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.