Should a lower quality organ go to the least sick patient? Model for end-stage liver disease score and donor risk index as predictors of early allograft dysfunction.
BACKGROUND
There is a global tendency to justify transplanting extended criteria organs (ECD; Donor Risk Index [DRI] ≥ 1.7) into recipients with a lower Model for End-Stage Liver Disease (MELD) score and to transplant standard criteria organs (DRI < 1.7) into recipients with a higher MELD scores. There is a lack of evidence in the current literature to justify this assumption.


METHODS
A review of our prospectively entered database for donation after brain death (DBD) liver transplantation (n = 310) between January 1, 2006, and September 30, 2010, was performed. DRI was dichotomized as <1.7 and ≥ 1.7. Recipients were divided into 3 strata, those with high (≥ 27), moderate (15-26), and low MELD (<15) scores. The recently validated definition of early allograft dysfunction (EAD) was used. We analyzed EAD and its relation with donor DRI and recipient MELD scores.


RESULTS
The overall incidence of EAD was 24.5%. Mortality in the first 6 months in recipients with EAD was 20% compared with 3.4% for those without EAD (relative risk [RR], 5.56, 95% confidence interval [CI], 1.96-15.73; P < .001). Graft failure rate in the first 6 months in those with EAD was 27% compared with 5.8% for those without EAD (RR, 4.63; 95% CI, 2.02-10.6; P < .001). In patients with low MELD scores, a significantly increased rate of EAD (25%) was seen in patients transplanted with a high DRI liver compared with those transplanted with a low DRI liver (6.25%; P = .012). In moderate and high MELD recipients, there was no significant difference in the rate of EAD in patients transplanted with a high DRI liver (62%) compared with those transplanted with a low DRI liver (59%).


CONCLUSIONS
These results suggest that contrary to common belief it is not justified to preferentially allocate organs with higher DRI to recipients with lower MELD scores.
Multi-Organ Transplant Program, London Health Sciences Centre, The University of Western Ontario, London, Canada.
K P
KP
Croome
P
P
Marotta
W J
WJ
Wall
C
C
Dale
M A
MA
Levstik
N
N
Chandok
R
R
Hernandez-Alejandro
D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D046148:Donor Selection; D005260:Female; D006085:Graft Survival; D006304:Health Status; D006305:Health Status Indicators; D006801:Humans; D015994:Incidence; D008107:Liver Diseases / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009864:Ontario; D018579:Patient Selection; D011237:Predictive Value of Tests; D055031:Primary Graft Dysfunction / Q000175:diagnosis / Q000209:etiology* / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014019:Tissue Donors; D016896:Treatment Outcome