MELD and UNOS James Trotter, MD Baylor University Medical Center Dallas, Texas
Jan 13, 2016
MELD and UNOS
James Trotter, MDBaylor University Medical Center
Dallas, Texas
U.S. liver transplant candidates
Liver transplants by year
Liver transplants by year
listed
transplants
Age of newly listed patients
%
Newly listed patients > 65 y
%
Newly listed patients MELD > 35
n
Percent liver-kidney transplants
year
advanced age
diabetes
MELD score3.8[ln bili] + 11.2[ln INR] + 9.6[ln Cr] + 6.4
Removed from list for death
Removed from list
died on list
removed, too sick
% died on list+too sick to transplant
MELD score
10(0.957ln(Cr) + 0.378ln(bilirubin) + 1.12ln(INR) + 0.643)
Wiesner et al. Gastro, 2003
high priority forwaiting time
list patients early in disease
list fills withnon-sick pts
transplant ofnon-sick pts
MELD-basedliver
allocation
sicker ptsdie waiting
changesin 2002
high priority forsickness
list sicker patients
list fills withsick pts
transplant ofvery sick pts
many delisted astoo sick to transplant
long rehabpoor fxnality reform is needed
current
Regional sharing – Share 35
Regional sharing – Share 35
Region 4
OKC
HOU
DFW
SAT
Region 4 – prior sharing system
OKC
HOU
DFW
SAT
Under old system,
liver procured
locally offered to
highest MELD
local pt, then
to region.
Region 4 – current regional sharing
OKC
HOU
DFW
SAT
Under new system,
liver procured
locally offered to
MELD > 35 local pt,
then to region
MELD > 35.
Regional sharing of organs
Pros Cons- equalize transplant - longer cold time MELD and death rate - more distance
traveled- more equitable organ - worse outcomes? allocation - local donation impact - doesn’t “go far
enough” - small center impact
Liver redistricting – new proposal
• “if some is good, more is better”• wider regional sharing in the US• fulfills “Final Rule” – access to donors not
limited by geographys• normalizes access/waitlist mortality• supported by: NYC, BOS, SFO, LAX
Liver redistricting – new proposal
Liver redistricting - concerns
• long-travel times (logistics/cost)• penalizes good DSA’s, rewards laggards• effects of share-35 not fully assessed• worsen outcomes• not supported by: organ-rich, low-MELD
regions: MO, KS, SC, TN, TX
Liver redistricting - proposal
110/12,000 = 0.9 % lives saved per year
58 DSA’s in US x 2 livers per year = 116 lives saved
Liver redistricting - summary
• at Chicago meeting 80 % opposed• tabled for now• Spring 2015 conference to reconsider
ALLOCATION OF LIVERS BASED ON THE “SHARE 35” POLICY HAS
NO IMPACT ON WAITING LIST MORTALITY AND WORSENS ORGAN
UTILIZATION IN UNOS REGION 4
James F. TrotterBaylor University Medical Center
Background – Share 35 allocation
• designed to "decrease wait list deaths and minimize distance traveled" of donor organs
• its impact has not been reported
• outcomes of liver transplant candidates and recipients before/after "Share 35" policy in the UNOS Region 4 (Oklahoma and Texas)
Region 4 – current regional sharing
OKC
HOU
DFW
SAT
Distance between region 4 cities
• OK City – San Antonio 422• Amarillo – Houston 533• El Paso – DFW 573
• New York – Cincinnati 568• New York – Charlotte 532
Background – Share 35 allocation
http://optn.transplant.hrsa.gov/PublicComment/pubcommentPropSub_288.pdf
Methods• outcomes of
– waiting list candidates on the waiting list
– organ disposition
– characteristics of liver transplant candidates
– 6 m before (12/17/2012 – 6/17/2013) and after (6/18/2013 – 12/18/2013) "Share 35 "
Results
livers recovered, notShare 35 recovered transplanted transplanted
pre 269 12 257
post 321 30 291
change +52 (19 %) +18 (150 %) +34 (13 %)
Results
too sickShare 35 died to transplant totalpre 66 (10 %) 120 (18 %) 186 post 82 (12.3 %) 97 (15 %) 179
Results
regional MELD wait list death
Share 35 organ share >= 35 + too sick
pre 9.0 % 18.3 % 28 %
post 28.5 % 32.2 % 27 %
Results
distance procured organ
Share 35 CIT organ travelled discarded
pre 6.2 hrs 130 miles 4.5 %
post 6.6 hrs 162 miles 9.3 %
Summary – “Share 35 allocation”
Although 19 % more livers were procured,
there was no change in the percentage of
patients removed from the list for
death or too sick to transplant.
Summary – “Share 35 allocation”
Despite predictions that “Share 35” would improve patient outcomes the opposite is true in UNOS Region 4.
Consider these findings as proposals for evenlarger regional sharing policies are under review.