Prioritization for liver transplantation

Abstract

There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit. The first is based on the severity of cirrhosis, using Child-Turcotte-Pugh score and, more recently, the Model for End-stage Liver Disease (MELD) score, or variants of MELD, for allocation. Although prospectively developed and validated, the MELD score has several limitations, including interlaboratory variations for measurement of serum creatinine and international normalized ratio of prothrombin time, and a systematic adverse female gender bias. Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy. The MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors incorporated into the scoring system. Several utility models are based on donor and recipient characteristics. Combined poor recipient and donor characteristics lead to very poor outcomes, which in a utility system would be considered unacceptable. Finally, transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation. However, complex statistical models are required, and unmeasured characteristics may unduly affect the models. Well-designed prospective studies and simulation models are necessary to establish the optimal allocation system in liver transplantation.

A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a “Blended Principle Model”

“…Several proposed models focusing on urgency, utility or benefit principles, or combinations thereof, involve adjusting scores, matching donors and recipients, and other optimizations, assuming that access to LT is not the only goal; delisting criteria, long-term transplantation outcomes, and organ availability must be considered, as well as the expected results of alternative therapies (6)(7)(8)(9)(10)(11)(12). The issue's complexity, the number of variables and different medical, social and political figures involved, and the huge differences in local and regional scenarios have all contributed to hindering the development of a consensual allocation/ priority system that considers all the above elements.…”

“…The score gives considerable weight to the severity of liver function impairment as an indication of the inapplicability of alternative therapies, and reflects the negative impact of a-fetoprotein on posttransplant prognosis. The system still needs prospective validation, however (7,26,27).…”

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

“…It would be very important that future investigations include appropriate risk stratifications, in order to identify subsets that particularly benefit from IVIg. Apart from that, adequate Morioka et al [167] LDLT n = 2; post-LDLT; treatment of AMR Plasmapheresis Normalization of liver function; survived Urbani et al [170] LT n = 1; post-LT; treatment of AMR Plasmapheresis Normalization of liver function; survived Ikegami et al [168] LDLT n = 1; post-LDLT; treatment of AMR Rituximab, plasma exchange, splenectomy Normalization of liver function; survived Testa et al [169] LDLT n = 5; pre-LDLT Plasmapheresis, splenectomy Patient and graft survival 80% at mean of 43 mo post-LDLT Urbani et al [172] LT n = 8; pre-and post-LT Plasma exchange Patient and graft survival 87.5% at 18 mo; no case of acute or chronic rejection, no ITBL Ikegami et al [161] LDLT n = 4; post-LDLT Rituximab, plasma exchange, splenectomy Survival rate 100% (28,8,6, 5 mo post-LDLT) Takeda et al [173] LDLT n = 3; post-LDLT; treatment of AMR Plasma exchange Normalization liver function; survived Mendes et al [174] LT n = 10; pre-and post-LT Rituximab, plasmapheresis Survival rate 50%; death mainly related to MOF and sepsis Kim et al [175] LDLT n = 14; post-LDLT Rituximab, plasma exchange Survival 100%; no case of acute or chronic rejection Lee et al [176] LDLT n = 15; post-LT Rituximab, plasma exchange Survival 100%; no case of bacterial or fungal infection; 3 cases of biliary strictures Shen et al [177] LT n = 35; pre-and post-LT Rituximab Survival rate 83.1% at 3-yr; one case of acute celluar rejection; two cases of AMR …”

“…As a result, donors' and recipients' selection criteria were considerably expanded and numbers of LTs performed were significantly increasing in recent years. Due to a dramatic donor organ shortage, growing waiting lists, prolonged waiting times and increasing pre-LT mortality rates have been reported [4][5][6] . 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.…”

Prognostic Factors for Survival in Patients with Liver Cirrhosis

“…(Cholongitas E, 2010) Biselli M et al (Biselli M 2010) evaluated the survival of patients with advanced liver cirrhosis, liver transplant candidates at 3, 6 and 12 months. Six scoring systems used, included the modified Child Pugh (MCTP) and the standard MELD, and four of its modifications.…”