Should liver transplantation in patients with model for end-stage liver disease scores <or= 14 be avoided? A decision analysis approach.
Studies have shown that liver transplantation offers no survival benefits to patients with Model for End-Stage Liver Disease (MELD) scores <or= 14 in comparison with remaining on the waitlist. The consensus of a 2003 transplant community national conference was that a minimum MELD score should be required for placement on the liver waitlist, but no minimum listing national policy was enacted at that time. We developed a Markov microsimulation model to compare results under the present US liver allocation policy with outcomes under a "Rule 14" policy of barring patients with a MELD score of <or=14 from the waitlist or transplantation. For probabilities in the microsimulation model, we used data on all adult patients (>or=18 years) listed for or undergoing primary liver transplantation in the United States for chronic liver disease from 1/1/2003 through 12/31/2007 with follow-up until 2/1/2008. The "Rule 14" policy gave a 3% improvement in overall patient survival over the present system at 1, 2, 3, and 4 years and predicted a 13% decrease in overall waitlist time for patients with MELD scores of 15 to 40. Patients with the greatest benefit from a "Rule 14" policy were those with MELD scores of 6 to 10, for whom a 17% survival advantage was predicted from waiting on the list versus undergoing transplantation. Our analysis supports changing the national liver allocation policy to not allow liver transplantation for patients with MELD <or= 14.
Perkins
James D
JD
Division of Transplantation, Department of Surgery, University of Washington, Seattle, WA 98195, USA. theperk@u.washington.edu
Halldorson
Jeffrey B
JB
Bakthavatsalam
Ramasamy
R
Fix
Oren K
OK
Carithers
Robert L
RL
Reyes
Jorge D
JD
D000328:Adult; D005260:Female; D006801:Humans; D017093:Liver Failure / Q000145:classification*; D016031:Liver Transplantation; D008297:Male; D008962:Models, Theoretical; D020380:Needs Assessment; D012720:Severity of Illness Index; D014850:Waiting Lists