title: Increasing the donor pool reduces the severity of liver disease: lessons learned from São Paulo, Brazil.
abstract: BACKGROUND
  A new liver allocation system driven by the model for end-stage liver disease (MELD) score was implemented in Brazil in 2006. In association with the new allocation policy, there was a concomitant expansion of the number of donors. We designed this study to assess whether a potential expansion of the donor pool with these educational campaigns had reduced the severity of liver disease at transplantation.
  
  
  METHODS
  We retrospectively reviewed the state of São Paulo liver transplant database from July 2003 through July 2009. Patients were divided into groups: those who were transplanted before (pre-MELD group) and those who were transplanted after (post-MELD group) the implementation of the MELD system. The number of transplantations and the severity of liver disease were the endpoints of the study.
  
  
  RESULTS
  There has been a significant shift towards an older donor population, mainly those who are dying of cerebrovascular accidents. The average MELD score has changed over time. Approximately one quarter of the patients have been transplanted with a MELD score of more than 30 in the post-MELD era. However, this number has decreased over the past 3 years (P = .012). Currently, it has been possible to transplant patients with a MELD score from 25 to 30. The number of transplantations due to hepatocarcinoma (HCC) has increased 8-fold.
  
  
  CONCLUSIONS
  An aggressive educational campaign has successfully expanded the donor pool with a concomitant yearly reduction of the average MELD score at the time of transplantation. Patients with HCC have been benefited tremendously with the new allocation system.
authors.affiliation: Liver Transplantation Unit, Hospital Israelita Albert Einstein, São Paulo, Brazil. salvalaggio@einstein.br
authors.forename: P R
authors.initials: PR
authors.lastname: Salvalaggio
authors.forename: R C
authors.initials: RC
authors.lastname: Afonso
authors.forename: L A
authors.initials: LA
authors.lastname: Pereira
authors.forename: B H
authors.initials: BH
authors.lastname: Ferraz-Neto
mesh_terms: D001938:Brazil; D016009:Chi-Square Distribution; D046148:Donor Selection; D007722:Health Knowledge, Attitudes, Practice; D006293:Health Promotion; D006801:Humans; D008107:Liver Diseases / Q000175:diagnosis / Q000601:surgery*; D016031:Liver Transplantation; D015999:Multivariate Analysis; D015397:Program Evaluation; D016016:Proportional Hazards Models; D011639:Public Opinion; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D014019:Tissue Donors / Q000600:supply & distribution*; D009927:Tissue and Organ Procurement; D014850:Waiting Lists