Inequity in organ allocation for patients awaiting liver transplantation: Rationale for uncapping the model for end-stage liver disease | SNFGE.org - Société savante médicale française d'hépato-gastroentérologie et d’oncologie digestive
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Intermédiaire
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Intermédiaire
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Immédiatement
 
 
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Docteur Jean-Louis PAYEN
Coup de coeur :
 
 
Journal of Hepatology
  2017/09  
 
  2017 Sep;67(3):517-525.  
  doi: 10.1016/j.jhep.2017.04.022.  
 
  Inequity in organ allocation for patients awaiting liver transplantation: Rationale for uncapping the model for end-stage liver disease  
 
  Nadim MK, DiNorcia J, Ji L, Groshen S, Levitsky J, Sung RS, Kim WR, Andreoni K, Mulligan D, Genyk YS  
  https://www.ncbi.nlm.nih.gov/pubmed/28483678  
 
 

Abstract

BACKGROUND & AIM:

The goal of organ allocation is to distribute a scarce resource equitably to the sickest patients. In the United States, the Model for End-stage Liver Disease (MELD) is used to allocate livers for transplantation. Patients with greater MELD scores are at greater risk of death on the waitlist and are prioritized for liver transplant (LT). The MELD is capped at 40 however, and patients with calculated MELD scores >40 are not prioritized despite increased mortality. We aimed to evaluate waitlist and post-transplant survival stratified by MELD to determine outcomes in patients with MELD >40.

METHODS:

Using United Network for Organ Sharing data, we identified patients listed for LT from February 2002 through to December 2012. Waitlist candidates with MELD ⩾40 were followed for 30days or until the earliest occurrence of death or transplant.

RESULTS:

Of 65,776 waitlisted patients, 3.3% had MELD ⩾40 at registration, and an additional 7.3% had MELD scores increase to ⩾40 after waitlist registration. A total of 30,369 (46.2%) underwent LT, of which 2,615 (8.6%) had MELD ⩾40 at transplant. Compared to MELD 40, the hazard ratio of death within 30days of registration was 1.4 (95% CI 1.2-1.6) for patients with MELD 41-44, 2.6 (95% CI 2.1-3.1) for MELD 45-49, and 5.0 (95% CI 4.1-6.1) for MELD ⩾50. There was no difference in 1- and 3-year survival for patients transplanted with MELD >40 compared to MELD=40. A survival benefit associated with LT was seen as MELD increased above 40.

CONCLUSIONS:

Patients with MELD >40 have significantly greater waitlist mortality but comparable post-transplant outcomes to patients with MELD=40 and, therefore, should be given priority for LT. Uncapping the MELD will allow more equitable organ distribution aligned with the principle of prioritizing patients most in need. Lay summary: In the United States (US), organs for liver transplantation are allocated by an objective scoring system called the Model for End-stage Liver Disease (MELD), which aims to prioritize the sickest patients for transplant. The greater the MELD score, the greater the mortality without liver transplant. The MELD score, however, is artificially capped at 40 and thus actually disadvantages the sickest patients with end-stage liver disease. Analysis of the data advocates uncapping the MELD score to appropriately prioritize the patients most in need of a liver transplant.

 

 
Question posée
 
Inéquité dans l'allocation d'organe pour les patients en attente d'une transplantation hépatique : Justification d’une adaptation du modèle basé sur le MELD pour les maladies hépatiques en phase terminale.
 
Question posée
 
Les patients dont le MELD est > à 40 ont une mortalité sur liste d'attente significativement plus grande, toutefois des survies comparables après la transplantation aux patients dont le MELD est égale à 40, ainsi ils devraient être prioritaires sur la liste de transplantation. Se libérer des règles actuelles utilisant le MELD permettrait une répartition plus équitable des organes en accord avec le principe de priorisation des patients les plus graves.
 
Commentaires

Ce travail rétrospectif entre 2002 et 2012 montre les limites des règles permettant de gérer la pénurie de greffons dans le domaine de la transplantation hépatique. Ces règles doivent être remises naturellement en cause à la lumière de l’expérience, comme cela a été discuté pour des situations singulières comme les tumeurs hépatiques, l’hépatite alcoolique grave …

 
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