A Multistep, Consensus-Based Approach to Organ Allocation in Liver Transplantation: Toward a "Blended Principle Model".
Since Italian liver allocation policy was last revised (in 2012), relevant critical issues and conceptual advances have emerged, calling for significant improvements. We report the results of a national consensus conference process, promoted by the Italian College of Liver Transplant Surgeons (for the Italian Society for Organ Transplantation) and the Italian Association for the Study of the Liver, to review the best indicators for orienting organ allocation policies based on principles of urgency, utility, and transplant benefit in the light of current scientific evidence. MELD exceptions and hepatocellular carcinoma were analyzed to construct a transplantation priority algorithm, given the inequity of a purely MELD-based system for governing organ allocation. Working groups of transplant surgeons and hepatologists prepared a list of statements for each topic, scoring their quality of evidence and strength of recommendation using the Centers for Disease Control grading system. A jury of Italian transplant surgeons, hepatologists, intensivists, infectious disease specialists, epidemiologists, representatives of patients' associations and organ-sharing organizations, transplant coordinators, and ethicists voted on and validated the proposed statements. After carefully reviewing the statements, a critical proposal for revising Italy's current liver allocation policy was prepared jointly by transplant surgeons and hepatologists.
Hepatobiliary Surgery and Liver Transplant Center, Padova University Hospital, Padova, Italy.
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Cillo
Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padova University Hospital, Padova, Italy.
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Burra
Hepato-Pancreatic-Biliary Surgery and Oncology National Cancer Institute (Istituto Nazionale Tumori), Milan, Italy.
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Mazzaferro
Department of Hepatology and Gastroenterology, Niguarda Hospital, Milan, Italy.
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Belli
Department of General Surgery and Transplantation, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy.
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Pinna
Istituto Mediterraneo Trapianti e Terapie ad Alta Specializzazione, University of Pittsburgh Medical Center in Italy, Palermo, Italy.
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Spada
Italian National Transplant Center, Rome, Italy.
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Nanni Costa
Medical Liver Transplant Section, Department of Medical Sciences Experimental and Clinical, University of Udine, Udine, Italy.
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Toniutto
D000465:Algorithms; D003661:Decision Support Techniques; D015276:Health Care Rationing / Q000592:standards*; D006801:Humans; D007558:Italy; D008107:Liver Diseases / Q000175:diagnosis / Q000601:surgery; D016031:Liver Transplantation / Q000592:standards*; D018579:Patient Selection; D012720:Severity of Illness Index