Liver transplant recipient selection: MELD vs. clinical judgment.
Minimization of death while waiting for liver transplantation involves accurate prioritization according to clinical status and appropriate allocation of donor livers. Clinical judgment in the Liver Transplant Unit Victoria (LTUV) was compared with Model for End-Stage Liver Disease (MELD) in a retrospective analysis of the LTUV database over the 2-year period August 1, 2002, through July 31, 2004. A total of 1,118 prioritization decisions occurred. Decisions were concordant in 758 (68%), comparing priorities assigned by clinical judgment with those assigned by MELD, P < 0.01. A total of 263 allocation decisions occurred. Decisions were concordant in 190 (72%) and 203 (77%) of the cases, comparing donor liver allocation with prioritization by MELD and clinical judgment, respectively. Of the 52 patients allocated a liver, only 23 would have been allocated on the basis of MELD while 29 had been prioritized on the waiting list in the week prior to transplantation. A total of 10 patients died on the waiting list in the 2-year period (annual adult waiting list mortality is 9.3%). Patients who subsequently died waiting were 3 times as likely to be prioritized by MELD as clinical judgment (29% vs. 9%, respectively). One half (3 of 6) of the patients who could have received a donor liver but who died waiting would have been allocated the organ on the basis of MELD. In conclusion, an allocation process based on MELD rather than clinical judgment would significantly alter organ allocation in Australia and may reduce waiting list mortality.
Fink
Michael A
MA
Liver Transplant Unit Victoria, Melbourne, Australia. mafink@unimelb.edu.au
Angus
Peter W
PW
Gow
Paul J
PJ
Berry
S Roger
SR
Wang
Bao-Zhong
BZ
Muralidharan
Vijayaragavan
V
Christophi
Christopher
C
Jones
Robert M
RM
D001315:Australia; D006528:Carcinoma, Hepatocellular / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D015331:Cohort Studies; D003657:Decision Making; D005260:Female; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D008113:Liver Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000601:surgery; D016031:Liver Transplantation / Q000592:standards* / Q000639:trends; D019520:Living Donors; D008297:Male; D020380:Needs Assessment; D018579:Patient Selection; D011336:Probability; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D015996:Survival Rate; D009927:Tissue and Organ Procurement / Q000592:standards* / Q000639:trends; D016896:Treatment Outcome; D014850:Waiting Lists