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Prioritization for liver transplantation

Nature Reviews Gastroenterology & Hepatology volume 7, pages 659–668 (2010)Cite this article

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Abstract

There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit. The first is based on the severity of cirrhosis, using Child–Turcotte–Pugh score and, more recently, the Model for End-stage Liver Disease (MELD) score, or variants of MELD, for allocation. Although prospectively developed and validated, the MELD score has several limitations, including interlaboratory variations for measurement of serum creatinine and international normalized ratio of prothrombin time, and a systematic adverse female gender bias. Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy. The MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors incorporated into the scoring system. Several utility models are based on donor and recipient characteristics. Combined poor recipient and donor characteristics lead to very poor outcomes, which in a utility system would be considered unacceptable. Finally, transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation. However, complex statistical models are required, and unmeasured characteristics may unduly affect the models. Well-designed prospective studies and simulation models are necessary to establish the optimal allocation system in liver transplantation.

Key Points

  • There are three possible policies for prioritization for liver transplantation: medical urgency, utility and transplant benefit

  • In an urgency policy, patients with worse outcomes on the waiting list are given higher priority for transplantation (based on the Child–Turcotte–Pugh score or the Model for End-stage Liver Disease [MELD] score)

  • The advantages of the MELD score are its statistical validation and the use of objective and widely available laboratory tests; however, the MELD score has important limitations

  • Adjustments to the original MELD equation and new scoring systems have been proposed to overcome these limitations; incorporation of serum sodium improves its predictive accuracy

  • The utility-based systems are based on post-transplant outcome, taking into account donor and recipient characteristics; the MELD score poorly predicts outcomes after liver transplantation due to the absence of donor factors

  • The transplant benefit models rank patients according to the net survival benefit that they would derive from transplantation; these models maximize the lifetime gained through liver transplantation

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Authors and Affiliations

  1. 4th Department of Internal Medicine, Medical School of Aristotle University, Hippocration General Hospital of Thessaloniki, 49 Konstantinopoleos Street, Thessaloniki, 54642, Greece

    Evangelos Cholongitas

  2. The Royal Free Sheila Sherlock Liver Centre and University Department of Surgery, Royal Free Hospital and UCL, Pond Street, Hampstead, NW3 2QG, London, UK

    Giacomo Germani & Andrew K. Burroughs

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  1. Evangelos Cholongitas
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  2. Giacomo Germani
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E. Cholongitas contributed to the research, discussion of content and writing of the article. G. Germani contributed to the research and discussion of content. A. K. Burroughs contributed to the discussion of content, writing and reviewing of the article.

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Correspondence to Andrew K. Burroughs.

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Cholongitas, E., Germani, G. & Burroughs, A. Prioritization for liver transplantation. Nat Rev Gastroenterol Hepatol 7, 659–668 (2010). https://doi.org/10.1038/nrgastro.2010.169

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