Liver Meeting speaker: HCC exceptions contributing to MELD inflation, transplant inequity
WASHINGTON – Changes should be considered to the Model for End-stage Liver Disease scoring system to improve equity on the transplant waiting list, Patrick G. Northup, MD, of the division of gastroenterology and hepatology in the department of medicine at the University of Virginia, said at The Liver Meeting.
“Regulatory authorities and the transplant community should decide whether transplant should be preferential to HCC [hepatocellular carcinoma], or whether it should treat all diseases equally,” he said. “The current system is self-fulfilling ... HCC exceptions have better wait-list survival and better short-term outcome.”
Researchers analyzed all adult, initial transplant candidates listed for liver transplantation from 2005 to 2012, other than status one candidates, to determine whether HCC exceptions are related to the increase in MELD scores on the U.S. liver transplant waiting list.
The study found those candidates with HCC exceptions experienced significantly fewer mean days on the waiting list in comparison to those without exceptions, largely due to the lower lab-based MELD score. Those with HCC waited a mean of 257 days, compared with 420 days for non-HCC patients (P<.0001)
Similar results were seen in HCC vs. non-HCC transplantation rates (65.4% to 44.2%, P<.0001) and waiting-list death rate (13.5% to 22.3%).
Furthermore, the number of exceptions granted for HCC patients was found to be directly and independently associated with the average MELD score of all candidates at the time of removal (P<.00001), Northup said.
Overall, MELD scores are increasing about 2% per year, he said, noting a strong association between those increasing scores and the upgrades transplant candidates with HCC exceptions are given.
“We should ask ourselves: ‘Does the current system truly give access to the sickest first?’ ” Northup said, before concluding that “we should use extreme caution when considering adding new exceptions to the MELD system … as upgrades to the current MELD system have unintended consequences.”
Disclosure: Northup receives grant and research support from Hemosonics, Bristol Myers Squibb.
For more information:
Northup P #1: MELD Inflation: The Current Hepatocellular Carcinoma Exception Policy is Primarily Responsible for Steadily Increasing MELD Scores at the Time of Liver Transplant in All Regions of the U.S. Presented at: The Liver Meeting 2013; Nov. 1-5, Washington.