Impact of the Model for End-Stage Liver Disease Allocation Policy on the Use of High-Risk Organs for Liver Transplantation

Received 22 May 2008; accepted 7 August 2008.

Refers to article:

Using Higher Risk Organs for Liver Transplantation: In Whom and at What Price? , 13 October 2008
Bilal Hameed, John R. Lake
Gastroenterology
November 2008 (Vol. 135, Issue 5, Pages 1452-1454)
Full Text | Full-Text PDF (111 KB)

Background & Aims

Although priority for liver transplantation is determined by the model for end-stage liver disease (MELD) score, the quality of organs used is subject to physician discretion. We aimed to determine whether implementation of MELD affected the quality of organs transplanted, the type of patients who receive the higher-risk organs, and the impact of these changes on their posttransplant survival.

Methods

Data were analyzed from the United Network for Organ Sharing of adults who underwent deceased-donor liver transplantation between January 1, 2007, and August 1, 2007 (n = 47,985). Dependent variables included the donor risk index (a continuous variable that measures the risk of graft failure associated with a particular organ) and patient survival after transplantation.

Results

The overall organ quality of transplanted livers has worsened since MELD implementation, with an increase in the donor risk index equivalent to a 4% increased risk of graft failure after adjusting for temporal trends (P < .001). This was accompanied by a shift from using the higher-risk organs in the more urgent patients (in the pre-MELD era) to using the higher-risk organs in the less urgent patients (in the post-MELD era). Posttransplant survival has worsened over time (hazard ratio, 1.017/y; P = .005) among the less urgent patients (MELD scores, <20); mediation analysis suggests this change in survival was caused primarily by changes in organ quality.

Conclusions

As an unintended consequence of the MELD allocation policy, patients that are least in need of a liver transplant now receive the highest-risk organs. This has reduced posttransplant survival in recent years among patients with low MELD scores.

Abbreviations used in this paper: CI, confidence interval, DRI, donor risk index, INR, international normalized ratio, MELD, model for end-stage liver disease, QOL, quality of life

⁎ Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan

§ Division of Transplant Surgery, University of Michigan, Ann Arbor, Michigan

∥ Division of General Medicine, University of Michigan, Ann Arbor, Michigan

‡ VA Health Services Research and Development Center of Excellence, VA Ann Arbor Healthcare System, Ann Arbor, Michigan

Address reprint requests to: Michael L. Volk, MD, MSc, Division of Gastroenterology and Hepatology, University of Michigan, 300 N Ingalls 7C27, Ann Arbor, Michigan 48109. fax: (734) 936-8944

The authors disclose no financial conflicts.

This work was supported in part by a grant from the Robert Wood Johnson Foundation and the Department of Veterans Affairs (to M.L.V.), and by Health Resources and Services Administration contract 234-2005-370011C (United Network for Organ Sharing).

The content is the responsibility of the authors alone, and does not necessarily reflect the views or policies of the Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the U.S. Government. The sponsors had no role in design or conduct of the study; collection, management, analysis, or interpretation of the data; or preparation, review, or approval of the manuscript.

PII: S0016-5085(08)01508-4

doi:10.1053/j.gastro.2008.08.003

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