MELD Inflation: The Current Hepatocellular Carcinoma Exception Policy is Primarily Responsible for Steadily Increasing MELD Scores at the Time of Liver Transplant in All Regions of the U. S
Patrick G. Northup, Nicolas M. Intagliata, Neeral L. Shah, Curtis K. Argo
Gastroenterology and Hepatology, University of Virginia, Charlottesville, VA
With large increases in hepatocellular carcinoma (HCC) diagnoses in recent years and advances in HCC locoregional therapies, more HCC patients are awaiting liver transplantation than ever before. It was the aim of this study to determine if HCC exceptions are related to the increase in MELD scores on the U. S. liver transplant waiting list. Methods: Data from all adult, non-status one, initial transplant candidates who were listed for liver transplantation between January 2005 and December 2012 were analyzed. Because of significant changes in HCC exceptions from 2002-2004, these years were excluded from the analysis. Yearly trends in waiting list characteristics and transplantation rates were analyzed for statistical association with MELD exceptions, especially HCC exceptions, using multivariate generalized linear modeling. Regional variations in these associations were also analyzed. Results: During the study period there was a significant difference between the mean initial laboratory MELD score for candidates with any MELD exception (11.5) and no exception (18.3), p < 0.001. This gap widened at the time of waiting list removal (exception 12.6 vs. non-exception 21.9, p < 0.0001). Because of the extra exception points given to HCC candidates every three months, the mean score used for allocation significantly favored the HCC exception candidate (24.3 vs. 21.6, P < 0.0001). Candidates with HCC exceptions fared much better on the waiting list due to the lower lab-based MELD score compared to those without exceptions in mean days waiting (HCC 257 vs. non-HCC 420, P < 0.0001), transplantation rates (HCC 65.4% vs. non-HCC 44.2%, p < 0.0001)and waiting list death rates (HCC 13.5% vs. non-HCC 22.3%). The number of HCC-exceptions granted was directly and independently associated with the average MELD score of all candidates at the time of removal (p < 0.0001). Although the absolute number of exceptions differed, this trend was near universal in all UNOS regions over the same time period. Conclusions: The rates of HCC MELD exceptions and MELD scores at waiting list removal have increased steadily over the past 8 years. The MELD upgrades afforded to HCC exception candidates drive the increase in average MELD scores for all candidates in all UNOS regions. Alteration of the MELD upgrade amount or frequency for HCC patients should be considered to optimize equity on the transplant waiting list for all candidates.
Patrick G. Northup - Grant/Research Support: Hemosonics, Bristol Meyer Squibb Neeral L. Shah - Grant/Research Support: Hemosonics
Curtis K. Argo - Consulting: Wellstat Diagnostics; Independent Contractor: Genentech/Roche
The following people have nothing to disclose: Nicolas M. Intagliata