The new liver allocation system: Moving toward... : Liver Transplantation (original) (raw)

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The new liver allocation system: Moving toward evidence-based transplantation policy

Freeman, Richard B. Jr MD*,1; Wiesner, Russell H.2; Harper, Ann3; McDiarmid, Sue V.4; Lake, Jack5; Edwards, Erick3; Merion, Robert6, 7; Wolfe, Robert8, 9; Turcotte, Jeremiah6; Teperman, Lewis2

1Department of Surgery, Tufts-New England Medical Center/Tufts University School of Medicine, Boston, MA

2Department of Medicine, Mayo Clinic, Rochester, MN

3United Network for Organ Sharing, Richmond, VA

4Department of Pediatrics, University of California at Los Angeles, Los Angeles, CA

5Department of Medicine, University of Minnesota, Minneapolis, MN

6Department of Surgery, University of Michigan, Ann Arbor, MI

7Department of Biostatistics, University of Michigan, Ann Arbor, MI

8Department of Scientific Registry of Transplant Recipients, Ann Arbor, MI

9Department of Surgery, New York University, New York, NY

E-mail:[email protected]

*Address reprint requests to Division of Transplant Surgery, New England Medical Center, Box 40, 750 Washington St, Boston, MA 02111. Telephone: 617-636-5592; FAX: 617-636-8228

Abstract

In 1999, the Institute of Medicine suggested that instituting a continuous disease severity score that de-emphasizes waiting time could improve the allocation of cadaveric livers for transplantation. This report describes the development and initial implementation of this new plan. The goal was to develop a continuous disease severity scale that uses objective, readily available variables to predict mortality risk in patients with end-stage liver disease and reduce the emphasis on waiting time. Mechanisms were also developed for inclusion of good transplant candidates who do not have high risk of death but for whom transplantation may be urgent. The Model for End-Stage Liver Disease (MELD) and Pediatric End-Stage Liver Disease (PELD) scores were selected as the basis for the new allocation policy because of their high degree of accuracy for predicting death in patients having a variety of liver disease etiologies and across a broad spectrum of liver disease severity. Except for the most urgent patients, all patients will be ranked continuously under the new policy by their MELD/PELD score. Waiting time is used only to prioritize patients with identical MELD/PELD scores. Patients who are not well served by the MELD/PELD scores can be prioritized through a regionalized peer review system. This new liver allocation plan is based on more objective, verifiable measures of disease severity with minimal emphasis on waiting time. Application of such risk models provides an evidenced-based approach on which to base further refinements and improve the model.