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Europeans with risk exceptions more likely to receive liver transplant

In Eurotransplant countries with MELD-based individual allocation, patients with standard and non-standard exceptions have better waitlist outcomes than patients without exceptions, according to a recently published study.

The Eurotransplant International Foundation, a Dutch non-profit organization, organizes multinational transplant organ allocation for its member countries. Of the member countries, Belgium, Germany and the Netherlands allocate waitlist position to individual patients, rather than to centers. Patients with certain risk factors may receive exceptions based upon disease-related risk factors.

“We believe this prioritization is unintended and not justified,” Andreas Umgelter, MD, from Technische Universität München, Germany, and colleagues wrote. “If the aim of equitable access to donor organs and equitable risk of adverse outcomes on the waiting-list for all patients qualifying for liver transplantation is to be upheld, modification of standard exceptions should be initiated and the application of non-standard-exceptions considerably reduced.”

Umgelter and colleagues gathered data on all patients listed in Eurotransplant countries with MELD score-based allocation from December 2006 to December 2015. The study comprised 17,506 patients, of which 3,548 patients left the waitlist with standard exceptions and 330 left the waitlist with non-standard exceptions.

The researchers deemed that patients had positive outcomes if they received a transplant (n = 10,201) or left the waitlist as recovered (n = 1,379), or had negative outcomes if they died on the waitlist (n = 4,051) or left the waitlist as too sick for transplant (n = 1,295). Outcomes were positive in 76.5% of those with standard exceptions, 90.1% of those with non-standard exceptions, and negative in 4,493 without standard exceptions.

Those without exceptions were significantly more likely to have negative outcomes than patients with standard or non-standard exceptions (P < .001). Additionally, compared with Belgium and the Netherlands, Germany had more frequent negative waitlist outcomes due to a higher proportion of waitlist deaths (P < .001).

“MELD exceptions have been introduced to match the ranking on the waiting-list of those patients whose mortality risk is not represented by laboratory MELD scores to the urgency based ranking of cirrhotic patients according to their laboratory MELD scores,” the researchers concluded. “Some [standard exceptions], however, seem to overshoot this aim. As an overall result, in the Eurotransplant MELD countries, patients without standard exceptions seem to be unintentionally disadvantaged concerning deceased donor liver allocation.”

To avoid “MELD-score inflation” among patients applicable for standard exceptions, the researchers recommend lower entry-level matched MELD-scores and a slower MELD-progression to adapt scores to the actual risks for mortality on the waitlist or removal due to disease progression.

The researchers stated that, regarding non-standard exceptions, the lack of formal prerequisites in the current procedure leads to gross overestimation of mortality risk. They recommend standardizing and restricted the allotted MELD scores related to application of non-standard exceptions. – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.