation somewhat more complex, MELD 3.0 seems to be completely superior to the original MELD. Therefore, it is worth replacing the existing MELD with MELD 3.0 in regions that currently use the MELD score.…”