Risk Assessment in High- and Low-MELD Liver Transplantation.

Area of Science:

• Hepatology
• Transplant Surgery
• Medical Economics

Background:

• Liver graft allocation is contentious, particularly for patients with high Model of End-stage Liver Disease (MELD) scores who face high mortality risk.
• Assessing outcomes in high-MELD liver transplant recipients is crucial for optimizing resource allocation and patient management.

Purpose of the Study:

• To compare post-transplantation morbidity, cost, and survival between high-MELD and low-MELD liver transplant recipients.
• To evaluate the predictive performance of various risk scoring models for outcomes in liver transplantation.
• To determine the utility of the Balance-of-Risk (BAR) score in guiding decisions for high-risk liver transplant recipients.

Main Methods:

• Analysis of a high-MELD cohort (MELD ≥30) and a propensity score-matched low-MELD cohort over 10 years.
• Application and comparison of six prediction models: D-MELD, Delta MELD, DRI, SOFT, BAR, and UCLA-FRS.
• Comparison of model performance against clinical judgment (hemofiltration plus ventilation).

Main Results:

• High-MELD recipients experienced significantly increased morbidity (Comprehensive Complication Index 56 vs. 36) and double the costs (US$179,631 vs. US$80,229).
• Five-year survival rates were only slightly lower in high-MELD patients (70% vs. 78%).
• The BAR score demonstrated a linear association with complications and showed utility in risk classification, outperforming several other models in predicting outcomes.

Conclusions:

• Despite higher morbidity and costs, high-MELD liver transplant recipients achieve comparable long-term survival to low-MELD patients.
• The BAR score is a valuable tool for risk stratification in liver transplantation, aiding in the allocation of scarce organs to high-risk individuals.
• Clinical decision-making for accepting liver grafts in high-risk patients can be enhanced by incorporating the BAR score.