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• W2078166385 abstract "Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15–20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score. Model for end-stage liver disease (MELD) score, initially developed to predict survival following transjugular intrahepatic portosystemic shunt was subsequently found to be accurate predictor of mortality amongst patents with end-stage liver disease. Since 2002, MELD score using 3 objective variables (serum bilirubin, serum creatinine, and institutional normalized ratio) has been used worldwide for listing and transplanting patients with end-stage liver disease allowing transplanting sicker patients first irrespective of the wait time on the list. MELD score has also been shown to be accurate predictor of survival amongst patients with alcoholic hepatitis, following variceal hemorrhage, infections in cirrhosis, after surgery in patients with cirrhosis including liver resection, trauma, and hepatorenal syndrome (HRS). Although, MELD score is closest to the ideal score, there are some limitations including its inaccuracy in predicting survival in 15–20% cases. Over the last decade, many efforts have been made to further improve and refine MELD score. Until, a better score is developed, liver allocation would continue based on the currently used MELD score. Allocation of organs for liver transplantation in the United States in the 1980s and early 1990s was prioritized based on the level of care required by the patient: hospitalized patients in the intensive care unit, hospitalized patients on the regular floor, and outpatient care. This approach had the potential of ‘gaming’ the system by keeping the patients in ICU in order to be transplanted. In 1996, a consensus conference mandating need for minimal criteria for listing the patients for liver transplantation (LT) introduced the Child–Pugh–Turcotte (CTP) score for liver allocation.1Lucey M.R. Brown K.A. Everson G.T. et al.Minimal criteria for placement of adults on the liver transplant waiting list: a report of a national conference organized by the American Society of Transplant Physicians and the American Association for the Study of Liver Diseases.Liver Transpl Surg. 1997; 3: 628-637Crossref PubMed Google Scholar CTP score is based on severity of 3 objective (serum albumin, serum bilirubin, and prothrombin time) and 2 subjective (ascites and encephalopathy) parameters. Subjective parameters vary with use of diuretics or paracenteses for ascites and use of lactulose for encephalopathy. CTP score introduced to some extent the concept of ‘sicker patient first’ with the introduction of status 1A for patients with fulminant hepatic failure, primary non-function or hepatic artery thrombosis within 7 days of transplantation, and decompensated Wilson's disease. Organ allocation for patients with end-stage liver disease (ESLD), however, largely depended on waiting time on the list. In 1998, the Institute of Medicine mandated that patients be allocated organs based on their disease severity and risk of death rather than on waiting time.2Van Meter C.H. The organ allocation controversy: how did we arrive here?.Ochsner J. 1999; 1: 6-11PubMed Google ScholarDevelopment of the Model for End-stage Liver Disease Score and Adoption by the United Network for Organ Sharing for Liver AllocationFebruary 27, 2002 was a historical day when the MELD score was adopted and approved by the United Network for Organ Sharing (UNOS) as a score to allocate organs for patients awaiting liver transplantation (LT) in the United States.3Kamath P.S. Wiesner R.H. Malinchoc M. et al.A model to predict survival in patients with end-stage liver disease.Hepatology. 2001; 33: 464-470Crossref PubMed Scopus (1882) Google Scholar This score changed the policy of organ allocation not only upholding the concept of “patient comes first” but also “sickest patient comes first”. That is, the patient most at risk for mortality would be at the highest priority for organ allocation.MELD score was developed by a group of researchers at the Mayo Clinic initially as a model to predict survival following transjugular intrahepatic portosystemic (TIPS) for refractory variceal bleeding or refractory ascites.4Malinchoc M. Kamath P.S. Gordon F.D. Peine C.J. Rank J. ter Borg P.C. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.Hepatology. 2000; 31: 864-871Crossref PubMed Google Scholar The model was later shown to quite accurately predict 3 months mortality amongst patients with chronic end-stage liver disease awaiting LT.5Brandsaeter B. Friman S. Broome U. et al.Outcome following liver transplantation for primary sclerosing cholangitis in the Nordic countries.Scand J Gastroenterol. 2003; 38: 1176-1183Crossref PubMed Scopus (40) Google Scholar, 6Said A. Williams J. Holden J. et al.Model for end stage liver disease score predicts mortality across a broad spectrum of liver disease.J Hepatol. 2004; 40: 897-903Abstract Full Text Full Text PDF PubMed Google Scholar As the score was objective and could predict mortality at 3 months with higher accuracy than the CTP score, allocation of livers for transplantation became MELD based, de-emphasizing the concept of waiting time.3Kamath P.S. Wiesner R.H. Malinchoc M. et al.A model to predict survival in patients with end-stage liver disease.Hepatology. 2001; 33: 464-470Crossref PubMed Scopus (1882) Google Scholar, 7Wiesner R. Edwards E. Freeman R. et al.Model for end-stage liver disease (MELD) and allocation of donor livers.Gastroenterology. 2003; 124: 91-96Abstract Full Text Full Text PDF PubMed Scopus (987) Google ScholarThe score was initially named as Mayo model for end-stage liver disease (MELD) score reflecting the institution where the score was developed. With the acceptance of this score by the UNOS for organ allocation, the model was renamed as model for end-stage liver disease. This allowed wider acceptability of the score keeping the same abbreviation of MELD.7Wiesner R. Edwards E. Freeman R. et al.Model for end-stage liver disease (MELD) and allocation of donor livers.Gastroenterology. 2003; 124: 91-96Abstract Full Text Full Text PDF PubMed Scopus (987) Google Scholar, 8Wiesner R.H. McDiarmid S.V. Kamath P.S. et al.MELD and PELD: application of survival models to liver allocation.Liver Transpl. 2001; 7: 567-580Crossref PubMed Scopus (486) Google Scholar Other changes made to the score by the UNOS were: capping serum creatinine at 4 mg/dl, capping the score at 40, and setting the lower limit for each component of the score to 1 in order to avoid negative scores. Further, etiology of the liver disease as a factor was removed from the model, as this did not impact mortality amongst patients with end-stage liver disease awaiting LT.5Brandsaeter B. Friman S. Broome U. et al.Outcome following liver transplantation for primary sclerosing cholangitis in the Nordic countries.Scand J Gastroenterol. 2003; 38: 1176-1183Crossref PubMed Scopus (40) Google ScholarComparison of Child–Pugh–Turcotte Versus Model for End-stage Liver Disease ScoreMortality and MELD score are linearly correlated amongst patients with end-stage liver disease listed for LT with 3 month mortality estimated to be 4%, 27%, 76%, 83%, and 100% for MELD scores of <10, 10–19, 20–29, 30–39, and 40 or more respectively. Predictive ability of any model or score is given by c-statistic, which ranges between 0 and 1. A ‘c’ statistic of 0.7 is considered clinically useful and a c-statistic of 0.8 or more qualifies for an accurate model. This means that if 2 patients are on the waiting list, a model with a c-statistic of 0.8 would be 80% accurate in predicting death of the patient with the higher score earlier than the patient with the lower score. In the initially developed model, c-statistic for MELD score was 0.87, which was superior to CTP score with c-statistic of 0.84. Other studies including meta-analyses have shown that both CTP and MELD scores are predictive of waitlist mortality.9Cholongitas E. Papatheodoridis G.V. Vangeli M. Terreni N. Patch D. Burroughs A.K. Systematic review: the model for end-stage liver disease – should it replace Child–Pugh's classification for assessing prognosis in cirrhosis?.Aliment Pharmacol Ther. 2005; 22: 1079-1089Crossref PubMed Scopus (77) Google Scholar, 10Cholongitas E. Senzolo M. Patch D. et al.Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit.Aliment Pharmacol Ther. 2006; 23: 883-893Crossref PubMed Scopus (98) Google Scholar However, the MELD score allows finer stratification than CTP score. Further, MELD incorporates serum creatinine, a factor which is important in predicting survival in patients with liver disease.11Charlton M.R. Wall W.J. Ojo A.O. et al.Report of the first international liver transplantation society expert panel consensus conference on renal insufficiency in liver transplantation.Liver Transpl. 2009; 15: S1-S34Crossref PubMed Scopus (1) Google Scholar, 12Sharma P. Welch K. Eikstadt R. Marrero J.A. Fontana R.J. Lok A.S. Renal outcomes after liver transplantation in the model for end-stage liver disease era.Liver Transpl. 2009; 15: 1142-1148Crossref PubMed Scopus (45) Google Scholar, 13Nair S. Verma S. Thuluvath P.J. Pretransplant renal function predicts survival in patients undergoing orthotopic liver transplantation.Hepatology. 2002; 35: 1179-1185Crossref PubMed Scopus (278) Google ScholarComponents of the Model for End-stage Liver disease Score and Limitations of Each ComponentMELD score is calculated using serum bilirubin, serum creatinine, and International Normalized Ratio (INR) and is given by the formula 9.57 × loge (creatinine) + 3.78 × loge (total bilirubin) + 11.2 × loge (INR) + 6.43. The score can be calculated using online website www.mayoclinicorg./gi-rst/mayomodel5html.Serum BilirubinProblems with using serum bilirubin as a variable are the potential for error in measurement and elevation in the presence of renal failure.14Gish R.G. Do we need to MEND the MELD?.Liver Transpl. 2007; 13: 486-487Crossref PubMed Scopus (5) Google Scholar Further, total bilirubin which is used for calculation of the MELD score may change due to increased indirect bilirubin from hemolysis, blood transfusion, and genetic variability of the bilirubin metabolism. The predictive ability of the MELD score does not change whether direct or total bilirubin is used, and hence the total bilirubin is used for calculating the MELD score in clinical practice.15Asrani S.K. Kim W.R. Model for end-stage liver disease: end of the first decade.Clin Liver Dis. 2011; 15: 685-698Abstract Full Text Full Text PDF PubMed Scopus (15) Google ScholarSerum CreatinineFor the purposes of organ allocation, serum creatinine is set at a lower limit of 1 mg/dl with a ceiling at 4 mg/dl. Any patient who received dialysis ≥2 times in the previous week irrespective of the serum creatinine value is determined to have a serum creatinine of 4 mg/dl. This ceiling value for serum creatinine is arbitrary and in one study, increasing the upper limit of serum creatinine to 5.5 had a small impact of 2.5% in 3 months mortality amongst wait listed candidates but improved accuracy of the MELD score in predicting 3 months mortality.16Huo T.I. Hsu C.Y. Lin H.C. et al.Selecting an optimal cutoff value for creatinine in the model for end-stage liver disease equation.Clin Transplant. 2010; 24: 157-163Crossref PubMed Scopus (3) Google Scholar The limitation of inclusion of serum creatinine is variation in its value depending on the method of measurement: colorimetric or enzymatic. Further, in the presence of high serum bilirubin, the colorimetric method is unreliable and underestimates the value of creatinine; the enzymatic method is preferred for measuring the serum creatinine in such situations.17Cholongitas E. Marelli L. Kerry A. et al.Different methods of creatinine measurement significantly affect MELD scores.Liver Transpl. 2007; 13: 523-529Crossref PubMed Scopus (83) Google Scholar Another limitation is gender with lower value amongst females compared to men for the same level of renal function.18Cirillo M. Anastasio P. De Santo N.G. Relationship of gender, age, and body mass index to errors in predicted kidney function.Nephrol Dial Transplant. 2005; 20: 1791-1798Crossref PubMed Scopus (146) Google Scholar A study comparing glomerular filtration rate (GFR) based on Modification of Diet in Renal Disease (MDRD) formula and serum creatinine showed similar results in estimating waitlist mortality.19Leithead J.A. MacKenzie S.M. Ferguson J.W. Hayes P.C. Is estimated glomerular filtration rate superior to serum creatinine in predicting mortality on the waiting list for liver transplantation?.Transplant Int. 2011; 24: 482-488Crossref PubMed Scopus (5) Google Scholar Another study using corrected MELD with estimated GFR was unable to predict short-term mortality at 3–6 months but was better in predicting mortality at 9–12 months after listing.20Huo S.C. Huo T.I. Lin H.C. et al.Is the corrected-creatinine model for end-stage liver disease a feasible strategy to adjust gender difference in organ allocation for liver transplantation?.Transplantation. 2007; 84: 1406-1412Crossref PubMed Scopus (21) Google Scholar In contrast, true GFR estimated using iohexol clearance is a better predictor of the renal function compared to MDRD or serum creatinine estimation as the latter methods tend to overestimate true GFR.21Francoz C. Prie D. Abdelrazek W. et al.Inaccuracies of creatinine and creatinine-based equations in candidates for liver transplantation with low creatinine: impact on the model for end-stage liver disease score.Liver Transpl. 2010; 16: 1169-1177Crossref PubMed Scopus (32) Google ScholarINRThe INR has a sigmoid shape effect on the 3 months mortality of wait listed candidates with maximum effect between INR of 1 and 3. INR measured using thromboplastin obtained from patients on anticoagulant therapy leads to variations in the inter-laboratory readings on the INR values.22Schouten J.N. Francque S. Van Vlierberghe H. et al.The influence of laboratory-induced MELD score differences on liver allocation: more reality than myth.Clin Transplant. 2012; 26: E62-E70Crossref PubMed Scopus (4) Google Scholar, 23Trotter J.F. Olson J. Lefkowitz J. Smith A.D. Arjal R. Kenison J. Changes in international normalized ratio (INR) and model for endstage liver disease (MELD) based on selection of clinical laboratory.Am J Transplant. 2007; 7: 1624-1628Crossref PubMed Scopus (53) Google Scholar Combined with geographic variation on the MELD threshold for transplantation, this limitation significantly impacts odds of liver allocation.22Schouten J.N. Francque S. Van Vlierberghe H. et al.The influence of laboratory-induced MELD score differences on liver allocation: more reality than myth.Clin Transplant. 2012; 26: E62-E70Crossref PubMed Scopus (4) Google Scholar Further, INR is prone to be confounded by use of warfarin. Use of liver specific thromboplastin using plasma from patients with cirrhosis instead of plasma from patients on warfarin eliminates this discrepancy and variation across laboratories.24Tripodi A. Chantarangkul V. Primignani M. et al.The international normalized ratio calibrated for cirrhosis (INR (liver)) normalizes prothrombin time results for model for end-stage liver disease calculation.Hepatology. 2007; 46: 520-527Crossref PubMed Scopus (87) Google Scholar However, this method is expensive and adds to confusion in ordering the same tests for different indications. In one study amongst patients with cirrhosis on stable anticoagulation, model without INR was less accurate than the original MELD model suggesting that even in anticoagulated patients MELD model should be used for estimation of prognosis.25Heuman D.M. Mihas A.A. Habib A. et al.MELD-XI: a rational approach to “sickest first” liver transplantation in cirrhotic patients requiring anticoagulant therapy.Liver Transpl. 2007; 13: 30-37Crossref PubMed Scopus (39) Google ScholarOther VariablesEtiology of liver disease was initially included into the model but was later shown to be not predictive of outcomes and was then removed from the model.5Brandsaeter B. Friman S. Broome U. et al.Outcome following liver transplantation for primary sclerosing cholangitis in the Nordic countries.Scand J Gastroenterol. 2003; 38: 1176-1183Crossref PubMed Scopus (40) Google Scholar Similarly, complications of cirrhosis and portal hypertension such as ascites, variceal bleeding, or hepatic encephalopathy being components of CTP score did not significantly add to accuracy of MELD score suggesting that these complications usually reflect the status of underlying liver function.26Botta F. Giannini E. Romagnoli P. et al.MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study.Gut. 2003; 52: 134-139Crossref PubMed Scopus (170) Google ScholarImpact of Implementing Model for End-stage Liver Disease ScoreImpact on OutcomesIntroduction of MELD score for organ allocation in the United States in the very first year resulted in about 12% reduction in waitlist mortality.7Wiesner R. Edwards E. Freeman R. et al.Model for end-stage liver disease (MELD) and allocation of donor livers.Gastroenterology. 2003; 124: 91-96Abstract Full Text Full Text PDF PubMed Scopus (987) Google Scholar This trend continued in later years with reduction in total number of deaths on waitlist from 2046 in 2001 to 1364 in 2005 with reduction in waiting time from 656 days to 416 days.27Wiesner R. Lake J.R. Freeman R.B. Gish R.G. Model for end-stage liver disease (MELD) exception guidelines.Liver Transpl. 2006; 12: S85-S87Crossref PubMed Scopus (29) Google Scholar Part of this reduction was due to increase in number of donor livers from 4671 in 2001 to 5160 in 2005. However, in spite of accounting for this, policy of allocating livers based on MELD score was responsible for this reduction as similar reduction in waitlist mortality did not occur amongst patients with fulminant hepatic failure (FHF).28Brown Jr., R.S. Lake J.R. The survival impact of liver transplantation in the MELD era, and the future for organ allocation and distribution.Am J Transplant. 2005; 5: 203-204Crossref PubMed Scopus (54) Google ScholarStudies have shown association of pre-LT MELD score with the hospital resource utilization such as operative time, use of red blood cell transfusions, duration of stay in the intensive care unit and total hospital stay and charges. In one study, MELD score of more than 23 predicted a higher morbidity and prolonged ICU stay.29Oberkofler C.E. Dutkowski P. Stocker R. et al.Model of end stage liver disease (MELD) score greater than 23 predicts length of stay in the ICU but not mortality in liver transplant recipients.Crit Care. 2010; 14: R117Crossref PubMed Scopus (19) Google Scholar In another study, there was about 55% increased cost of transplanting a patient as compared to pre-MELD era.30Dutkowski P. Oberkofler C.E. Bechir M. et al.The model for end-stage liver disease allocation system for liver transplantation saves lives, but increases morbidity and cost: a prospective outcome analysis.Liver Transpl. 2011; 17: 674-684Crossref PubMed Scopus (28) Google Scholar However, data on increased resource utilization since the implementation of MELD score are controversial with no such change reported in a large database retrospective study.31Bambha K. Kim W.R. Benson J. et al.Economic impact of meld-based allocation of liver transplants.Am J Transplant. 2005; 5: 425Crossref PubMed Scopus (3) Google Scholar However, there is also significant improvement in quality of life resulting in dynamic improvement in the cost to quality adjusted life years (QALY) ratio especially after 3–5 years of follow up amongst patients with high MELD scores prior to transplantation.32Aberg F. Maklin S. Rasanen P. et al.Cost of a quality-adjusted life year in liver transplantation: the influence of the indication and the model for end-stage liver disease score.Liver Transpl. 2011; 17: 1333-1343Crossref PubMed Scopus (14) Google ScholarImpact on Disparities in Liver TransplantationEthnic disparities on waitlist mortality and receipt of liver transplant within 3 years of registering have reduced.33Moylan C.A. Brady C.W. Johnson J.L. Smith A.D. Tuttle-Newhall J.E. Muir A.J. Disparities in liver transplantation before and after introduction of the MELD score.JAMA. 2008; 300: 2371-2378Crossref PubMed Scopus (100) Google Scholar, 34Mathur A.K. Schaubel D.E. Gong Q. Guidinger M.K. Merion R.M. Racial and ethnic disparities in access to liver transplantation.Liver Transpl. 2010; 16: 1033-1040Crossref PubMed Scopus (22) Google Scholar Incorporation of serum creatinine into the model resulted in gender disparities in receipt of transplant and higher waitlist mortality among women by 13% compared to men.35Myers R.P. Shaheen A.A. Aspinall A.I. Quinn R.R. Burak K.W. Gender, renal function, and outcomes on the liver transplant waiting list: assessment of revised MELD including estimated glomerular filtration rate.J Hepatol. 2011; 54: 462-470Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar This is due to the fact that for the given renal function, women tend to have lower serum creatinine compared to men due to lower muscle mass in women.Model for End-stage Liver Disease and Post-transplant SurvivalIn spite of transplanting patients with a higher MELD score, post-LT survival did not change in the MELD era. Post-transplant survival is a multidimensional non-linear issue and depends upon multiple recipient and donor factors along with experience of transplant center. In one study, use of multi-layer perceptron (MLP) using 18 different recipient and donor variables was better predictor of post-transplant outcomes as compared to MELD and sequential organ failure assessment (SOFA) scores.36Zhang M. Yin F. Chen B. et al.Pretransplant prediction of posttransplant survival for liver recipients with benign end-stage liver diseases: a nonlinear model.PloS ONE. 2012; 7: e31256Crossref PubMed Scopus (7) Google Scholar In another study, 3 months post-transplant mortality was predicted by a SOFT (survival outcomes following transplantation) score incorporating 18 recipient and donor factors in addition to MELD score.37Rana A. Hardy M.A. Halazun K.J. et al.Survival outcomes following liver transplantation (SOFT) score: a novel method to predict patient survival following liver transplantation.Am J Transplant. 2008; 8: 2537-2546Crossref PubMed Scopus (84) Google ScholarIn order to match graft with the MELD score and other recipient factors, a balance risk (BAR) score has been suggested in order to achieve a balance between waitlist mortality and post-transplant outcomes.38Dutkowski P. Oberkofler C.E. Slankamenac K. et al.Are there better guidelines for allocation in liver transplantation? A novel score targeting justice and utility in the model for end-stage liver disease era.Ann Surg. 2011; 254 (discussion 53): 745-753Crossref PubMed Scopus (35) Google Scholar In one study, combination of 3 extended donor criteria (EDC): age, steatosis >30% and cold ischemia time with MELD >28 predicted graft failure.39Briceno J. Ciria R. de la Mata M. Rufian S. Lopez-Cillero P. Prediction of graft dysfunction based on extended criteria donors in the model for end-stage liver disease score era.Transplantation. 2010; 90: 530-539Crossref PubMed Scopus (22) Google Scholar Worsening MELD score or delta-MELD (current MELD-maximum score in the last 3 months) has been shown to impact post-transplant outcome,40Gyori G.P. Silberhumer G.R. Zehetmayer S. et al.Dynamic changes in MELD score not only predict survival on the waiting list but also overall survival after liver transplantation.Transplant Int. 2012; 25: 935-940Crossref PubMed Scopus (5) Google Scholar and one should avoid graft with >1 EDC for such patients.41Silberhumer G.R. Pokorny H. Hetz H. et al.Combination of extended donor criteria and changes in the model for end-stage liver disease score predict patient survival and primary dysfunction in liver transplantation: a retrospective analysis.Transplantation. 2007; 83: 588-592Crossref PubMed Scopus (44) Google Scholar Similar observations by another study on patients with Hepatitis B virus (HBV) related liver disease and MELD >29 showed that downgrading MELD score using anti-HBV drugs improved outcomes of LT compared to emergency LT.42Ling Q. Xu X. Wei Q. et al.Downgrading MELD improves the outcomes after liver transplantation in patients with acute-on-chronic hepatitis B liver failure.PloS ONE. 2012; 7: e30322Crossref PubMed Scopus (7) Google Scholar In this respect, product of age and delta-MELD less than 1600 may be required for optimal post-transplant outcomes.43Halldorson J.B. Bakthavatsalam R. Fix O. Reyes J.D. Perkins J.D. D-MELD, a simple predictor of post liver transplant mortality for optimization of donor/recipient matching.Am J Transplant. 2009; 9: 318-326Crossref PubMed Scopus (70) Google ScholarImpact on Liver AllocationThe aims of liver allocation are to reduce wait-list mortality and achieve significant transplant benefit. Although, sickest patients are expected to derive most transplant benefit, disease severity also impacts immediate post-transplant outcomes. Hence, in clinical practice, a balanced approach is needed to optimize liver allocation.44Weismuller T.J. Fikatas P. Schmidt J. et al.Multicentric evaluation of model for end-stage liver disease-based allocation and survival after liver transplantation in Germany – limitations of the ‘sickest first’-concept.Transplant Int. 2011; 24: 91-99Crossref PubMed Scopus (48) Google Scholar Etiology of liver disease is not factored into the calculation of MELD score; patients with viral etiology of cirrhosis and MELD >15 had significantly lower survival than alcoholic cirrhosis patients with similar MELD suggesting that viral cirrhosis patients may be disadvantaged in the MELD allocation policy.45Angermayr B. Luca A. Konig F. et al.Aetiology of cirrhosis of the liver has an impact on survival predicted by the model of end-stage liver disease score.Eur J Clin Invest. 2009; 39: 65-71Crossref PubMed Scopus (12) Google Scholar For a given MELD score between 15–17 and 24–40, a patient with higher serum creatinine is shown to have higher waitlist mortality compared to a patient with lower serum creatinine. This factor, if taken into consideration, would affect the liver allocation.12Sharma P. Welch K. Eikstadt R. Marrero J.A. Fontana R.J. Lok A.S. Renal outcomes after liver transplantation in the model for end-stage liver disease era.Liver Transpl. 2009; 15: 1142-1148Crossref PubMed Scopus (45) Google Scholar Laboratory variations of INR and serum creatinine across transplant centers also result in variations in the MELD score. This combined with geographic variation results in a varying MELD threshold for receiving organs.46Ahmad J. Bryce C.L. Cacciarelli T. Roberts M.S. Differences in access to liver transplantation: disease severity, waiting time, and transplantation center volume.Ann Intern Med. 2007; 146: 707-713Crossref PubMed Google Scholar In addition, allocation of a specific score for patients with Hepatocellular carcinoma (HCC) and other conditions47Argo C.K. Stukenborg G.J. Schmitt T.M. Kumer S.C. Berg C.L. Northup P.G. Regional variability in symptom-based MELD exceptions: a response to organ shortage?.Am J Transplant. 2011; 11: 2353-2361Crossref PubMed Scopus (4) Google Scholar significantly impacts odds of liver allocation.22Schouten J.N. Francque S. Van Vlierberghe H. et al.The influence of laboratory-induced MELD score differences on liver allocation: more reality than myth.Clin Transplant. 2012; 26: E62-E70Crossref PubMed Scopus (4) Google Scholar In this respect, normalization of MELD score based on corrected value of each variable normalized to the maximal normal value (Vmax) of each laboratory and given as: corrected value = measured value × Vmax of lab 1/Vmax of lab 2 may optimize liver allocation.48Ravaioli M. Masetti M. Ridolfi L. et al.Laboratory test variability and model for end-stage liver disease score calculation: effect on liver allocation and proposal for adjustment.Transplantation. 2007; 83: 919-924Crossref PubMed Scopus (19) Google ScholarModel for End-stage Liver Disease Exception Points and Liver AllocationPatients with HCC with lower MELD have a risk of progression of the tumor while waiting for transplant, leading to death or progression of disease which may exclude them from receiving an organ. On the other hand, HCC patients with higher biological MELD have been shown to have poor post-transplant survival compared to comparable MELD in non-HCC patients.49Ioannou" @default.
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• W2078166385 date "2013-03-01" @default.
• W2078166385 modified "2023-09-30" @default.
• W2078166385 title "Model for End-stage Liver Disease" @default.
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