The Effects of MELD-Based Liver Allocation on Patient Survival and Waiting List Mortality in a Country with a Low Donation Rate.

Paul V Ritschl,Johann Pratschke,Frank Tacke,Leke Wiering,Matthias Biebl,Tomasz Dziodzio,Nathanael Raschzok,Igor M Sauer,Jochen Kruppa,Uwe Schoeneberg,Max Maurer,Philippa Seika,Frederike Butz,Robert Öllinger,Maximilian Jara,Brigitta Globke,Moritz Schmelzle,Wenzel Schöning

doi:10.3390/jcm9061929

Abstract

The Model for End-Stage Liver Disease (MELD)-based allocation system was implemented in Germany in 2006 in order to reduce waiting list mortality. The purpose of this study was to evaluate post-transplant results and waiting list mortality since the introduction of MELD-based allocation in our center and in Germany. Adult liver transplantation at the Charité—Universitätsmedizin Berlin was assessed retrospectively between 2005 and 2012. In addition, open access data from Eurotransplant (ET) and the German Organ Transplantation Foundation (DSO) were evaluated. In our department, 861 liver transplantations were performed from 2005 to 2012. The mean MELD score calculated with the laboratory values last transmitted to ET before organ offer (labMELD) at time of transplantation increased to 20.1 from 15.8 (Pearson’s R = 0.121, p < 0.001, confidence interval (CI) = 0.053–0.187). Simultaneously, the number of transplantations per year decreased from 139 in 2005 to 68 in 2012. In order to overcome this organ shortage the relative number of utilized liver donors in Germany has increased (85% versus 75% in non-German ET countries). Concomitantly, 5-year patient survival decreased from 79.9% in 2005 to 60.3% in 2012 (p = 0.048). At the same time, the ratio of waiting list mortality vs. active-listed patients nearly doubled in Germany (Spearman’s rho = 0.903, p < 0.001, CI = 0.634–0.977). In low-donation areas, MELD-based liver allocation may require reconsideration and inclusion of prognostic outcome factors.

Highlights

With the increasing success of modern transplant medicine, the desire for life-saving transplantation has unmasked the lack of appropriate donors [1]
On 16 December 2006, Model for End-Stage Liver Disease (MELD)-based allocation was implemented in Germany
We report a strong decrease in 5-year patient survival from the preMELD to the MELD era

Summary

Introduction

With the increasing success of modern transplant medicine, the desire for life-saving transplantation has unmasked the lack of appropriate donors [1]. A high MELD score represents a major risk factor for death while on the waiting list and a need for urgent transplantation [6], it has simultaneously been identified as a major risk factor of post-transplant patient survival [4,7,8,9]. This creates an ethical conflict in terms of the utilization of limited resources with respect to the balance between individual urgency and fair allocation [10]

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Conclusion