title: Higher Mortality in registrants with sudden model for end-stage liver disease increase: Disadvantaged by the current allocation policy.
abstract: Liver allocation is based on current Model for End-Stage Liver Disease (MELD) scores, with priority in the case of a tie being given to those waiting the longest with a given MELD score. We hypothesized that this priority might not reflect risk: registrants whose MELD score has recently increased receive lower priority but might have higher wait-list mortality. We studied wait-list and posttransplant mortality in 69,643 adult registrants from 2002 to 2013. By likelihood maximization, we empirically defined a MELD spike as a MELD increase ≥ 30% over the previous 7 days. At any given time, only 0.6% of wait-list patients experienced a spike; however, these patients accounted for 25% of all wait-list deaths. Registrants who reached a given MELD score after a spike had higher wait-list mortality in the ensuing 7 days than those with the same resulting MELD score who did not spike, but they had no difference in posttransplant mortality. The spike-associated wait-list mortality increase was highest for registrants with medium MELD scores: specifically, 2.3-fold higher (spike versus no spike) for a MELD score of 10, 4.0-fold higher for a MELD score of 20, and 2.5-fold higher for a MELD score of 30. A model incorporating the MELD score and spikes predicted wait-list mortality risk much better than a model incorporating only the MELD score. Registrants with a sudden MELD increase have a higher risk of short-term wait-list mortality than is indicated by their current MELD score but have no increased risk of posttransplant mortality; allocation policy should be adjusted accordingly.
authors.affiliation: Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD; Department of Epidemiology, Johns Hopkins School of Public Health, Baltimore, MD.
authors.forename: Allan B
authors.initials: AB
authors.lastname: Massie
authors.forename: Xun
authors.initials: X
authors.lastname: Luo
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Alejo
authors.forename: Anna K
authors.initials: AK
authors.lastname: Poon
authors.forename: Andrew M
authors.initials: AM
authors.lastname: Cameron
authors.forename: Dorry L
authors.initials: DL
authors.lastname: Segev
mesh_terms: D058625:End Stage Liver Disease / Q000601:surgery*; D005260:Female; D006801:Humans; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D018579:Patient Selection; D011379:Prognosis; D012042:Registries; D040841:Resource Allocation; D012189:Retrospective Studies; D012306:Risk; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index; D013997:Time Factors; D009927:Tissue and Organ Procurement; D016896:Treatment Outcome; D014481:United States; D014850:Waiting Lists