A Decade of Model for End-Stage Liver Disease (MELD): Is it Time to Uncap the MELD?
Mitra K. Nadim1, Randall Sung2, Kenneth Andreoni3, David C. Mulligan4, Josh Levitsky5, W. Ray Kim6, Yuri Genyk1;
1University of Southern California, Los Angeles, CA; 2University of Michigan, Ann Arbor, MI; 3University of Florida, Gainesville, FL; 4Mayo Clinic, Phoenix, AZ; 5Northwestern University, Chicago, IL; 6Mayo Clinic, Rochester, MN
Background: MELD scoring system was developed so that allocation of livers would be based on the severity of the liver disease with the intention of reducing wait-list (WL) mortality. Currently, MELD is arbitrarily caped at 40 and no additional priority is given to patients with MELD >40.The purpose of this study was to determine WL mortality and post transplant (Tx) survival outcomes of patients with Lab MELD ≧ 40. Methods: OPTN data from 2002–2011, for adult candidates who were removed from WL due to death, too sick for Tx or underwent cadaveric Tx was analyzed. Status-1 and MELD exception patients were excluded. Patients were grouped based on MELD at time of WL and liver Tx into the following groups: MELD 35–39, 40–44, 45–49, ≧50. Results: The number of patients listed and transplanted with MELD ≧40 has increased steadily over the past decade from 2002 (WL n=188, Tx n=104) to 2011 (WL n=470, Tx n=390). Between 2002–2011, 7170 patients were listed with a MELD ≧ 35 (MELD 35–39 n=3698, MELD 40–44 n=2394, MELD 45–49 n=806,MELD ≧ 50 n=272). Figure 1 demonstrates a higher 4 week WL mortality as the MELD increases above 40 (25% MELD 34–39, 33% MELD 40–44, 42% MELD 45–49, 57% MELD ≧ 50) with similar 1-year post Tx survival (82% MELD 34–39, 79% MELD 40–44 & 45–49, 81% MELD ≧ 50). Conclusion: This is the first study to compare WL mortality and post Tx survival of patients with MELD ≧40. Based on the OPTN outcome data from the past decade, WL mortality is higher with increasing MELD up to and beyond 40. Uncapping the MELD beyond 40 has the potential to increase access to transplantation and reduce overall WL mortality without compromising post-transplant survival.
4-week wait list mortality (Top) and 1-year post-transplant survival (Bottom) based on Lab MELD
Josh Levitsky - Grant/Research Support: Salix, Novartis; Speaking and Teaching: Gilead, Salix, Novartis
W. Ray Kim - Advisory Committees or Review Panels: Salix; Consulting: Bristol Myers Squibb, Gilead
The following people have nothing to disclose: Mitra K. Nadim, Randall Sung, Kenneth Andreoni, David C. Mulligan, Yuri Genyk