Towards a better liver transplant allocation system

Burroughs, Andrew K.; Marelli, Laura; Cholongitas, Evangelos; Manousou, Pinelopi; Rolles, K; Karam, Vincent; Delvart, V.; Adam, René; Sabin, Caroline

doi:10.1002/lt.21110

Cited by 7 publications

(9 citation statements)

References 9 publications

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“…In addition, Ioannou G [10] has shown that several donor and recipient characteristics are associated with post-LT mortality. Interestingly, in this study [10], gender and ethnicity in both donor and recipient were significant for predicting outcome after LT. We believe that disease-specific models (along with donor characteristics) need to be developed, since recurrence of primary liver disease affects long-term post-LT survival [8]. Thus, we agree with Schaubel et al [1], who stated that a ''transplant benefit" system is needed for allocation and prioritization of recipients, taking into account donor and/or operative factors and matching donor to recipient characteristics for optimal outcomes.…”

Section: Bert Wolterssupporting

confidence: 62%

“…In the UNOS database, women were more likely to die on the waiting list in the post-MELD era, compared to the pre-MELD era, although women were listed with lower median MELD scores, compared to men (14 vs. 15, p < 0.001). These findings are likely to be the result of not considering lower Cr in women for the same renal function (GFR), as in men [8], as we documented in our paper [6]. Interestingly, we found that correcting Cr by equalising the GFR between men and women resulted in an increase in MELD score by 2 or 3 points in 65% of female LT candidates [6].…”

Section: Bert Wolterssupporting

confidence: 42%

“…In order to assess likelihood of a good outcome, we have proposed a MELDD score -a second D for donor [2,8]. This would allow a utilitarian approach to allocation on top of the ''solely justice approach" of MELD and would lead to a transplant benefit model for allocation.…”

Section: Referencesmentioning

confidence: 99%

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Towards a better liver allocation system

Germani

Tsochatzis

Burroughs

2009

Journal of Hepatology

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failures because primary HB-vaccination failures occur in over 5% of adult vaccinees. Not only awareness that vaccine-induced immunity against HBV can wane over time, but also awareness of which factors are associated with waning immunity is important for preventing HBV infection in general and in the healthcare setting in particular. References[1] Boot HJ, van der Waaij LA, Schirm J, Kallenberg CGM, van Steenbergen J, Wolters B. Acute hepatitis B in a healthcare worker: A case report of genuine vaccination failure. J Hepatol 2009;50:426-431. [2] Wiersma ST. Hepatitis B vaccine continues to provide long-term protection to healthcare workers. Journal of Hepatology [1]. Although we agree that the MELD score is basically a ''justice system" which allocates patients according to severity of liver disease however it is not necessarily the best system [2] and indeed some limitations of the MELD score were totally ignored in the forum mentioned above. For example, significant variations of the MELD score have been found using different laboratory methodologies for INR measurement [3], as well as creatinine (Cr) as we have published [4], and recently MELD-Na [5]. These variations, which may be cumulative when summated, lead to inequalities in prioritization of candidates, especially in those with the highest priority for LT (more jaundiced, greater renal dysfunction and lower serum sodium). A system of allocation that inherently does not have standardized measurements cannot reflect true justice for individuals on waiting lists -this needs to be addressed. Moreover, there is an issue of potential gender bias, highlighted by us [6] and reported by Moylan et al. [7]. In the UNOS database, women were more likely to die on the waiting list in the post-MELD era, compared to the pre-MELD era, although women were listed with lower median MELD scores, compared to men (14 vs. 15, p < 0.001). These findings are likely to be the result of not considering lower Cr in women for the same renal function (GFR), as in men [8], as we documented in our paper [6]. Interestingly, we found that correcting Cr by equalising the GFR between men and women resulted in an increase in MELD score by 2 or 3 points in 65% of female LT candidates [6]. Our findings with Cr are also pertinent to ethnicity differences. South Asian candidates have worse GFR for the same Cr values than Caucasians, and the opposite is true for black Africans, whether Americans or otherwise. A correction factor for gender and ethnicity could be introduced [6].Regarding post-LT survival, it is true that the MELD score is a weak predictor of mortality after LT, so it cannot be used as a predictor. In order to assess likelihood of a good outcome, we have proposed a MELDD score -a second D for donor [2,8]. This would allow a utilitarian approach to allocation on top of the ''solely justice approach" of MELD and would lead to a transplant benefit model for allocation. A recent evaluation of the European Liver Transplant Registry data [9], demonstrated that donor age, total ischaemi...

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Section: Bert Wolterssupporting

confidence: 62%

Section: Bert Wolterssupporting

confidence: 42%

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Towards a better liver allocation system

Germani

Tsochatzis

Burroughs

2009

Journal of Hepatology

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“…a survival benefit system) [56]. This policy is currently under serious consideration for LT in the USA, while it is already used for lung allocation in the USA [63].…”

Section: Discussionmentioning

confidence: 99%

“…However, MELD and UKELD scores are weak predictors of mortality after LT [53-55], since post-LT outcomes depend on both the pre-LT parameters of recipient, and donor “quality”. In the face of organ shortage, optimization of donor/recipient pairing would have great importance for a better outcome after LT. A MELDD score -a second D for donor- [56] has been proposed by us for a utilitarian ap-[56] has been proposed by us for a utilitarian ap-utilitarian approach, which could lead to a transplant benefit model for allocation. A simple arithmetic product [57] of donor age and preoperative MELD (DMELD) has been proposed.…”

Section: Utility-based Allocation Systems (Table 2)mentioning

confidence: 99%

Prioritization for liver transplantation

Cholongitas

Germani

Burroughs

2010

Nat Rev Gastroenterol Hepatol

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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.

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