MELD 3.0 corrects disparity in access to liver transplant for women
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An updated MELD 3.0 amends existing sex-based disparities in access to liver transplantation among women, according to a presenter at the American Transplant Congress 2022.
“Before we implemented MELD, allocation was based primarily on the Child-Turcotte Pugh score which saw a fair amount of subjective criteria and defaulted primarily to waiting time,” Julie Heimbach, MD, professor of surgery and director of the Mayo Clinic Transplant Center in Rochester, Minnesota, said.
“After MELD was implemented, there was a significant amount of attention that was placed on trying to optimize that, especially with regard to over prioritization of [hepatocellular carcinoma]. We also developed the standard MELD exceptions. ... It's important to note that during this time we uncovered that there was a problem with MELD in how it prioritized female waitlisted candidates.”
Although the implementation of MELD scoring disseminated baseline documentation and streamlined LT allocation, disparities continued and actually worsened among the female population, Heimbach noted.
According to a study that primarily evaluated racial disparities in LT allocation, Cynthia A. Moylan, MD, and colleagues continuously found decreased transplant rates among women compared with men (64.8% vs. 67.6% and 39.9% vs. 48.7%) and increased risk for death (22.4% vs. 21.9% and 23.7% vs. 21.4%) in both pre- and post-MELD cohorts, respectively.
In addition, Jayme E. Locke, MD, MPH, and colleagues reported that compared with men, women were 8.6% more likely to die while on the LT wait list and 14.4% less likely to receive a deceased donor LT (DDLT). Further, after adjusting for size and serum creatinine levels, women were 8.4% and 4.7% less likely to receive a DDLT, respectively.
“Why is this happening?” Heimbach asked. “It comes down to three things: HCC exceptions during this time period were over-prioritized and the rate of HCC in men is higher than in women. There was also a relationship to height, but the primary factor was the creatinine-based MELD points.”
A revised model, MELD 3.0, adds sex and albumin variables while updating coefficients of existing variables — such as capping creatinine at 3 mg/dL — to potentially improve waitlist mortality.
In a 2021 study, W. Ray Kim, MD, and colleagues reported that MELD 3.0 eliminated access disparity among female candidates and “works better for everyone” compared with MELD-Na (C-statistic: 0.869 vs. 0.862).
“The increased waitlist mortality and decreased transplant rate for female waitlisted candidates was first recognized around 2008,” Heimbach concluded. “MELD 3.0 corrects this problem and has actually gone out through the whole policy development process.
“It is now being considered for approval by the board at the end of June, so it's hopeful that this situation is maybe going to be resolved.”
Reference:
Kim WR, et al. Gastroenterology. 2021;doi:10.1053/j.gastro.2021.08.050.
Locke JE, et al. JAMA Surg. 2020;doi:10.1001/jamasurg.2020.1129.
Moylan CA, et al. JAMA. 2008;doi:10.1001/jama.2008.720.
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Heimbach J. Sex-based disparities in liver transplant: Historical perspective and current state. Presented at: American Transplant Congress; June 4-8, 2022; Boston (hybrid meeting).
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