The new liver allocation system: Moving toward evidence-based transplantation policy

Abstract

In 1999, the Institute of Medicine suggested that instituting a continuous disease severity score that de-emphasizes waiting time could improve the allocation of cadaveric livers for transplantation. This report describes the development and initial implementation of this new plan. The goal was to develop a continuous disease severity scale that uses objective, readily available variables to predict mortality risk in patients with end-stage liver disease and reduce the emphasis on waiting time. Mechanisms were also developed for inclusion of good transplant candidates who do not have high risk of death but for whom transplantation may be urgent. The Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease (PELD) scores were selected as the basis for the new allocation policy because of their high degree of accuracy for predicting death in patients having a variety of liver disease etiologies and across a broad spectrum of liver disease severity. Except for the most urgent patients, all patients will be ranked continuously under the new policy by their MELD/PELD score. Waiting time is used only to prioritize patients with identical MELD/PELD scores. Patients who are not well served by the MELD/PELD scores can be prioritized through a regionalized peer review system. This new liver allocation plan is based on more objective, verifiable measures of disease severity with minimal emphasis on waiting time. Application of such risk models provides an evidenced-based approach on which to base further refinements and improve the model. (Liver Transpl2002;8:851-858.)

The sickest first? Disparities with model for end-stage liver disease-based organ allocation: One region[apos ]s experience

“…This flexibility would allow the system to be adjusted for a maximization of outcomes. 10 The MELD also allows for reproducible comparison of patients awaiting transplantation, as well as comparison of transplant recipients across geographic areas. From these data, it has become clear that there is disparity among transplant centers when it comes to the selection of patients for transplantation.…”

Systematic Review and Meta-Analysis of the Impact of Computed Tomography–Assessed Skeletal Muscle Mass on Outcome in Patients Awaiting or Undergoing Liver Transplantation

“…However, no multivariable analysis has been performed for bacterial infections. (27) Pre-OLT sarcopenia associated with mortality (p = 0.06) 1 Non-significant association of continued reduction in muscle area with higher mortality (p = 0.08) Only one study reported that five patients had confirmed acute graft rejection without specifying them as (non)sarcopenic (27).…”

“…The combination of waiting list mortality and posttransplantation survival are key deciding factors in waiting list placement. Currently, the Model for End-stage Liver Disease (MELD) score, a validated risk-based system that predicts waiting list mortality, is used to allocate donor livers (1). Although the introduction of the MELD score has led to a decreased number of patients on the waiting list, shortened waiting time, and decreased waiting list mortality despite increasing disease severity (2), objective parameters reflecting a patient's nutritional and functional status in particular are lacking and attempts have been made to modify and improve the MELD score (3,4).…”

Influence of Serum Sodium on MELD-Based Survival Prediction in Alcoholic Hepatitis

“…In this regard, mortality risk in patients with AH can be predicted by various models, including the Model for End-Stage Liver Disease (MELD) score. [2][3][4][5][6][7] Hyponatremia is a sign of excessive vasopressin secretion and is predictive of poor survival in patients with cir- CONCLUSION: MELD and MELDNa were similar predictors of 180-day mortality; however, MELDNa was a better predictor of mortality than MELD in patients with ascites. Hyponatremia in patients with AH without ascites is not a predictor of mortality because it may have a dilutional basis secondary to excessive intake of low-osmolar alcohol.…”