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Einleitung und Fragestellung / Introduction and Background

The Eurotransplant (ET) liver transplant allocation system is based on the Model for End-Stage Liver Disease (MELD) score and priorititizes patients with higher scores within a defined ET member country. Mortality in certain other disease entities is not reflected by the MELD-score. Therefore certain patient populations, such as patients with hepatocellular carcinoma, receive standard MELD exception points (SE) or individual non-standard exception points (NSE) under predefined circumstances to confer equitable access to donor organs. We assessed rates of transplantation of cirrhotic patients and patients with standard (SE) and non-standard exceptions (NSE)

Methodik / Methods

Based on ET-waitlist-data, we analyzed wait-list outflow of adult (non HU) patients waiting with and without N(SE)s in ET MELD countries (Germany, Belgium, Netherlands) between 2007-2015.

Ergebnisse und Schlussfolgerungen / Results and Conclusions

Of 17506 patients, 10201 were transplanted (TRANS), 1379 were delisted recovered (DL-R) 4051 died on the waitlist (DOWL) and 1295 were delisted unfit for transplantation (DL-U). The most common SEs were HCC (2511), PSC (292) biliary sepsis/SSC (225) and polycystic liver disease PcLD (225). Of patients with HCC, PSC BS/SSC and PcLD 75.0%, 81.5%, 59.1% and 85.5% were transplanted, among patients with NSE, with SE and without (N)SE 80.6%, 75.3% and 53.9%, respectively.

Regarding positive (TRANS/DL-R) vs (DOWL/DL_U) negative outcome, statistical analysis by model based recursive partitioning identified 5 subgroups. The most important predictor of TRANS/DL-R vs DOWL/DL_U was belonging to a group comprising SEs for porto-pulmonary hypertension, biliary sepsis or no SE versus a group comprising SEs for HCC, PSC, hepatopulmonary syndrome (HPS) or PcLD.

From this data it appears that (N)SE based liver allocation may overshoot the original aim of conferring equitable access to donor organs across different disease entities and that patients without (N)SE have a higher wait-list mortality. Accordingly, (N)SE criteria should be recalibrated.

Einleitung und Fragestellung / Introduction and Background

The BCLC system excludes many patients from potentially curative treatment. Integration of individual markers of tumor biology may help to identify patients that benefit from surgical treatment.

Methodik / Methods

In our institution we use a modified BCLC treatment algorithm that also includes markers of individual, tumor biology such as response to therapy, grading, and AFP. We have analyzed the outcome of our HCC resection and transplantation cohort (2007-2015) with BCLC stage 0-B.

Ergebnisse und Schlussfolgerungen / Results and Conclusions

A total of 259 patients were analyzed, 109 of them received a liver transplantation. 5 year-survival after resection was 51.1% after transplantation 72.8%. The MILAN stage had no influence on outcome (n.s.).   

Even patients who would be subjected to palliative treatment by using the BCLC treatment algorithm can be cured after surgical treatment. The inclusion of markers of individual tumor biology may be more adequate in treatment allocation as compared to plain BCLC score.

Einleitung und Fragestellung / Introduction and Background

The MELD-based allocation system has been implemented in Germany in 2006 in order to decrease waiting list mortality in patients with end stage liver disease. However, the MELD score not only reflects the probability to die within 3 months, but simultaneously represents a major risk factor for post transplantation graft and patient survival. Purpose of this study is to evaluate post transplant results and their development since the introduction of MELD-based allocation.

Methodik / Methods

MELD scores at time of transplantation, 1- and 3-year graft- as well as patient survival were assessed from 2005 -2015 using our own and Eurotransplant data. Statistical analysis was carried out using Graphpad Prism 5.01.

Ergebnisse und Schlussfolgerungen / Results and Conclusions

In our departement 1172 liver transplantations were performed from 2005 to 2015. The average Lab-MELD at time of transplantation increased from 16.19 to 21.22 (Pearson r=0.55, p= 0.078). The Match-MELD growth in this era was even higher from 16.19 to 24.47 (Pearson r=0.68, p= 0.021). Concomitantly, while no significant changes were seen in 1-year survival over time, 3-year patient survival decreased from 85% in 2005 to 70% in 2012 (Pearson r=-0.78, p= 0.022). Similarly, in the Eurotransplant area the average 3-year patient survival was 77% in the years 2000-2006 and decreased to 72% in the period 2007-2012. In these years approximately 60 percent of all liver transplantations were performed in Germany. At our center, donor and/or recipient age have not significantly changed over the analyzed period, however the number of transplantations per year has dramatically decreased from 158 in 2005 to 79 in 2015.

Lab- and Match-MELD values have significantly increased since the implementation of the MELD based allocation system, accompanied by a diminished 3-year survival. This data has to be reevaluated, analyzed and discussed in the context of organ scarcity and waitlist mortality. Hence, under current circumstances MELD-based allocation may need reconsideration or at least modifications.