Use of the MELD System for Liver Allocation

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Use of the MELD System for Liver Allocation

• Brendan McGuire, MD, MS
• UAB Liver Center

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Introduction

• The Scope of Liver Disease
• Recommendations to Improve Organ Allocation
• Transplant Listing Criteria After 2/02
• Model for End-stage Liver Disease (MELD) Score
• Potential Changes for Liver Allocation

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Introduction

• The Scope of Liver Disease
• Recommendations to Improve Organ Allocation
• Transplant Listing Criteria After 2/02
• Model for End-stage Liver Disease (MELD) Score
• Potential Changes for Liver Allocation

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Scope of Liver Disease in USA
6,500
Transplants performed in 2007 including 266
living donors
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Scope of Liver Disease in USA
6,500
16,781
Listed for Liver Transplantation (7/6/08)
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Scope of Liver Disease in USA
6,500
16,781
44,000
Yearly Deaths from Liver Disease
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Introduction

• The Scope of Liver Disease
• Recommendations to Improve Organ Allocation
• Transplant Listing Criteria After 2/02
• Model for End-stage Liver Disease (MELD) Score
• Potential Changes for Liver Allocation

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Recommendations to Improve Organ Allocation

• Organs should be allocated to the recipient with
  the greatest degree of medical urgency
• Waiting times should not be the major determinant
  for who receives a transplant
• Donor organs are a precious resource and should
  be placed in recipients with a high likelihood of
  success

Health and Human Services, 1999
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Introduction

• The Scope of Liver Disease
• Recommendations to Improve Organ Allocation
• Transplant Listing Criteria After 2/02
• Model for End-stage Liver Disease (MELD) Score
• Potential Changes for Liver Allocation

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Transplant Listing Criteria After 2/02
Status Criteria I Acute liver failure
II Model for End-stage Liver Disease (MELD) -
Continuous disease severity scale, ranging from
6 (mild disease) 40 (severe disease) -
Patients with the higher MELD score will get
transplanted first - The tie breaker, if gt 2
patients are listed with the same score
blood type, will be the patient with the
longest waiting time at that level
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Introduction

• The Scope of Liver Disease
• Recommendations to Improve Organ Allocation
• Transplant Listing Criteria After 2/02
• Model for End-stage Liver Disease (MELD) Score
• Potential Changes for Liver Allocation

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Model for End-stage Liver Disease

• Prospectively followed 231 patients at 4 medical
  centers who underwent elective TIPS
• 70 patients died within 3 months
• Using Cox proportional-hazards regression, 3
  factors were identified as predicting mortality
• Total bilirubin
• INR
• Creatinine

Hepatology 200031864.
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MELD ScorePredicted 3 Month Survival
Survival ()
MELD Score
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MELD ScoreCalculation

• Calculated using
• Total bilirubin measures how effectively the
  liver excretes bile
• INR (prothrombin time) measures the livers
  ability to make blood clotting factors
• Creatinine measures kidney function (impaired
  kidney function is often associated with severe
  liver disease)

Maximum score 40
Average score for transplantation 24
UAB minimal listing score 18
Minimum score 6
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MELD Score Equation
Maximum value is 4 mg/dL

• Or go to the following website
• www.unos.org/resources/meldpeldcalculator.asp

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MELD ScoreExceptions

• Hepatocellular Carcinoma (HCC)
• If 1 lesion 2-5 cm or 2-3 lesions all lt 3 cm
• MELD score of 22
• Severe Hepatopulmonary Syndrome
• If PaO2 lt 60 mmHg on room air evidence of
  portal hypertension, MELD score of 24
• Familial amyloidosis primary oxaluria
• Will receive a MELD score of 20

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MELD ScoreRecertification
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MELD ScoreWaitlist Mortality Rates
Log (RR)
Acute Liver Failure
Hepatocellular Carcinoma
Mortality Rates
MELD Score
Data censored at time of transplant, removal from
the waitlist for reason of improved condition or
end of study. Patients added to the list 2/27/02
2/26/03. Follow-up is through 9/30/03.
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MELD Score Average One Year Waitlist Mortality
Rates
Rate/1000 Patient Years
Waitlist
lt 10 10-14 15-19 20-24 25-29 30-34
35-39 gt 40 Status 1
MELD Score
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MELD Score Average One Year Post-Transplant
Mortality Rates
Rate/1000 Patient Years
Transplant
lt 10 10-14 15-19 20-24 25-29 30-34
35-39 gt 40 Status 1
MELD Score
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MELD Score Average One Year Mortality Rates
Rate/1000 Patient Years
Hazard Ratios are located above the bars
Waitlist
0.03
0.06
0.07
0.36
Transplant
0.12
0.32
0.62
2.19
1.77
lt 10 10-14 15-19 20-24 25-29 30-34
35-39 gt 40 Status 1
MELD Score
P lt 0.01 at all points
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MELD ScoreAverage One Year Mortality Rates
Hazard Ratio (HR)
Adverse (HR gt 1) for MELD Score lt 15
Waitlist Reference
Benefit (HR lt 1) for MELD Score gt 15
MELD Score
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Introduction

• The Scope of Liver Disease
• Recommendations to Improve Organ Allocation
• Transplant Listing Criteria After 2/02
• Model for End-stage Liver Disease (MELD) Score
• Potential Changes for Liver Allocation

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Potential Changes for Liver Allocation

• Increase Minimal Listing Criteria
• Minimal Transplant Criteria
• Serum Sodium
• Transplant Benefit