Allocation of liver grafts worldwide - Is there a best system?
Christoph Tschuor, Alberto Ferrarese, Christoph Kuemmerli, Philipp Dutkowski, Patrizia Burra, Pierre-Alain Clavien, Liver Allocation Study Group, Javier Lendoire, Oscar Imventarza, Michael Crawford, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Roberto Hernandez-Alejandro, M Katherine Dokus, Koji Tomiyama, Shusen Zheng, Gabriel Jaime Echeverri, Pavel Taimr, Jiri Fronek, Marieke de Rosner-van Rosmalen, Serge Vogelaar, Mickael Lesurtel, Jean-Yves Mabrut, Sanjay Nagral, Farzad Kakaei, Seyed Ali Malek-Hosseini, Hiroto Egawa, Alan Contreras, Jaroslaw Czerwinski, Teresa Danek, Hugo Pinto-Marques, Sergey V Gautier, Artem Monakhov, Espen Melum, Bo-Göran Ericzon, Koo Jeong Kang, Myoung Soo Kim, Patricia Sanchez-Velazquez, Christian Eugen Oberkofler, Beat Müllhaupt, Michael Linecker, Dilmurodjon Eshmuminov, Lukasz Filip Grochola, Zhoulon Song, Patryk Kambakamba, Chao-Long Chen, Mehmet Haberal, Sezai Yilmaz, Ian A C Rowe, Philipp Kron, Christoph Tschuor, Alberto Ferrarese, Christoph Kuemmerli, Philipp Dutkowski, Patrizia Burra, Pierre-Alain Clavien, Liver Allocation Study Group, Javier Lendoire, Oscar Imventarza, Michael Crawford, Wellington Andraus, Luiz Augusto Carneiro D'Albuquerque, Roberto Hernandez-Alejandro, M Katherine Dokus, Koji Tomiyama, Shusen Zheng, Gabriel Jaime Echeverri, Pavel Taimr, Jiri Fronek, Marieke de Rosner-van Rosmalen, Serge Vogelaar, Mickael Lesurtel, Jean-Yves Mabrut, Sanjay Nagral, Farzad Kakaei, Seyed Ali Malek-Hosseini, Hiroto Egawa, Alan Contreras, Jaroslaw Czerwinski, Teresa Danek, Hugo Pinto-Marques, Sergey V Gautier, Artem Monakhov, Espen Melum, Bo-Göran Ericzon, Koo Jeong Kang, Myoung Soo Kim, Patricia Sanchez-Velazquez, Christian Eugen Oberkofler, Beat Müllhaupt, Michael Linecker, Dilmurodjon Eshmuminov, Lukasz Filip Grochola, Zhoulon Song, Patryk Kambakamba, Chao-Long Chen, Mehmet Haberal, Sezai Yilmaz, Ian A C Rowe, Philipp Kron
Abstract
Background & aims: An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. The most frequent principles for allocation policies in liver transplantation are therefore criteria that rely on pre-transplant survival (sickest first policy), post-transplant survival (utility), or on their combination (benefit). However, large differences exist between centers and countries for ethical and legislative reasons. The aim of this study was to report the current worldwide practice of liver graft allocation and discuss respective advantages and disadvantages.
Methods: Countries around the world that perform 95 or more deceased donor liver transplantations per year were analyzed for donation and allocation policies, as well as recipient characteristics.
Results: Most countries use the model for end-stage liver disease (MELD) score, or variations of it, for organ allocation, while some countries opt for center-based allocation systems based on their specific requirements, and some countries combine both a MELD and center-based approach. Both the MELD and center-specific allocation systems have inherent limitations. For example, most countries or allocation systems address the limitations of the MELD system by adding extra points to recipient's laboratory scores based on clinical information. It is also clear from this study that cancer, as an indication for liver transplantation, requires special attention.
Conclusion: The sickest first policy is the most reasonable basis for the allocation of liver grafts. While MELD is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors, predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.
Lay summary: An optimal allocation system for scarce resources should simultaneously ensure maximal utility, but also equity. While the model for end-stage liver disease is currently the standard for this model, many adjustments were implemented in most countries. A future globally applicable strategy should combine donor and recipient factors predicting probability of death on the waiting list, post-transplant survival and morbidity, and perhaps costs.
Keywords: Allocation; ELTR; Liver transplantation; MELD; Organ donation; UNOS.
Copyright © 2019 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
Source: PubMed