Liver transplantation in the MELD era--analysis of the OPTN/UNOS registry

OVERVIEW OF THE MODEL FOR END-STAGE LIVER DISEASE (MELD): MELD has been successful in its initial aim of reducing pre-transplant mortality by better organ allocation; at the same time, it generated a new challenge of achieving better posttransplant outcomes by adjusting the hierarchy of allocation to sicker patients. Our analysis of 49,867 adult patients in the MELD era (2002 through 2011) showed a change in the dynamics of the transplant population: the number of patients with higher priority (MELD-exception patients and high-MELD patients) has been progressively increasing while the number of those without priority has remained constant or has been decreasing depending on their disease. The re-transplantation rate has been increasing for high-MELD patients. An increase in number has also observed of major racial groups other than Whites. Overall graft survival-including that for re-transplant-has improved, regardless of MELD levels, during the decade since MELD implementation in 2002. 2. MELD WITH PRIMARY DISEASES: Over the past two decades, the incidence of hepatitis C virus (HCV) has been increasing, and after the inception of MELD, hepatocellular carcinoma (HCC) and non-alcoholic liver disease (NASH) have been progressively increasing. There appears to be a general tendency toward lower graft survival in high-MELD patients in both deceased- and living-donor transplantation. However, this trend differed among the 12 primary diseases, in which significantly lower graft survival was observed in high-MELD patients with alcoholic liver disease (ALD), NASH, autoimmune disorders (AI), HCV, hepatitis B virus (HBV) or non-HCC cancers. Overall, HCV seropositive patients had lower graft survival than HCV seronegative patients. This was also true in each high- and low-MELD group. However, analysis of the primary diseases showed four patterns for the impact of HCV seropositivity related to MELD levels: lower graft survival with anti-HCV regardless of MELD level (with acute hepatic failure, metabolic disorders and HBV); no correlation between the impact of HCV antibodies and MELD levels (with primary biliary cirrhosis [PBC], primary sclerosing cholangitis [PSC] and HCC); lowest graft survival with high MELD scores in the presence of HCV antibodies (with AI, ALD and NASH); and worse survival without HCV (non-HCC cancers). 3. MELD EXCEPTION: Among the primary diseases, the five with a high rate of HCC exception (> 70%) were HCC, HCV, HBV, ALD and AI; the four with a high rate of non-HCC exception (> 60%) were non-HCC cancers, PSC, PBC, and "Others." HCC patients with HCC-exception appear to have derived a greater benefit from transplantation, with better graft survival, than HCC patients without exception. The same beneficial effect of non-HCC exception has been observed with non-HCC cancers, the majority of them cholangiocarcinoma.