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Regional Variation in Appropriateness of Non-Hepatocellular Carcinoma Model for End-Stage Liver Disease Exception
Robert M Cannon1, Eric G Davis2, David S Goldberg3
1Department of Surgery, University of Alabama at Birmingham, Birmingham, AL.
Background:
Patients thought to be at greater risk of liver waitlist dropout than their laboratory Model for End-Stage Liver Disease (lMELD) score reflects are commonly given MELD exceptions, where a higher allocation MELD (aMELD) score is assigned that is thought to reflect the patient's risk. This study was undertaken to determine whether exceptions for reasons other than hepatocellular carcinoma (HCC) are justified, and whether exception aMELD scores appropriately estimate risk.
Methods:
Adult primary liver transplantation candidates listed in the current era of liver allocation in the United Network for Organ Sharing database were analyzed. Patients granted non-HCC-related MELD exceptions and those without MELD exceptions were compared. Rates of waitlist dropout and liver transplantation were analyzed using cause-specific hazards regression, with separate models fitted to adjust for lMELD and aMELD.
Results:
There were 29,243 patients, with 2,555 in the exception group. Nationally, exception patients were more likely to dropout (hazard ratio [HR] 1.60; 95% CI, 1.45 to 1.76; p < 0.001) or undergo liver transplantation (HR 3.49; 95% CI, 3.32 to 3.67; p < 0.001) than their lMELD-adjusted counterparts. Adjusting for aMELD, exception patients were less likely to dropout (HR 0.77; 95% CI, 0.70 to 0.85; p < 0.001) and less likely to undergo liver transplantation (HR 0.76; 95% CI, 0.72 to 0.80; p < 0.001). Exception patients were not at significantly increased risk of waitlist dropout when adjusted for lMELD in 4 of 11 United Network for Organ Sharing regions.
Conclusions:
Despite appropriate use of non-HCC MELD exceptions on a national level, patients with non-HCC MELD exceptions were awarded inappropriately high priority for transplantation in many regions. This highlights the need to consider local conditions faced by transplantation candidates when estimating waitlist mortality and determining priority for transplantation.
Insights
MELD exceptions for liver transplant candidates not due to cancer are often justified nationally. However, these exceptions may grant inappropriately high transplant priority in some regions, necessitating local risk assessment.
Area of Science:
- Hepatology
- Transplantation Medicine
- Health Services Research
Background:
- Patients at higher risk of liver transplant waitlist dropout than their laboratory Model for End-Stage Liver Disease (lMELD) score suggests often receive MELD exceptions.
- These exceptions assign a higher allocation MELD (aMELD) score to reflect perceived patient risk.
Purpose of the Study:
- To determine if non-hepatocellular carcinoma (HCC) MELD exceptions are justified.
- To assess if exception aMELD scores accurately reflect patient risk.
Main Methods:
- Analysis of adult primary liver transplant candidates from the United Network for Organ Sharing database.
- Comparison of patients with and without non-HCC MELD exceptions using cause-specific hazards regression, adjusting for lMELD and aMELD.
Main Results:
- Nationally, exception patients had higher dropout and transplant rates than lMELD-adjusted counterparts.
- However, adjusting for aMELD showed exception patients had lower dropout and transplant rates.
- Risk of waitlist dropout was not significantly increased for exception patients in 4 of 11 regions when adjusted for lMELD.
Conclusions:
- Non-HCC MELD exceptions are appropriately used nationally but can lead to excessive transplant priority in certain regions.
- Local factors influencing waitlist mortality and transplant priority require consideration.
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