Model for end-stage liver disease (MELD) exception guidelines: Results and recommendations from the MELD exception study group and conference (MESSAGE) for the approval of patients who need liver transplantation with diseases not considered by the standard MELD formula
✍ Scribed by Richard B. Freeman Jr.; Robert G. Gish; Ann Harper; Gary L. Davis; John Vierling; Leslie Lieblein; Goran Klintmalm; Jamie Blazek; Robert Hunter; Jeffrey Punch
- Publisher
- John Wiley and Sons
- Year
- 2006
- Tongue
- English
- Weight
- 105 KB
- Volume
- 12
- Category
- Article
- ISSN
- 1527-6465
- DOI
- 10.1002/lt.20979
No coin nor oath required. For personal study only.
✦ Synopsis
Determining need for liver transplantation (LT) can be effectively estimated when the actual liver disease is highly likely to cause death in the near future. However, for many conditions, the liver disease itself does not carry a high risk of short-term mortality, and other factors contribute to defining the need for LT. The existence of these so-called exceptional cases was recognized in the initial development of the Model for End-Stage Liver Disease (MELD)-and Pediatric End-Stage Liver Disease (PELD)-based liver allocation policy, 1 most notably in the case of hepatocellular cancer (HCC). In this instance, the driving imperative for LT is not life-threatening liver failure, but the progression of cancer to a point where a high probability of cure is no longer possible. Using the well-established Milan Criteria 2 as selection criteria for good outcome, policymakers initially equated the risk of HCC progression beyond Milan Criteria to 15% for stage 1 lesions and 30% for stage 2 lesions within 3 months of listing analogous to MELD-defined mortality risk. These initial estimates proved to be too high based on publications citing much lower risks of progression in cohorts of waiting LT candidates with HCC, 4,5 and subsequently, the risk of HCC progression was reestimated to be much lower. The HCC priority policy was revised accordingly.The HCC example illustrates two important principles for allocating livers to patients with low mortality risk who fall into these exceptional diagnosis categories. First, a nonmortality endpoint, namely the risk of progression beyond Milan Criteria, where a patient would be removed from the LT waiting list, was defined. For any such endpoint, patient-specific, objective definitions must be used. In the case of HCC, the risk of tumor progression beyond the Milan Criteria meets such standards because the risk of progression does not depend on extrinsic influences like geography, lo-