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• W3200210982 abstract "We applaud Kim et al1Kim W.R. et al.Gastroenterology. 2021; 161: 1887-1895Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar for their important step to improve liver allocation in the United States with Model for End-Stage Liver Disease (MELD) 3.0. As highlighted, the liver transplant population has evolved markedly in the last decade from a middle-aged cohort of patient with viral hepatitis, with or without alcohol-related injury and few comorbid conditions, into a dichotomous group of younger patients with alcohol-induced liver disease and older patients with nonalcoholic fatty liver disease with marked comorbid conditions, often chronic kidney disease (CKD). MELD 3.0 also finally addresses the disadvantage that women have faced in the liver allocation system since the inception of MELD, and for this we also greatly appreciate MELD 3.0.2O’Leary J.G. et al.Dig Dis Sci. 2017; 62: 768-776Crossref PubMed Scopus (15) Google Scholar With changing demographics and realization of disparities, it is imperative to adjust allocation scoring systems accordingly. Although MELD 3.0 is a significant step for womankind, we would like to highlight a few things that may need further clarification/investigation. First, we agree that height and sex are collinear and understand your choice of sex over height, given that height does not affect risk for death in men. Also, osteoporosis in advanced liver disease can affect height through vertebral fractures, changes that may more commonly affect women with unknown impact on outcomes. However, sarcopenia surely has a larger impact on outcomes than sex. And although sex was chosen for its objectivity, it is a surrogate for the impact of muscle mass on renal function. There will be invariable issues that arise during the vetting process, such as: How do we categorize transgender persons? As we know sex is genetically defined, whereas gender is based on socially constructed features. At the current time we do not know how gender alteration affects renal function measurement. And what do we do with women taller than 175 cm? They would receive additional priority without incurring greater risk. Therefore, a more nuanced but defined approach based on objective muscle mass quantification, rather than sex, may be needed to ensure true objectivity and equity.3Tandon P. et al.J Hepatol. 2021; 75: S147-S162Abstract Full Text Full Text PDF PubMed Scopus (50) Google Scholar,4Engelmann C. et al.Aliment Pharmacol Ther. 2018; 48: 1271-1281Crossref PubMed Scopus (26) Google Scholar Second, the coefficient of creatinine has increased from 9.57 to 11.14.5Kamath P.S. et al.Hepatology. 2001; 33: 464-470Crossref PubMed Scopus (3792) Google Scholar The upper bound has been appropriately lowered from 4.0 to 3.0 mg/dL, given the plateau of risk for death seen at a serum creatinine of 2.7 mg/dL. However, it is well known that the type of renal dysfunction has a significant impact on a patient’s risk for death, with acute kidney injury–hepatorenal syndrome and acute kidney injury from infection having the highest risk for short-term mortality vs CKD, which has a markedly lower risk for death.6Martin-Llahi M. et al.Gastroenterology. 2011; 140: 488-496.e4Abstract Full Text Full Text PDF PubMed Scopus (251) Google Scholar With the increasing recognition of the entity of acute-on-chronic CKD,7Wong F. et al.Liver Transpl. 2019; 25: 870-880Crossref PubMed Scopus (32) Google Scholar it would be interesting to see the MELD 3.0 scores for patients with compensated cirrhosis on dialysis with hypoalbuminemia, presumably from proteinuria. This would allow the transplant community to ensure these stable patients would not receive undue priority compared with patients with decompensated cirrhosis. Third, the increase in priority of bilirubin from a coefficient of 3.78 to 4.56 will improve the equity of MELD allocation for patients with primary biliary cholangitis.8Singal A.K. et al.Transpl Int. 2017; 30: 454-462Crossref PubMed Scopus (29) Google Scholar Patients with cholestatic liver disease represent a minority of listed patients, and it would be educational to evaluate how the new MELD 3.0 compares with MELDNa for their allocation, which we hope and expect will better represent their true mortality risk. In conclusion, MELD 3.0 is a definite step in the right direction of increasing equity and evolving the current MELDNa score to keep up with changing demographics. However, further information on important subgroups is needed. Ultimately, reconsideration of replacing the new objective but divisive and politically charged variable of sex for a neutral variable that objectively quantitates muscle mass will improve operationalization and elevate MELD 3.0 from one small step for womankind to one big step for everyone. MELD 3.0: The Model for End-Stage Liver Disease Updated for the Modern EraGastroenterologyVol. 161Issue 6PreviewAn updated version of the Model for End-Stage Liver Disease (MELD) affords improved prediction of mortality risk for patients with cirrhosis and corrects the sex disparity. Full-Text PDF ReplyGastroenterologyVol. 162Issue 6PreviewWe appreciate Dr O’Leary and Dr Bajaj’s letter as a valuable contribution to the discussion regarding refinement of the Model for End-Stage Liver Disease (MELD).1,2 The authors note relevant considerations concerning the proposed modifications in MELD 3.0, which include (1) the addition of sex and albumin, (2) updated coefficients and interaction terms, and (3) a lowered upper bound of serum creatinine from 4 to 3 mg/dL. Full-Text PDF" @default.
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• W3200210982 title "MELD 3.0: One Small Step for Womankind or One Big Step for Everyone?" @default.
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