A recent study (Hepatology 2015; 61: 285 & editorial 28-31) takes a closer look at US liver organ allocation and outcomes.
The editorial notes that our allocation in the US is targeted towards “need.” Since February 2001, the MELD score was adopted with “the stated aim of reducing deaths on the waiting list.” Other potential aims:
- Equity –so any one who might benefit from a graft has an equal chance and a first-come, first-served approach is adopted
- Utility –organs are allocated to the recipient who is likely to have the best outcomes
- Benefit –organs are allocated to the patient who has the greatest benefit, so taking into account the risks of dying with and without a transplant
- Fairness — ‘an ill-defined combination of all the approaches’
The editorial notes that “despite the concerns the approach has been highly effective in achieving its goal in reducing waiting list mortality.”
“Like any system, it can be manipulated and, given the life-saving nature of transplantation, it is scarcely surprising that both legal and illegal methods have been adopted to artificially raise the MELD score and distort allocation.”
The study reviewed 78,595 adult liver transplant candidates (2005-2012). 27.3% of the waiting list was occupied by candidates with exceptions.
Candidates with exceptions fared much better on the waiting list compared to those without exceptions in mean days waiting (HCC 237 versus non-HCC 426), transplantation rates (HCC 79.1% versus non-HCC 40.6%), and waiting list death rate (HCC 4.5% versus non-HCC 24.6%).
The editorialists recommend that “we should consider diverting some of the resources used to develop and implement a perfect allocation scheme into increasing the number of donors and livers used for transplant and, in the longer term, finding treatments and interventions that will render liver transplantation a treatment of historic interest.” Now that’s a lofty goal.
Related blog posts:
- Picking winners and losers with liver transplantation allocation
- “Facebook Plea Gets Liver Transplant for 3-Year-Old …