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

Abstract

Summary 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.

Model for End-stage Liver Disease

“…Hence, in clinical practice, a balanced approach is needed to optimize liver allocation. 44 Etiology of liver disease is not factored into the calculation of MELD score; patients with viral etiology of cirrhosis and MELD >15 had significantly lower survival than alcoholic cirrhosis patients with similar MELD suggesting that viral cirrhosis patients may be disadvantaged in the MELD allocation policy. 45 For a given MELD score between 15-17 and 24-40, a patient with higher serum creatinine is shown to have higher waitlist mortality compared to a patient with lower serum creatinine.…”

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

“…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.…”

“…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.…”

“…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.…”

“…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] .…”