August 16, 2018
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MELD-Na allocation improves liver transplant waitlist outcomes

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Liver allocation based on MELD-Na score improved transplant waitlist outcomes and provided significant benefit to hyponatremic patients, according to recently published data.

Shunji Nagai, MD, PhD, from the Henry Ford Hospital in Michigan, and colleagues designed the study to compare waitlist and posttransplant outcomes between the MELD and MELD-Na allocation periods after the Share 35 rule was implemented.

“As expected, the MELD-Na based allocation helped alleviate the adverse prognostic impact of hyponatremia on waitlist outcomes,” Nagai and colleagues wrote. “Hyponatremia is a well-known factor associated with mortality in liver cirrhosis patients and this was clearly observed in the MELD period. These findings support the rationale for the implementation of MELD-Na score into liver allocation.”

Compared with the MELD period, the MELD-Na period had lower 90-day (–26.2%; P < .001) and overall waitlist mortality rates (–33.5% P < .001) and higher rates of 90-day (21.7%; P < .001) and overall transplant probability (19.7%; P < .001). One-year graft loss or patient death rates were similar between the two periods.

Additionally, 90-day waitlist mortality in the MELD-Na period decreased significantly among patients with normal serum sodium concentration (HR = 0.825; 95% CI, 0.738-0.922) and in those with mild (HR = 0.656; 95% CI, 0.558-0.765), moderate (HR = 0.64; 95% CI, 0.513-0.8) or severe hyponatremia (HR = 0.526; 95% CI, 0.368-0.752).

“Our results suggest that higher scores secondary to hyponatremia probably led to better waitlist outcomes especially in the population who benefited from Share 15,” the researchers wrote.

In an analysis that included “removal for too sick to transplant” as waitlist mortality, the researchers found that waitlist mortality rates were similar between the MELD (318.2 per 1,000 patients) and MELD-Na periods (307 per 1,000 patients).

“The Share 15 rule ... has not been reviewed for over a decade but is still maintained in upcoming policy,” the researchers wrote. “Our study revealed that the MELD-Na based allocation provided significant benefit to hyponatremic patients with lower MELD score and that survival benefit of liver transplant in patients with MELD-Na score between 15 [to] 20 became unclear and questionable in the MELD-Na period.”

Nagai and colleagues proposed a new “Share 21” rule by raising the cutoff score from 15 to 21 to promote “sicker patient access to transplant by allocating the liver efficiently.” – by Talitha Bennett

Disclosure: The authors report no relevant financial disclosures.

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